So You Think Checking For Plaquenil Toxicity Will Not Make A Difference?

A STORY THAT NEEDS TO BE TOLD

Recently new guidelines for the management of patients taking PLAQUENIL were released. Two of the authors of this article published in this area, being the first to point to the importance of assessing kidney and liver function in all patients scheduled to be placed on PLAQUENIL.

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Refer to the article, HYDROXYCHLOROQUINE AND CHLOROQUINE TOXICITY THE KIDNEY AND LIVER CONNECTION, in the article section of eyelessons.com for an up to date report.

http://www.eyelessons.com/articles/item/hydroxchloroquine-and-chloroquine-toxicity

Likewise it was cautioned that many patients are overdosed and up until the advent of SDOCT the detection of PLAQUENIL retinotoxicity occurred long after the initial damage had occurred. 

While the academic aspect of the PLAQUENIL issue is important, this “real life” story brings home the importance of assessing these patients.  This is the story of a very astute doctor, Dwayne Yeager, OD FAAO and a very bright patient, Kim Sneed, LPN, CMC and their journey together.  Dr. Yeager discovered the PLAQUENIL retinotoxicity in the patient, Kim.  Kim then helped Drs. Yeager and Alexander put together the link to liver and kidney disorders in many of these patients.

THE CASE 

Patient entered on 8/11/2011 with complaints of dry, sandy, and gritty feeling in her eyes and a PLAQUENIL follow up examination.  At that point the cumulative dose of PLAQUENIL was approximately 950,000 mg.  The classic definition of the “tipping point” for PLAQUENIL retinotoxicity is considered to be 1,000,000 mg.  Of interest was the lab history of severely elevated liver enzymes in 1990.  When the liver is dysfunctional, the PLAQUENIL is not cleared as efficiently and the buildup occurs more rapidly.  Best-corrected visual acuity was 20/20 O.U. with IOPs of 10 mm Hg OD and 12 mm Hg OS.  Other than positive testing for dry eye the exam was unremarkable.  Under the new guidelines SDOCT with RTVue was performed revealing:

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Right Eye: CPT:92135; Instrument utilized; Optical coherence tomography.  Interpretation and report; Scanning laser analysis demonstrates abnormal qualitative and/or quantitative findings in the areas scanned.  THINNING in the peri-macula area.  However the Photoreceptor integrity line is intact.

Left Eye: CPT:92135; Instrument utilized; Optical coherence tomography.  Interpretation and report; Scanning laser analysis demonstrates abnormal qualitative and/or quantitative findings in the areas scanned.  THINNING in the peri-macula area.  However the Photoreceptor integrity line is intact.

The fundus revealed no “classic PLAQUENIL bulls eye.”  This points to the fact that “you can’t see what you can’t see.”

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Likewise 10-2 Threshold Visual Fields showed no evidence of functional damage.

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The entire case is in the power-point section of eyelessons.com.  A referral to the PCP for PLAQUENIL taper was done and the taper was achieved over 8 weeks.

KIM SNEED’S STORY

An email sent by Kim to Drs. Yeager and Alexander on February 18, 2013

I know that Dr. Yeager realizes the impact of the " discovery" of my eye condition - but I want Dr. Alexander to know also. When I was 36, just completing nursing school, I went for my annual physical and some of my laboratory results were abnormal. Unfortunately with those positive results a hysterectomy was scheduled. I went for the post-op visit and was told that the surgical tissue contained no abnormal cells.  The lab that performed the initial tests had actually mixed my results up with someone else. I was so happy that I did not have cancer that I didn’t much care that the mistake had been made. While being grateful for my good fortune, my thoughts turned to prayer for the woman who was given my results.  Unfortunately, she now had to face the cancer.

Soon after that adventure, I was the given the diagnosis of Systemic Lupus Erythematosus (SLE).  All of this mis-adventure revolved around “hormonal” issues and I learned that sometimes SLE is associated with hormonal fluctuations.  Over the course of the process, I lost most functional use of my hands for some time - requiring assistance to tie my shoes and to dress.  It was during this time that I was placed on PLAQUENIL. While on PLAQUENIL, I was always exhausted and experienced a lot of joint pain. From age 36 until age 54 I was only outside for a few minutes at a time and then wore special clothing to protect me from the sun. I was never able to play outside with my 3 children, take them swimming, nor watch my youngest daughter play baseball.  I feared I would eventually miss out on playing outdoors with my grandchildren as well.  As of right now my life has changed because Dr. Yeager closely monitored my vision over the years.  He found the PLAQUENIL toxicity issue on his new Spectral Domain OCT technology and consulted with Dr. Alexander via telemedicine. Dr. Yeager discussed the issue with both my PCP and me and the PLAQUENIL was discontinued.  Within 2 months of stopping the PLAQUENIL, I begin seeing improvement in my health … my family noticed it too.  I had energy… I moved more quickly… and rarely did I experience any pain. This past summer my husband and I took a vacation and for the first time in 19 years – planned OUTDOOR activities.  I did not even wear the sun-protective clothing, but I did use sunscreen. Actually, at this point my doctors can’t find any signs of SLE.  I am so looking forward to this summer when I can take my 2-year-old granddaughter outside to play and swing, which is something most people would take for granted. I truly believe that God allows things to come our way - we have to decide if those difficult times will make us BITTER or BETTER. I am thankful, for even the tough times that have brought me where I am today and for talented dedicated doctors like you who helped get me through those times. I do hope that your work will encourage physicians to dose PLAQUENIL more carefully, taking into consideration not only the weight of the patient, but also their renal and liver function, especially since many lupus patients suffer from renal issues. My doctor would not even issue me a refill prescription for PLAQUENIL until I went for my annual eye exams! I very am thankful for that too.

