Chloroquine-induced bull’s eye maculopathy in rheumatoid arthritis: related to disease duration?

Abstract

Chloroquine diphosphate has been used in the treatment of various rheumatic diseases, including rheumatoid arthritis. The most important of its side effects is retinopathy. If not diagnosed early, this lesion can evolve into irreversible bull's eye maculopathy and visual loss. The aim of this study was to define the outcome of chloroquine-induced maculopathy after cessation of chloroquine therapy and also to identify the risk factors involved in case of retinopathy evolution. The design of this cohort study was longitudinal and retrospective. Over the period spanning 2000 to 2005, out of 607 medical records of patients with rheumatoid arthritis followed in our Division of Rheumatology, 27 had been diagnosed with chloroquine-induced maculopathy through clinical funduscopy with pupil dilation. In all cases, there was immediate chloroquine intake cessation. After a mean time of 5 years, 16 of these patients were available for follow-up and underwent a new ophthalmologic evaluation by funduscopy, using biomicroscopy and angiofluorescein when necessary. Sequelae maculopathy were reconfirmed in all 16 cases, but progression to advanced stage (bull's eye maculopathy) was found in half of the cohort, even though chloroquine had been suspended. All patients complained of visual alterations, but without progression. Comparison between patient groups with and without bull's eye maculopathy revealed a statistically significant longer rheumatoid arthritis disease history in the former group. Also, the bull's eye group had higher dose intakes of chloroquine and over a longer period compared to the other group, but not statistically significant. This study corroborates the progression of maculopathy even after cessation of chloroquine intake, pointing out the need for careful screening in the high-risk patients. Furthermore, it indicates that duration of rheumatoid arthritis disease could be a possible factor linked to worse prognosis of chloroquine-induced maculopathy.

A comparative study of the usefulness of color vision, photostress recovery time, and visual evoked potential tests in early detection of ocular toxicity from hydroxychloroquine

“…Shinjo and Tizzianni [18] reported that in RA patients with CQ induced bull's eye maculopathy, whenever disease duration increases, the prognosis for maculopathy recovery worsens. According to our results, for the Int.2 group the mean disease duration was significantly more than other groups, but it was not an independent factor and was related to treatment duration and cumulative dose.…”

Complicações oculares da terapêutica com a cloroquina e derivados

“…A toxicidade retiniana aos derivados com 4-aminoquinolonas tem sido reportada entre 0,5 e 3,5% nos pacientes sob uso de doses terapêuticas de hidroxicloroquina e 10-25% nos pacientes em uso de cloroquina (3,(7)(8) . A Academia Americana de Oftalmologia, por meio de revisão de literatura publicada sobre essas drogas, constatou que em um milhão de indivíduos que as tenham utilizado, menos de 20 casos de toxicidade foram descritos (9) .…”

“…Nesse estágio, a interrupção da droga não mais reverte o escotoma; no entanto, o diagnóstico, neste momento, é de fundamental importância, pois há pequena alteração visual. Do estágio 3 em diante, a interrupção do medicamento poderá não impedir a progressão do quadro retinano (8,26) . (Figura 1A) …”

Tomografia de coerência óptica na avaliação da camada de fibras nervosas peripapilar nos usuários de cloroquina

“…Entretanto, seu uso crônico pode acarretar uma degeneração retiniana irreversível que pode evoluir mesmo com a suspensão da medicação (1)(2) . A cloroquina se une à melanina do epitélio pigmentar retiniano e essa junção talvez sirva para concentrar e prolongar a ação tóxica desse agente.…”