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Correspondence on “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 Submission18-Jan-2020
Date of Acceptance18-Jan-2021

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

DOI: 10.4103/injr.injr_16_21

How to cite this URL:
Roy AN, Samala V, Kumar YA, Fatima SS. Correspondence on “assessing the risk of retinopathy in indian patients using hydroxychloroquine for rheumatic and musculoskeletal diseases: A retrospective observational study” – Reply. Indian J Rheumatol [Epub ahead of print] [cited 2021 Jul 29]. Available from:

Dadhaniya et al.[1] have raised several pertinent questions regarding our study which we would like to answer. This is the largest study conducted in India till date employing all the four screening modalities for hydroxychloroquine (HCQ) retinopathy as per the recommendations.[2] We tried to dwell upon all the various aspects of HCQ retinopathy as such a study is lacking in this country. We would like to reiterate the fact that as there is no evidence of a gold standard test to identify HCQ retinopathy, the consensus is to combine results of structural (Spectral Domain Optical Coherence Tomography (SD-OCT) and Fundus autofluorescence (FAF)) as well as functional tests (Humphrey visual field (HVF) and Multifocal Electroretinography (mfERG)).[3]

The high prevalence of retinal toxicity reported by us (13.5%) points to the unidentified burden in our population. Dadhaniya et al.[1] reported a prevalence of 6.36% employing only HVF and SD-OCT, whereas we used all the screening modalities, viz., HVF, SD-OCT, FAF, and mfERG, which must have contributed to the increased prevalence. Further combining both “possible” and “definite” retinopathy cases also gave rise to increased numbers. We did not find any statistical difference between the retinopathy and nonretinopathy group as far as mean dose/day/kg body weight is concerned though the median duration of usage between the groups was significant.

There are hardly any studies to suggest a low prevalence of HCQ retinopathy below 5 years, especially in the Indian context. Recently, Pandey et al. noted the presence of macular defect in a case using 4 mg/kg/day, a case of “definite” retinopathy even at 1 year and two cases of “possible” retinopathy below 5 years in their case series without even using mfERG and FAF.[4] We believe that until and unless a prospective study in this area is duly conducted, the exact incidence of this retinopathy will not be known. Further, these guidelines were primarily made in the Western population, and hence, India centric guidelines are much needed.

We agree that mfERG has high sensitivity and variable specificity and should primarily be employed in patients having reproducible HVF abnormalities consistent with HCQ retinopathy in a patient with normal SD-OCT and FAF imaging as it has a good correlation to 10-2 visual field testing.[5],[6] We too found a good correlation of HVF abnormalities with mfERG.[2] Further, three of our patients for whom mfERG was repeated after 6 months demonstrated reversibility and thus reiterates the significance of this modality as a sensitive functional indicator for early retinal abnormalities induced by HCQ as well as changes observed after treatment withdrawal.[7],[8]

As per the previous recommendations, 10-2 HVF was done in most of our patients. We have clearly mentioned the number of patients who underwent the various field patterns [Table 4]. We too found a high prevalence of retinal abnormalities with the wider field patterns which correlated with mfERG.

Finally, we clearly mentioned in our discussion that we need to be cautious in interpreting these abnormalities lest we over diagnose patients with retinopathy and stop important drug like HCQ.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Dadhaniya NV, Sood I, Patil A, Uma M, Upadhyaya S, Handa R, et al. Screening for Hydroxychloroquine Retinal Toxicity in Indian Patients. Journal of Clinical Rheumatology: 2020 - Volume Publish Ahead of Print-Issue-doi: 10.1097/RHU.0000000000001479.  Back to cited text no. 1
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. 2
  [Full text]  
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: Exec summ Eye (Lond) 2018;32:1168-73.  Back to cited text no. 3
Pandey S, Kumar P, Moulick PS, Vats S. Spectral domain optical coherence tomography-based prevalence of hydroxychloroquine maculopathy in Indian patients on hydroxychloroquine therapy: A utopia of under diagnosis. Med J Armed Forces India 2020;76:395-401.  Back to cited text no. 4
Pandya HK, Robinson M, Mandal N, Shah VA. Hydroxychloroquine retinopathy: A review of imaging. Indian J Ophthalmol 2015;63:570-4.  Back to cited text no. 5
[PUBMED]  [Full text]  
Lai TY, Ngai JW, Chan WM, Lam DS. Visual field and multifocal electroretinography and their correlations in patients on hydroxychloroquine therapy. Doc Ophthalmol 2006;112:177-87.  Back to cited text no. 6
Moschos MM, Nitoda E, Chatziralli IP, Gatzioufas Z, Koutsandrea C, Kitsos G. Assessment of hydroxychloroquine 16. Maculopathy after cessation of treatment: An optical coherence tomography and multifocal electroretinography study. Drug Des Devel Ther 2015;9:2993-9.  Back to cited text no. 7
Kellner U, Renner AB, Tillack H. Fundus autofluorescence and mfERG for early detection of retinal alterations in patients using chloroquine/hydroxychloroquine. Invest Ophthalmol Vis Sci 2006;47:3531-8.  Back to cited text no. 8


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