Research progress of hydroxychloroquine retinopathy_Chinese Journal of Ocular Fundus Diseases

Authors：

Liang Jia , Fang Dong , Chen Lu , Xie Ting , Wei Pengxue ,  Zhang Shaochong

Shenzhen Eye Hospital of Jinan University, Shenzhen Institute of Eye Disease Control, Shenzhen 518040, China;

Corresponding author：

Zhang Shaochong, Email: zhangshaochong@gzzoc.com

Keywords：

Hydroxychloroquine retinopathy; Drug toxicity; Pathogenesis; Clinical manifestations; Multimodal imaging; Disease management; Review

DOI：

10.3760/cma.j.cn511434-20220215-00087

Video：

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Abstract Full text Figures/Tables Video References Cited by

Hydroxychloroquine is widely used in a variety of autoimmune diseases. However, long-term use of hydroxychloroquine can cause severe retinopathy, which has a complex pathogenic mechanism and diverse clinical manifestations, mainly manifested as photoreceptor and retinal pigment epithelial damage and irreversible vision loss. Identifying damage before retinitis pigment epithelium lesions preserve central vision, so early detection is crucial to slow disease progression and reduce vision loss. The development of multimodal imaging technology and the issuance of the latest treatment guidelines provide a powerful tool for the early screening and treatment of hydroxychloroquine retinopathy. Proficient in the latest guidelines for the treatment of hydroxychloroquine can better guide clinicians to do a good job in disease screening and management, recommend risks, safe dosages and appropriate screening procedures to patients and strengthen the prevention of hydroxychloroquine retinopathy, which will help save the vision of more patients and reduce the waste of medical resources.

Citation： Liang Jia, Fang Dong, Chen Lu, Xie Ting, Wei Pengxue, Zhang Shaochong. Research progress of hydroxychloroquine retinopathy. Chinese Journal of Ocular Fundus Diseases, 2023, 39(6): 515-519. doi: 10.3760/cma.j.cn511434-20220215-00087 Copy

