Impact of the revised american academy of ophthalmology guidelines regarding hydroxychloroquine screening on actual practice.

PURPOSE

To determine the impact of the revised academy guidelines on screening for hydroxychloroquine retinopathy.

DESIGN

Retrospective, observational cohort study.

METHODS

setting: Private practice of 29 doctors. study population: Total of 183 patients for follow-up and 36 patients for baseline screening. observation procedure: Review of charts, 10-2 visual fields (VFs), multifocal electroretinograms (mfERG), and spectral-domain optical coherence tomography (SD-OCT) images before and after the revised guidelines. main outcome measure: Rates of use of ancillary tests and clinical intervention, costs of screening, follow-up schedules, and comparative sensitivity of tests.

RESULTS

New hydroxychloroquine toxicity was found in 2 of 183 returning patients (1.1%). Dosing above 6.5 mg/kg/d was found in 28 of 219 patients (12.8%), an underestimate because patient height, weight, and daily dose were not determined in 77 (35.1%), 84 (38.4%), and 59 (26.9%), respectively. In 10 of the 28 (35.7%), the dose was reduced, in 2 (7.1%) hydroxychloroquine was stopped, but in 16 (57.1%) no action was taken. The cost of screening rose 40%/patient after the revised guidelines. Fundus autofluorescence imaging was not used. No toxicity was detected by adding mfERG or SD-OCT. In no case was a 5-year period free of follow-up recommended after baseline screening in a low-risk patient.

CONCLUSIONS

Detection of toxic daily dosing is a cost-effective way to reduce hydroxychloroquine toxicity, but height, weight, and daily dose were commonly not checked. The revised guidelines, emphasizing mfERG, SD-OCT, or FAF, raised screening cost without improving case detection. The recommended 5-year screening-free interval for low-risk patients after baseline examination was ignored.