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Hydroxychloroquine (Plaquenil) was originally used to treat malaria and is now used mostly to treat rheumatological and dermatological diseases. Its most frequent use now is for rheumatoid arthritis (RA) and Lupus and is often very effective in mitigating the joint and arthritic symptoms these diseases can cause.

One of the most significant side effects of the drug is its possibility of causing eye problems resulting in blurred or decreased vision. The most common issue is damage to the retina. It can impair your color vision or damage the retinal cells, particularly in the area right around the central vision.

In your retina, the area that you use to look straight at an object is called the fovea. The fovea is the area that provides you with the most definition when looking at an object. The area just around the fovea is called the macula and it has the ability to see objects with slightly less definition than the fovea but significantly better than the rest of your retina, which accounts for your peripheral vision. The most common place for Hydroxychloroquine to cause a problem is in a ring of the macula surrounding the fovea.

The reason it is important to detect any of these changes as early as possible is because in many instances the changes are not reversible even if you come off the medication.

The risk of this happening is highly correlated with the cumulative dose of the drug you have received. So, the higher the dose and the longer you have been on it the higher your risk.

The current recommendation is a daily dose that does not exceed 6.5 mg/kg/day (that is milligrams per kilograms per day).  There are approximately 2.2 pounds. in a kilogram.  The pills come in 200 mg tablets.  Most people who are on this drug are on either 200 mg once a day or 200 mg twice a day. The safety break point comes at around 135 pounds. People weighing more than that will stay within the safety guidelines (not more than 6.5mg/kg/day) at 400mg per day, but people under 135 pounds should probably only be taking 200 mg per day.

Other risk factors for Hydroxychloroquine retinal toxicity include kidney or liver disease and obesity. Obesity is a risk factor because the drug does not penetrate fat tissue so there is more of the drug in your lean body mass (including your retina and its supporting cells called the retinal pigment epithelium). What that means in real terms is that if you take two people who each weigh 140 pounds and put them both on 400 mg a day and one person is 4-foot 11 and the other is 5-foot 9, the 4-foot 11 inch person is at greater risk for side effects because the shorter person has more of their body weight in fat tissue. Since the hydroxychloroquine can’t penetrate the fat tissue that means there is a higher concentration of it in sensitive tissues like the retina.  People with kidney and liver problems have a tougher time eliminating the drug from their system so they are at higher risk because the body is going to retain more of the drug for a longer period of time.

The recommendation is to have a baseline eye exam with dilation and a visual field test before or soon after starting the drug. A repeat of that exam should occur every year if there is no evidence of toxicity.  

The actual incidence of retinal toxicity from hydroxychloroquine is difficult to pin down because there is usually a long time between being started on the drug and the start of any identifiable retinal toxicity. The overall rate of probable retinal toxicity is in the range of 1 of every 200 people treated. The rate is much lower than that in the first 7 years of treatment but gets to about 5 times higher after 7 years of treatment. Some of that data is old now and there is much greater awareness currently about keeping people below that 6.5 mg/kg/day dosage level.

I have been in practice for over 25 years and have seen “probable” retinal toxicity from hydroxychloroquine a total of 5 times and only once in the last 10 years when people have been more careful about keeping the dosage in the right range.

The drug can be very effective in its treatment of RA and Lupus and the likelihood of serious vision problems is small and can potentially be avoided with the correct dosing and monitoring of the eyes. Other drugs in the treatment for RA or Lupus may have more frequent or serious side effects then Hydroxychloroquine so it would be wise to consider it a viable treatment option and not easily dismiss it because of the risk of what amounts to a fairly infrequent eye issue.

Article contributed by Dr. Brian Wnorowski, M.D.

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Ask Dr. Stewart Your Eye Care Questions

What can be expected during a contact lens fitting?

A patient can expect to have a different experience when having a contact lens fitting. In addition to the eyeglass exam, questions will be asked to determine which contact lens will work best for them. Will they want to leave the lenses in their eyes overnight or will they remove them every day? Will they wear them only occasionally or will they be for everyday use? Do they want a contact lens that they throw away every day or do they want a contact lens that they have to clean and disinfect? If the patient is over age 40 and has a compromised ability to see up close, how will they see up close with their contact lenses? Will they wear readers over their distant contacts, or will they wear multifocal contacts, or will they wear monovision?

Are some people more prone to having Dry Eyes than others?

Experiencing dry eye symptoms is more common as we grow older, particularly in people 50 years of age and older. Hormonal changes in women who are experiencing menopause or who are post-menopausal. Inflammation in our body can affect the tear gland's ability to produce tears. Eye or health conditions such as glaucoma, diabetes, lupus, rheumatoid arthritis, and Sjogren's Syndrome can be associated with Dry Eyes. Environmental conditions such as dry winter air, dry indoor heated air, working on the computer, and wearing contact lenses can cause Dry Eyes.

Are there advantages to single-use contact lenses? What are they?

Single-use daily wear contacts are convenient to the patient and a healthy recommendation from their eye doctor. At the end of the day, the patient only has to dispose of the contacts. There is no need to take the contacts out to clean and disinfect them. The patients time and money spent on solutions and caring for them are eliminated. Not to mention that the next time they wear a contact, they will be wearing a brand new contact! The single best recommendation your eye doctor can make is to recommend single-use daily wear contacts. They are the healthiest contact that can be worn. The contact lens pathology issues of wearing the same contact for two or four weeks such as neovascularization, microcystic edema, and bacterial infections are greatly reduced.

What is an eye infection?

Your eyes can get infections from bacteria, fungi, or viruses. Eye infections can occur in different parts of the eye and can affect just one eye or both. Two common eye infections are conjunctivitis (also known as pink eye) and lid styes which are swollen lid bumps that can also be painful. Common signs of an eye infection are pain, itching, or a sensation of a foreign body in the eye, photosensitivity, redness or small red lines in the white of the eye, discharge of yellow pus that may be crusty upon awaking, and tears.

What happens during a typical Diabetic Eye Exam?

Your Eye Doctor will evaluate the back of your eye called the Retina to check for leaking blood vessels. Diabetic retinopathy occurs when elevated blood sugars damage the walls of the blood vessels. The vessel walls may thicken, leak, develop clots, close off, or grow balloon-like defects called microaneurysms.

My eyes tear all the time. Why do you call it Dry Eyes?

Your eyes have extra tears because your eyes produce extra tears to combat irritation and dryness. A better way to describe Dry Eyes is tear film instability, which refers to the composition of your tears not being in the proper composition. Stopping eyes from producing extra tears is a goal in the treatment of Dry Eyes.

At what age should my child have his/her eyes examined?

If you ask 10 different Doctors you will get 10 different answers. Newborns have their eyes checked in the birthing ward for starters. From birth to age 5 their eyes are growing. At age 5 is a good time to schedule a regular eye examination, however, if any unusual eye behavior is observed under age 5 an eye exam should be scheduled at that time. Unusual eye behavior such as eye squinting, a head tilt, or having to get close to see.