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Plaquenil = Hydroxychloroquine
- Indication: Malaria, Rheumatoid Arthritis, Systemic Lupus Erythematosus (SLE)
- Side Effect: Chloroquine Maculopathy (advanced stage known as “Bull’s Eye Maculopathy”)
- Differential Diagnoses
-
- Age-Related Macular Degeneration (AMD)
- Cone dystrophy
- Stargardt disease
- Albinism
- Risk Factors
-
- High dose and long duration of therapy
- For Chloroquine (e.g., Chloroquine, Nivaquine): maintenance dose >3.5mg/kg/day (approximately 250mg)
- For Hydroxychloroquine (Plaquenil): maintenance dose >5mg/kg/day
- Therapy with Chloroquine/Hydroxychloroquine for over 5 years
- Renal insufficiency
- Pre-existing maculopathy
- Concurrent use of Tamoxifen
- High dose and long duration of therapy
- Work-up
-
- History taking: vision, scotomas, coloured halos, metamorphopsia, diplopia, etc.
- Slit lamp examination: Cornea verticillata? Subcapsular lens opacities? (including dilated fundus examination) Peripheral pigment clumping?
- Autofluorescence: RPE atrophy?
- OCT
- Visual field testing G2 (Asians) or M2 (Europeans) Octopus
- (Farnsworth Colour Test)
- In cases of suspected Chloroquine Maculopathy or with vision reduction/visual field defects, additional examinations like fluorescein angiography, photography, multifocal ERG, and consider therapy discontinuation
- Follow-up
-
- Initially within the first year of therapy to rule-out pre-existing maculopathy
- thereafter, annually after 5 years from the start of therapy if no risk factors; earlier if risk factors are present
Ethambutol
- Indication: Tuberculosis
- Side Effect: Optic nerve damage
- Risk Factors
-
- Maintenance dose: Greater than 15mg/kg/day.
- Renal insufficiency (Ethambutol dose not adjusted according to kidney function.
- Diabetes mellitus
- Work-up
-
- History taking: vision, central clouding/blurry vision, colour vision
- Farnsworth Colour Test
- Ishihara
- Dilated fundus examination
- Consider visual field testing Octopus G2
- Consider OCT of the macula and optic nerve
- Follow-up
-
- If the dose is <15mg/kg body weight per day: every 4 months
- If the dose is >15mg/kg body weight per day: every 6 months
Lithium
- Indication: Antidepressant, mood stabilizer
- Side Effects
-
- Pseudotumor Cerebri/Papilledema
- Downbeat Nystagmus: Check in lateral/down gaze, as the nystagmus increases in down gaze (may only be visible there) and in lateral gaze, because it only beats downwards and not obliquely, unlike gaze-evoked nystagmus
Gilenya
- Active Ingredient: Fingolimod, a selective immunosuppressant; modulator of the sphingosine-1-phosphate receptor
- Indication: Multiple Sclerosis
- Side Effect: Macular oedema
- Work-up: OCT
- Follow-up: Before starting and 3-4 months after beginning Gilenya therapy. Ophthalmic examination only if there is vision deterioration; annual checks may be recommended. (Vision tests every 6 months by the treating neurologist.)
Tysabri
- Active Ingredient: Natalizumab, a selective immunosuppressant; anti-alpha-4-integrin antibody
- Indication: Multiple Sclerosis
- Side Effect: PML (Progressive Multifocal Leukoencephalopathy) involving the posterior visual pathway with homonymous or diffuse visual field defects (very rare!)
- Work-up
-
- PCR to rule out latent JC Virus infection before starting therapy
- Goldman visual field testing if symptomatic
- Follow-up: if symptomatic
Aminoglycosides (Gentamycin, Tobramycin, Amikacin)
Side Effects: Retinal toxicity after intravitreal injection of a toxic dose with white retinal areas (ischaemic), retinal haemorrhages, optic atrophy, pigment shifts
Thioridazin = Mellaril
- Indication: Schizophrenia
- Toxic Dose: typically 1200mg/day
- Clinical Presentation:
-
- Reduced vision
- night blindness
- +/-color vision impairment
- Findings
-
- Peripheral retinal pigmentary changes
- Pigment deposits in the eyelids, cornea, and lens
Exjade = Deferasirox = Jadenu
- Indication: Sickle Cell Anaemia
- Side Effect: Cataract, maculopathy, optic neuropathy
- Work-up:
-
- Vision test
- Visual field testing (Goldmann)
- OCT and autofluorescence
- Fundus examination in mydriasis
- Fundus photography for documentation
- Follow-up: Annually (every 12 months)
Orkambi
- Active Ingredients: Lumacaftor und Ivacaftor
- Indication: Cystic fibrosis
- Side Effect: Cataract
- Follow-up: Annually (every 12 months), especially in paediatric patients
Sources
- EyeWiki
- Compendium
- Recommendations on Screening for Chloroquine and Hydroxychloroquine Retinopathy (2016 Revision), Marmor, Michael F. et al. Ophthalmology, Volume 123, Issue 6, 1386 – 1394
- The Wills Eye Manual: Office and Emergency Room Diagnosis and Treatment of Eye Disease; Kalla Gervasio MD, Travis Peck MD et al; Lippincott Williams&Wilkins; 8th Edition (2021)
- Kanski’s Clinical Ophthalmology: A Systematic Approach; John E Salmon MD; Elsevier; 9th Edition (2019)