She suffered from Sjogren syndrome and inflammatory arthritis and was currently treated with prednisone and methotrexate. She was previously treated with hydroxychloroquine (Plaquenil) 200mg bid (6.5mg/kg) for 10 years, which was stopped one year prior to presentation. Hydroxychloroquine plaquenil withdrawal symptoms How chloroquine causes itch Hydroxychloroquine retinopathy causes destruction of macular rods and cones with sparing of foveal cones. This pattern provides the typical bullseye appearance. RPE migrates into the areas of destructed photoreceptors, causing pigment laden cells to be detected in the outer nuclear and outer plexiform layers 1. Many systemic medications may cause retinal toxicity. One such commonly used medication for dermatologic and rheumatologic inflammatory conditions is hydroxychloroquine Plaquenil, a chloroquine derivative. It is used to treat many diseases including malaria, rheumatoid arthritis and systemic lupus erythematosus. Importance Hydroxychloroquine sulfate is widely used for the long-term treatment of autoimmune conditions but can cause irreversible toxic retinopathy. Prior estimations of risk were low but were based largely on short-term users or severe retinal toxicity bull’s eye maculopathy. Review of systems: Blurred vision, halos, dry eye, dry mouth, gastroesophageal reflux, joint pain Pupils: Reactive to light in each eye from 5 mm in the dark to 2 mm in the light. Extraocular movements: Full, both eyes (OU) Confrontation visual fields: Full OU Intra-ocular pressure The optic nerves appeared healthy with a 0.3 cup-to-disc ratio. Past Ocular History: None Medical History: Sjogren syndrome and inflammatory arthritis, supraventricular tachycardia, anxiety, depression, peptic ulcer disease Medications: prednisone, methotrexate, amitriptyline, ranitidine, estradiol, tizanidine, diltiazem, Restasis Allergies: codeine, droperidol Family History: heart disease, arthritis, cancer Social History: occasional alcohol but no tobacco or intravenous drug use. Oct hydroxychloroquine retinopathy Retinal Physician - Hydroxychloroquine Maculopathy An Update., Hydroxychloroquine-Induced Retinal Toxicity - American. Chloroquine disadvantages givPlaquenil and rheumatoid arthritis reviewsPlaquenil stomach upsetChloroquine dose for lupusHydroxychloroquine also called Spectral-Domain OCT By generating high-resolution, cross-sectional images of the retina in vivo, SD-OCT may detect significant structural alterations prior to development of visible HCQ retinopathy. Multimodal Imaging in Plaquenil Toxicity. Toxic Retinopathy With Hydroxychloroquine Therapy - JAMA. Hydroxychloroquine Plaquenil Toxicity and Recommendations.. Lally DR, Heier, JS, Baumal C, et al. Expanded spectral domain-OCT findings in the early detection of hydroxychloroquine retinopathy and changes following drug cessation. Int J Retina Vitreous. 2016;. 3. Marmor MF, Kellner U, Lai TYY, et al. Recommendations on screening for chloroquine and hydroxychloroquine retinopathy. And screening for hydroxychloroquine retinopathy should be given to all patients. GPP All patients should undergo 10-2 Humphrey visual fields testing using a white stimulus, followed by pupillary dilation and imaging with both spectral domain optical coherence tomography SD-OCT and widefield fundus autofluorescence FAF. B Spectral domain optical coherence tomography SD OCT images, red-free photos, and fundus autofluorescence FAF demonstrate a spectrum of findings seen with different stages of hydroxychloroquine retinopathy. Note the increased signal of choroidal vessels.