In this edition of Eye, Yeo et al. investigate how many patients in their area are maintained on hydroxychloroquine 1 year after initiating therapy [1]. Their take home message is of patients starting hydroxychloroquine, 25% had discontinued by 6 months and 33% at 12 months. As a result, they suggest timing the baseline retinopathy referral between 6 and 12 months from starting hydroxychloroquine. This is a useful paper and hopefully should help Eye departments to plan their local hydroxychloroquine monitoring services. Managing the complications of hydroxychloroquine retinopathy is an evolving process driven by research papers such as this. The Royal College of Ophthalmologists has recently developed new guidelines for the monitoring of hydroxychloroquine retinopathy [2]. These were developed in collaboration with colleagues from rheumatology and dermatology after an extensive literature review. These guidelines were based on evidence that the prevalence of retinopathy in long term use patients appears to be around 7.5% and depending on dose and duration of therapy can increase to 20–50% after 20 years of therapy. Risk increases for patients taking more than 5 mg/kg/day. The retinopathy is manifest as damage to the photoreceptors and subsequent degeneration of the retinal pigment epithelium (RPE). This may produce a “Bull’s eye maculopathy” and central visual loss. This is important as the only intervention to prevent further damage is stopping the drug. The risk is increased for patients taking more than 5 mg/kg/day, those also taking Tamoxifen, and those with renal impairment. In some patients, toxicity may first present as pericentral retinopathy and thus requires screening outside the macula. The guidelines recommend that all patients planning to take hydroxychloroquine long term i.e. over five years have a baseline examination in a hospital eye department ideally within six months, but definitely within 12 months, of starting therapy with a colour retinal photograph and spectral domain optical coherence tomography (SD-OCT) scans of the macula. Patients should be referred for annual screening after five years of therapy and be reviewed annually thereafter. The number of patients taking hydroxychloroquine is increasing and monitoring patients on therapy is challenging in the currently over stretched hospital eye service [3]. A recent paper estimates that 36,444 patients were commenced on HCQ in 2016 with an estimated 166,673 patients already on HCQ [4]. These estimates are higher than in the RCOphth guideline. This analysis captured prescriptions for hydroxychloroquine for any indication, and counted the number of people prescribed hydroxychloroquine rather than only the number of prescriptions. This suggests the burden of monitoring might be higher than previously estimated. Therefore, it is clear significant extra resources are needed to introduce monitoring of hydroxychloroquine retinopathy into the hospital eye service. The specialities which for good reason initiate a prescription of hydroxychloroquine need to support their colleagues in ophthalmology who are then tasked with monitoring for complications. Similarly, ophthalmologists need to generate the data to help the guidelines evolve so they are effective but minimise as much as possible the resource impact on ophthalmology departments. To that end, there is currently a BOSU survey of sight loss from hydroxychloroquine usage. It would be useful if ophthalmologists could report all cases of sight loss from hydroxychloroquine use to this survey. In addition, monitoring services should audit their results as this will also inform the true demand for monitoring. The paper by Yeo et al. in this edition of Eye is a good example of how useful data can be generated. Unfortunately, hydroxychloroquine monitoring while challenging is the only solution to prevent progressive and irreversible sight loss [5, 6]. Similar conclusions and recommendations have been made by the American Academy of Ophthalmology [7]. * Andrew Lotery a.j.lotery@soton.ac.uk

中文翻译：

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监测羟氯喹视网膜病变

在本期 Eye 中，Yeo 等人。调查他们所在地区有多少患者在开始治疗后 1 年仍继续服用羟氯喹 [1]。他们带回家的信息是开始使用羟氯喹的患者，25% 的患者在 6 个月时停药，33% 的患者在 12 个月时停药。因此，他们建议在开始使用羟氯喹后 6 至 12 个月之间进行基线视网膜病变转诊。这是一篇有用的论文，希望能帮助眼科部门规划他们当地的羟氯喹监测服务。管理羟氯喹视网膜病变的并发症是一个由此类研究论文驱动的不断发展的过程。英国皇家眼科学院最近制定了监测羟氯喹视网膜病变的新指南 [2]。这些是在广泛查阅文献后与风湿病学和皮肤病学的同事合作开发的。这些指南基于长期使用患者视网膜病变的患病率似乎约为 7.5% 的证据，并且根据治疗剂量和持续时间的不同，在治疗 20 年后可能会增加到 20-50%。服用超过 5 毫克/公斤/天的患者的风险增加。视网膜病变表现为光感受器的损伤和随后的视网膜色素上皮 (RPE) 的退化。这可能会导致“牛眼黄斑病”和中央视力丧失。这很重要，因为防止进一步损害的唯一干预措施是停药。服用超过 5 毫克/公斤/天的患者、同时服用他莫昔芬的患者和肾功能不全的患者的风险会增加。在一些患者中，毒性可能首先表现为中央周围视网膜病变，因此需要在黄斑外进行筛查。该指南建议所有计划长期服用羟氯喹的患者，即超过 5 年，最好在开始治疗后的 6 个月内，但绝对在 12 个月内，在医院眼科进行基线检查，并使用彩色视网膜照片和光谱域光学相干断层扫描(SD-OCT) 黄斑扫描。患者应在治疗五年后转诊进行年度筛查，并在此后每年进行复查。服用羟氯喹的患者人数正在增加，在目前过度紧张的医院眼科服务中，对接受治疗的患者进行监测具有挑战性[3]。最近的一篇论文估计，2016 年有 36,444 名患者开始使用 HCQ，估计有 166 名，673 名患者已经接受 HCQ [4]。这些估计值高于 RCOphth 指南中的估计值。该分析捕获了任何适应症的羟氯喹处方，并计算了处方羟氯喹的人数，而不仅仅是处方数。这表明监测的负担可能比先前估计的要高。因此，很明显需要大量额外资源将羟氯喹视网膜病变的监测引入医院眼科服务。有充分理由开具羟氯喹处方的专业需要支持他们的眼科同事，然后他们负责监测并发症。相似地，眼科医生需要生成数据来帮助指南发展，使其有效，但尽可能减少对眼科部门的资源影响。为此，目前有一项关于使用羟氯喹造成视力丧失的 BOSU 调查。如果眼科医生能够向本次调查报告所有因使用羟氯喹而导致视力丧失的病例，那将会很有用。此外，监测服务应审核其结果，因为这也将告知监测的真实需求。Yeo 等人的论文。在这个版本的 Eye 中是一个很好的例子，说明了如何生成有用的数据。不幸的是，尽管具有挑战性，但羟氯喹监测是防止渐进性和不可逆视力丧失的唯一解决方案 [5, 6]。美国眼科学会[7]也得出了类似的结论和建议。