OSLI Retina

February 2017

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February 2017 ยท Vol. 48, No. 2 97 obesity do not seem of major importance. Significant macular disease (more than just a few hard drusen) is a contraindication because it seems irrational to add a toxic drug to diseased tissue, and also because it may interfere with recognition of HCQ damage in visual fields or SD-OCT. Pattern of Fundus Damage Parafoveal scotomas and photoreceptor thinning have been considered the hallmark signs of toxicity, but the fact is that Asian patients will most often (but not always) show initial damage outside the central macula, near the arcades (Figure). 5 This must be tak- en into account when planning field tests and imag- ing. One can cover all bases with Asian patients by testing both 10-2 and 24-2 using a rapid SITA-FAST protocol (takes no longer than a standard 10-2), and by getting wide-field fundus autofluorescence imag- es or extrafoveal OCT scans. Note that HCQ damage most often begins inferiorly. Photoreceptor Damage Some papers have suggested that the inner retina might be involved in HCQ retinopathy, but more re- cent work has found no clinically relevant changes in the inner retina. For practical purposes, HCQ is a photoreceptor toxin, and even the outer retina will remain clinically normal until frank retinopathy de- velops. 6 Sensitivity Versus Specificity Visual fields (and multifocal electroretinograms [mfERGs]) are functional tests, as well as the most sensitive screening procedures; they sometimes show scotomas before damage is visible in the SD-OCT. 7 However, not all patients are good field-takers, and Figure. Fundus autofluorescence images showing racial differences in the pattern of damage from hydroxychloroquine retinopathy. (A) Normal eye. (B) Typical pattern in European patients (parafoveal bull's eye). (C) Mixed damage in both parafovea and arcade regions. (D) Typical pattern in Asian patients (pericentral damage near arcades). From Melles and Marmor; 5 used with permission.

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