Intravitreal dexamethasone implant therapy for the treatment of cystoid macular Oedema due to hydroxychloroquine retinopathy: a case report and literature review.

BACKGROUND: Cystoid macular oedema (CMO) is an uncommon complication associated with hydroxychloroquine (HCQ) retinopathy threatening central vision. We report a patient with HCQ retinopathy and CMO, for which an intravitreal dexamethasone implant was used, which led to complete resolution of oedema. CASE PRESENTATION: A 57-year-old woman with systemic lupus erythematosus (SLE) complaining of blurred vision in both eyes was diagnosed with bilateral HCQ retinopathy and CMO based on characteristic photoreceptor defects and cystoid spaces on optical coherence tomography, hypo-autofluorescence on fundus autofluorescence, and corresponding visual field defects. After treatment with systemic acetazolamide and topical dorzolamide, CMO showed partial resolution in the right eye. Owing to worsening renal function, an intravitreal dexamethasone implant was placed in the right eye, which resulted in resolution of CMO and visual improvement from 20/50 to 20/30. CONCLUSION: Intravitreal dexamethasone implant may be effective for the treatment of CMO in HCQ retinopathy, particularly for the cases refractory to systemic or topical carbonic anhydrase inhibitors.

Evaluation of Hydroxychloroquine Retinopathy Using Ultra-Widefield Fundus Autofluorescence: Peripheral Findings in the Retinopathy.

OBJECTIVES: To investigate the application of ultra-widefield fundus autofluorescence (UWF-FAF) imaging in evaluating hydroxychloroquine (HCQ) retinopathy and to report peripheral autofluorescence findings in Asian patients with this condition. DESIGN: Retrospective case series. METHODS: Setting: institutional. PATIENT POPULATION: 58 eyes of 29 patients with HCQ retinopathy. OBSERVATION PROCEDURES: UWF-FAF imaging was performed, and the images were compared to conventional FAF images obtained using a confocal digital ophthalmoscope. The sensitivities of detecting retinopathy using the 2 modalities were compared. Peripheral autofluorescence findings in the eyes with HCQ retinopathy were assessed, and their association with the Humphrey visual field test results obtained using the 30-2 and full-field 120 (FF-120) protocols was analyzed. Main outcome measurements were abnormal FAF findings. RESULTS: In 41 of 58 eyes (70.7%) with HCQ retinopathy, abnormal FAF findings were noted in the retinal periphery outside the field of view of conventional FAF as hypoautofluorescent (23 eyes, 39.7%) and hyperautofluorescent (38 eyes, 65.5%) lesions. In 5 eyes (8.6%), differences were revealed between conventional FAF and UWF-FAF in detecting retinopathy. Most of the eyes with severe retinopathy showed the most extensive hypoautofluorescence in the nasal peripheral retina. The areas with abnormal FAF findings were significantly correlated with the number of unseen spots on FF-120 results and mean deviation and pattern standard deviation of the 30-2 test results (all P < .001). CONCLUSIONS: Peripheral autofluorescence findings varied in eyes with HCQ retinopathy according to the severity of the retinopathy. The retinal findings with UWF-FAF were functionally correlated to visual field results. UWF-FAF may be useful for evaluating HCQ retinopathy, particularly in Asian patients.

En Face Optical Coherence Tomography Imaging of the Photoreceptor Layers in Hydroxychloroquine Retinopathy.

PURPOSE: To investigate the application of en face optical coherence tomography (OCT) imaging in eyes with hydroxychloroquine (HCQ) retinopathy. DESIGN: Retrospective case series. METHODS: Setting: Institutional. PATIENT POPULATION: Sixty-two eyes of 31 Asian patients with HCQ retinopathy. OBSERVATION PROCEDURES: Macular volume scanning using swept-source OCT was performed in 6 × 6-mm and 9 × 9-mm areas centered on the fovea. Segmentation of the photoreceptor layers was automatically performed between the inner border of the ellipsoid zone and that of the retinal pigment epithelium-Bruch membrane complex to obtain en face OCT images. Findings from the en face images were qualitatively and quantitatively evaluated; they were analyzed and correlated with the fundus autofluorescence and visual field findings. MAIN OUTCOME MEASURES: En face OCT findings. RESULTS: All eyes with HCQ retinopathy had a beaten-bronze appearance in the areas with photoreceptor defects, whereas those with intact photoreceptors had areas with smooth surfaces, which were occasionally demarcated by hyporeflective margins, on the en face OCT images. The presence and extent of the retinopathy could be quickly determined using the images. They also provided quantitative information on the progression based on the areas of intact photoreceptors compared over several visits. Furthermore, the area of central intact photoreceptors significantly correlated with the mean deviation, pattern standard deviation, and visual field index of 30-2 visual field examinations (all P < .001). CONCLUSIONS: En face OCT may be useful for visualizing the presence and extent of HCQ retinopathy and its progression. The area of central intact photoreceptors measured on en face OCT images showed a significant association with functional visual field defects. This imaging may be a helpful adjunct for screening and follow-up examinations of HCQ retinopathy.

Optical Coherence Tomography Protocols for Screening of Hydroxychloroquine Retinopathy in Asian Patients.

PURPOSE: To investigate the distribution of outer retinal changes in hydroxychloroquine (HCQ) retinopathy and explore optical coherence tomography (OCT) protocols to maximize the sensitivity of HCQ retinopathy detection in Asian patients. DESIGN: Diagnostic validity assessment. METHODS: Setting: Institutional. PATIENT POPULATION: Forty-eight eyes (24 patients) with HCQ retinopathy underwent 6-mm horizontal and vertical line scans and 6 × 6-mm2 volume scans using spectral-domain OCT (SD-OCT), and 9-mm line scans and 6 × 6-mm2 and 12 × 9-mm2 volume scans using swept-source OCT (SS-OCT). OBSERVATION PROCEDURES: Distances from the fovea to the defective photoreceptors were measured in the temporal, nasal, superior, and inferior directions from line scan OCT images. The sensitivity of retinopathy detection, indicated by photoreceptor defects, was compared among protocols. MAIN OUTCOME MEASURES: Detection of photoreceptor defects and distances from the fovea to the defects. RESULTS: The average minimum distance from the fovea to an area of photoreceptor defects was 1.84 ± 1.26 mm (mean ± standard deviation). The distances were greater than 3 mm horizontally and vertically in 15 (31.3%) and 17 (35.4%) eyes with HCQ retinopathy, respectively, and only wide-field line or volume scans could detect defects in the eyes. The 9-mm line scans detected HCQ retinopathy significantly better than 6-mm scans (P < .001); the sensitivity of the wide volume scan was significantly greater than the standard volume scan (P = .001). The 12 × 9-mm2 volume scan detected retinopathy with the greatest sensitivity (100%). CONCLUSIONS: Our study recommends a wide-field OCT scan to screen Asian patients taking HCQ medications.