May God continue blessing you both!

Kim Sneed, LPN, CMC

THE EYELESSON AND LIFE LESSON

LESSON 1 CHECK FOR PLAQUENIL TOXICITY BASED ON THE FOLLOWING GUIDELINES FROM eyelessons.com ARTICLE HYDROXYCHLOROQUINE AND CHLOROQUINE TOXICITY..THE KIDNEY AND LIVER CONNECTION

http://www.eyelessons.com/presentations/item/plaquenil-retinotoxicity-updated-guidelines

Step 1

The first step in the process should be the education of the patient regarding the potential issues associated with the medication.  The patient must be engaged in the process and the discussion should be documented in the chart.  The patient should also have a determination of liver and kidney function prior to initiation of treatment.  The status of the liver and kidneys should offer guidance regarding adjustment of dosages.

Step 2

The restyled guidelines also mandate an examination prior to the initiation of hydroxychloroquine.  While the primary physician should be aware of the new guidelines a general letter to the local doctors would be appropriate. 

Step 3

Assess the patient and carefully chart document regarding:

  • Question visual complaints including near vision
  • Obtain a thorough medical history with emphasis on liver and kidney disorders more common in SLE
  • Document the Duration and Dosage of hydroxychlorquine
  • Best corrected visual acuities
  • Biomicroscopic evaluation of corneal epithelium for vortex deposits as a possible harbinger of retinal toxicity
  • Careful dilated ocular examination paying attention to pigmentary abnormalities in macula and periphery and retinal vasculature
  • Visual field evaluation with 10-2 or other VF test of equal resolution (2 degrees) with attention to pattern deviation.  Paracentral defects occur most often with 10-2 testing. It has been suggested that microperimetry will reveal early functional change. It has likewise been reported that Preferential Hyperacuity Perimetry (PHP) as well as Frequency Doubling Technology (FDT) may also be a useful adjunct for testing of patients suspicious of toxicity.

Step 4

Apply at least one of the following specialized tests or obtain a consult to do so:

  • Spectral Domain OCT assessing inner and outer retinal thickness and inner/outer segment (PIL) juncture in the perifoveal region with emphasis on the 1-1.5 mm zone from the fovea. Pavafoveal thinning of retinal tissue precedes RPE damage affecting the inferotemporal quadrant first. 
  • Fundus auto-fluorescence imaging to reveal subtle RPE defects and early photoreceptor damage.
  • Multifocal Electro-retinogram to assess for localized paracentral depression appears to show changes prior to observable structural changes.  But there is the caution that considerable work must be done in this area.

Note that the following are no longer recommended for early detection of hydroxychloroquine and chloroquine retinotoxicity:

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Step 5

After establishing baseline screening for toxicity on an annual basis should be continued no later than 5 years after starting the medication.    This recommendation must, however, be modified based on the patient’s existing medical situation.

Step 5  represents a minimal recommendation and annual examinations after baseline determination would be judicious.  Should early toxicity be detected and the drug discontinued, it is important to remember that even with discontinuation, the condition has the potential to progress and appropriate follow-up is indicated.  It would likewise be judicious to communicate all findings and recommendations in writing to the primary care physician with a copy to the dispensing pharmacist.  A sample customizable letter is available as a download on eyelessons.com.

Focus on the Zone

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Wednesday, 20 February 2013 Written by Larry J Alexander OD FAAO, Kim Sneed, LPN, CNC, Dwayne Yeager BSRT, OD, FAAO Posted in Philosophy/Editorials

Related Articles

Hydroxchloroquine and Chloroquine Toxicity
Plaquenil Letter to GPs
Plaquenil Retinotoxicity Updated Guidelines
The Value Of Pre-emptive SDOCT Testing In The Prevention Of Vision Loss

About the Author(s)

Larry J Alexander OD FAAO

Larry J Alexander OD FAAO

Dr. Alexander (1948-2016) was a 1971 graduate of Indiana University School of Optometry. He served in the US Navy then served as a Professor at the University of Alabama Birmingham School of Optometry. Larry contributed to a number of chapters in textbooks and has published three editions of Primary Care of the Posterior Segment, as well as contributed to the professional literature. He also lectured extensively in the area of ocular and systemic disease. His areas of special interest included dysfunctional tear syndrome, glaucoma and macular degeneration.  His lessons are the basis for this site and he will be dearly missed. 


Kim Sneed, LPN, CNC

Kim Sneed, LPN, CNC

Kim Sneed, LPN, CNC has been a nurse for 19 years. Most of those years were spent as a Case Manager, bridging the patient care and financial aspect of healthcare. She is now the Director of Data Analysis for a Critical Access Hospital, where she monitor all hospital statistics and trends as well as negotiate hospital contracts.


Dwayne Yeager BSRT, OD, FAAO

Dwayne Yeager BSRT, OD, FAAO

Dr. Yeager acquired a Bachelor of Science in Radiologic Technology from Northeast Louisiana University, Monroe in 1978. He received his Doctorate of Optometry in 1986 from University of Houston. He has practiced primary care Optometry in West Monroe since 1986. His subspecialties include contact lenses, dry eye, glaucoma, and retinal disease management. He is an Externship Preceptor / Adjunct Associate Professor at the University of Houston College of Optometry. He is an Externship Preceptor at the University Of Alabama School of Optometry. He is a Fellow of the American Academy of Optometry, a member of the American Optometric Association, Beta Sigma Kappa Honor Fraternity and Gold Key International Honor Society. He is Currently the Secretary/Treasure of the Optometry Association of Louisiana.

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