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 Table of Contents  
LETTER TO EDITOR
Year : 2022  |  Volume : 17  |  Issue : 2  |  Page : 204-205

Assessing the risk of retinopathy in indian patients using hydroxychloroquine for rheumatic and musculoskeletal diseases: A retrospective observational study – Reply


1 Department of Rheumatology, Yashoda Hospitals, Secunderabad, Telangana, India
2 Tanvi Eye Center, Secunderabad, Telangana, India

Date of Submission08-Jan-2021
Date of Acceptance13-Jan-2021
Date of Web Publication03-May-2022

Correspondence Address:
Dr. Arindam Nandy Roy
Department of Rheumatology, Yashoda Hospitals, Behind Hari Hara Kala Bhavan, S.D Road, Secunderabad - 500 003, Telangana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/injr.injr_6_21

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How to cite this article:
Roy AN, Samala V, Kumar YA, Fatima SS. Assessing the risk of retinopathy in indian patients using hydroxychloroquine for rheumatic and musculoskeletal diseases: A retrospective observational study – Reply. Indian J Rheumatol 2022;17:204-5

How to cite this URL:
Roy AN, Samala V, Kumar YA, Fatima SS. Assessing the risk of retinopathy in indian patients using hydroxychloroquine for rheumatic and musculoskeletal diseases: A retrospective observational study – Reply. Indian J Rheumatol [serial online] 2022 [cited 2022 Jul 4];17:204-5. Available from: https://www.indianjrheumatol.com/text.asp?2022/17/2/204/344593



Dear Editor,

We are thankful to Manoj M et al. for their comments on our article. We would like to answer certain queries raised by them. At the outset, we would like to highlight that this study was not done with the intention of stopping hydroxychloroquine (HCQ) but to make readers aware of the different aspects of HCQ retinopathy and their early detection in the Indian scenario.

We agree that the total prevalence is more as both “possible” and “definite” retinopathy cases were studied together but that does not mean that we advocate stopping of HCQ in each case. HCQ was withdrawn/dose reduced only when humphrey visual field (HVF) repeated over 3 and 6 months showed reproducible scotomas along with retinal thinning (definite retinopathy) in due consultation with the ophthalmologist and the rheumatic condition being treated. HCQ was never stopped in cases of “possible” retinopathy, but these cases were followed up more intensively. Because of adequate monitoring, only one of our patients developed bull's-eye retinopathy and visual symptoms in the last 10 years.

Patients were prescribed HCQ as per their actual body weight. One hundred and twenty-two out of 133 (91.72%) patients having retinopathy received the lowest daily dose (200 mg/day), so we believe that we have not overdosed short obese individuals in our study. A significant number of our patients taking the permissible dose got affected even within a period of 5 years, thereby highlighting the fact that the guidelines are not foolproof and we need to be cautious particularly in the Indian context. We are of the view that a prospective study should be undertaken employing these modern methods (at least wide field HVF and spectral-domain optical coherence tomography [SD-OCT]) to find out the incidence of HCQ retinopathy in the Indian population.

We believe that the high prevalence of retinopathy in our study points to the unidentified burden in our population. The other factors include employing modern methods of screening including the use of 24-2 and 30-2 HVF patterns (Asian pattern) and combining both “possible” and “definite” retinopathy cases.

A comparison of screening procedures revealed that all of these methods can pick up damage at an early stage of HCQ toxicity, but it is not predictable as to which test will be most definitive for any given individual.[1] We believe that as a routine, fundus autofluorescence (FAF) was used in this study rather than a widefield one and hence the discordance with multifocal electroretinography (mfERG). Further mfERG should be used in patients with persistent and significant visual field defects consistent with HCQ toxicity but without evidence of structural defects on SD-OCT or FAF.[2] In most of the previous studies to detect HCQ retinopathy, 10-2 protocol was followed, so most of our patients were subjected to 10-2 protocol rather than 24-2 and 30-2. We totally agree with the fact that wider field patterns (10-2 and 30-2) can detect more cases of retinopathy in our population, as is evident in Table 4 of our study.[3] Further, there are no data to suggest that the association of HCQ retinopathy with age could possibly be due to prolonged drug use.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Marmor MF. Comparison of screening procedures in hydroxychloroquine toxicity. Arch Ophthalmol 2012;130:461-9.  Back to cited text no. 1
    
2.
Yusuf IH, Foot B, Galloway J, Ardern-Jones MR, Watson SL, Yelf C, et al. The Royal College of Ophthalmologists recommendations on screening for hydroxychloroquine and chloroquine users in the United Kingdom: Executive summary. Eye (Lond) 2018;32:1168-73.  Back to cited text no. 2
    
3.
Roy AN, Samala V, Kumar YA, Fatima SS. Assessing the risk of retinopathy in Indian patients using hydroxychloroquine for rheumatic and musculoskeletal diseases: A retrospective observational study. Indian J Rheumatol 2021;16:23-9.  Back to cited text no. 3
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