Original article
Impact of the Revised American Academy of Ophthalmology Guidelines Regarding Hydroxychloroquine Screening on Actual Practice

https://doi.org/10.1016/j.ajo.2012.09.025Get rights and content

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.

Section snippets

Methods

This was a retrospective, observational cohort study. Waiver of informed consent and waiver of HIPAA authorization was approved by the Presbyterian Hospital institutional review board. The revised guidelines were published in February 2011.1 The medical records of 219 patients undergoing hydroxychloroquine screening in a multispecialty ophthalmology practice of 26 ophthalmologists and 3 optometrists between May 3, 2011 and June 12, 2012 were reviewed using a prespecified template for the

Results

Characteristics of the patients and eyes reviewed are listed in Table 1. Of the 219 patients screened, 36 (16.4%) were for baseline examinations and 183 (83.6%) were for follow-up examinations. Women made up 91.3% (200/219) of those screened. Seventy-six percent (166/219) of patients took hydroxychloroquine for systemic lupus erythematosus or rheumatoid arthritis. Factors that place a patient at higher risk include preexisting macular disease, concomitant renal or liver disease, higher age, and

Discussion

In the United States, it is estimated that 150 000 patients take hydroxychloroquine for autoimmune diseases. The screening costs associated with an annual eye examination and 10-2 VF at 2011 Medicare reimbursement levels, as in the 2002 guidelines, would be $29.0 million. Although both these guidelines and the 2011 guidelines allow for a 5-year period without screening for low-risk patients, this study shows that clinicians ignore this proviso. The screening costs associated with the 2011

David J. Browning MD, PhD, is a retina specialist with Charlotte Eye, Ear, Nose, and Throat Associates. His research interests are diabetic retinopathy, retinal vein occlusions, and medical retina.

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    David J. Browning MD, PhD, is a retina specialist with Charlotte Eye, Ear, Nose, and Throat Associates. His research interests are diabetic retinopathy, retinal vein occlusions, and medical retina.

    See Accompanying Editorial on page 413.

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