1.	Chandler LC, Yusuf IH, McClements ME, et al. Immunomodulatory effects of hydroxychloroquine and chloroquine in viral infections and their potential application in retinal gene therapy[J]. Int J Mol Sci, 2020, 21(14): 4972. DOI: 10.3390/ijms21144972.
2.	Gordon C, Amissah-Arthur MB, Gayed M, et al. The british society for rheumatology guideline for the management of systemic lupus erythematosus in adults[J]. Rheumatology (Oxford), 2018, 57(1): e1-e45. DOI: 10.1093/rheumatology/kex286.
3.	Fanouriakis A, Tziolos N, Bertsias G, et al. Update οn the diagnosis and management of systemic lupus erythematosus[J]. Ann Rheum Dis, 2021, 80(1): 14-25. DOI: 10.1136/annrheumdis-2020-218272.
4.	Nicolò M, Ferro Desideri L, Bassetti M, et al. Hydroxychloroquine and chloroquine retinal safety concerns during COVID-19 outbreak[J]. Int Ophthalmol, 2021, 41(2): 719-725. DOI: 10.1007/s10792-020-01593-0.
5.	Doyno C, Sobieraj DM, Baker WL. Toxicity of chloroquine and hydroxychloroquine following therapeutic use or overdose[J]. Clin Toxicol (Phila), 2021, 59(1): 12-23. DOI: 10.1080/15563650.2020.1817479.
6.	Lotery A, Burdon M. Monitoring for hydroxychloroquine retinopathy[J]. Eye (Lond), 2020, 34(8): 1301-1302. DOI: 10.1038/s41433-020-0795-2.
7.	Marmor MF, Carr RE, Easterbrook M, et al. Recommendations on screening for chloroquine and hydroxychloroquine retinopathy: a report by the American Academy of Ophthalmology[J]. Ophthalmology, 2002, 109(7): 1377-1382. DOI: 10.1016/s0161-6420(02)01168-5.
8.	Yusuf IH, Foot B, Galloway J, et al. The royal college of ophthalmologists recommendations on screening for hydroxychloroquine and chloroquine users in the United Kingdom: executive summary[J]. Eye (Lond), 2018, 32(7): 1168-1173. DOI: 10.1038/s41433-018-0136-x.
9.	Eo DR, Lee MG, Ham DI, et al. Frequency and clinical characteristics of hydroxychloroquine retinopathy in Korean patients with rheumatologic diseases[J]. J Korean Med Sci, 2017, 32(3): 522-527. DOI: 10.3346/jkms.2017.32.3.522.
10.	Jorge A, Ung C, Young LH, et al. Hydroxychloroquine retinopathy-implications of research advances for rheumatology care[J]. Nat Rev Rheumatol, 2018, 14(12): 693-703. DOI: 10.1038/s41584-018-0111-8.
11.	Allahdina AM, Chen KG, Alvarez JA, et al. Longitudinal changes in eyes with hydroxychloroquine retinal toxicity[J]. Retina, 2019, 39(3): 473-484. DOI: 10.1097/iae.0000000000002437.
12.	Pham BH, Marmor MF. Sequential changes in hydroxychloroquine retinopathy up to 20 years after stopping the drug: implications for mild versus severe toxicity[J]. Retina, 2019, 39(3): 492-501. DOI: 10.1097/iae.0000000000002408.
13.	Xu C, Zhu L, Chan T, et al. Chloroquine and hydroxychloroquine are novel inhibitors of human organic anion transporting polypeptide 1A2[J]. J Pharm Sci, 2016, 105(2): 884-890. DOI: 10.1002/jps.24663.
14.	Yusuf IH, Sharma S, Luqmani R, et al. Hydroxychloroquine retinopathy[J]. Eye (Lond), 2017, 31(6): 828-845. DOI: 10.1038/eye.2016.298.
15.	Li JH, Xu ZY, Li MJ, et al. LC-MS based metabolomics reveals metabolic pathway disturbance in retinal pigment epithelial cells exposed to hydroxychloroquine[J/OL]. Chem Biol Interact, 2020, 328: 109212[2020-09-01]. https://linkinghub.elsevier.com/retrieve/pii/S0009-2797(20)30475-0. DOI: 10.1016/j.cbi.2020.109212.
16.	Melles RB, Marmor MF. Pericentral retinopathy and racial differences in hydroxychloroquine toxicity[J]. Ophthalmology, 2015, 122(1): 110-116. DOI: 10.1016/j.ophtha.2014.07.018.
17.	Martín-Iglesias D, Artaraz J, Ruiz-Irastorza G. Hydroxychloroquine retinal toxicity and its association with dosage[J]. J Rheumatol, 2021, 48(1): 150. DOI: 10.3899/jrheum.200843.
18.	Lee DH, Melles RB, Joe SG, et al. Pericentral hydroxychloroquine retinopathy in Korean patients[J]. Ophthalmology, 2015, 122(6): 1252-1256. DOI: 10.1016/j.ophtha.2015.01.014.
19.	Elhusseiny AM, Relhan N, Smiddy WE. Docetaxel-induced maculopathy possibly potentiated by concurrent hydroxychloroquine use[J/OL]. Am J Ophthalmol Case Rep, 2019, 16: 100560[2019-09-26]. https://linkinghub.elsevier.com/retrieve/pii/S2451-9936(19)30103-3. DOI: 10.1016/j.ajoc.2019.100560.
20.	Grassmann F, Bergholz R, Mändl J, et al. Common synonymous variants in ABCA4 are protective for chloroquine induced maculopathy (toxic maculopathy)[J]. BMC Ophthalmol, 2015, 15: 18. DOI: 10.1186/s12886-015-0008-0.
21.	Liu J, Lu W, Reigada D, et al. Restoration of lysosomal pH in RPE cells from cultured human and ABCA4(-/-) mice: pharmacologic approaches and functional recovery[J]. Invest Ophthalmol Vis Sci, 2008, 49(2): 772-780. DOI: 10.1167/iovs.07-0675.
22.	Geerlings MJ, de Jong EK, den Hollander AI. The complement system in age-related macular degeneration: a review of rare genetic variants and implications for personalized treatment[J]. Mol Immunol, 2017, 84: 65-76. DOI: 10.1016/j.molimm.2016.11.016.
23.	Katsman D, Sanfilippo C, Sarraf D. Panretinal degeneration associated with long-term hydroxychloroquine use and heterozygous USH2A mutation[J]. Retin Cases Brief Rep, 2017, 11 Suppl 1: S77-80. DOI: 10.1097/icb.0000000000000421.
24.	Mack HG, Kowalski T, Lucattini A, et al. Genetic susceptibility to hydroxychloroquine retinal toxicity[J]. Ophthalmic Genet, 2020, 41(2): 159-170. DOI: 10.1080/13816810.2020.1747093.
25.	Petri M, Elkhalifa M, Li J, et al. Hydroxychloroquine blood levels predict hydroxychloroquine retinopathy[J]. Arthritis Rheumatol, 2020, 72(3): 448-453. DOI: 10.1002/art.41121.
26.	Marmor MF, Kellner U, Lai TY, et al. Recommendations on screening for chloroquine and hydroxychloroquine retinopathy (2016 revision)[J]. Ophthalmology, 2016, 123(6): 1386-1394. DOI: 10.1016/j.ophtha.2016.01.058.
27.	Browning DJ. The prevalence of hydroxychloroquine retinopathy and toxic dosing, and the role of the ophthalmologist in reducing both[J]. Am J Ophthalmol, 2016, 166: ix-xi. DOI: 10.1016/j.ajo.2016.03.044.
28.	Kim KE, Ryu SJ, Kim YH, et al. Visual field examinations using different strategies in Asian patients taking hydroxychloroquine[J]. Sci Rep, 2022, 12(1): 14778. DOI: 10.1038/s41598-022-19048-0.
29.	Carter KL, Do DV. Hydroxychloroquine-induced retinal toxicity[J]. J Rheumatol, 2020, 47(4): 632. DOI: 10.3899/jrheum.190538.
30.	Kim KE, Ahn SJ, Woo SJ, et al. Use of OCT retinal thickness deviation map for hydroxychloroquine retinopathy screening[J]. Ophthalmology, 2021, 128(1): 110-119. DOI: 10.1016/j.ophtha.2020.06.021.
31.	Missner S, Kellner U. Comparison of different screening methods for chloroquine/hydroxychloroquine retinopathy: multifocal electroretinography, color vision, perimetry, ophthalmoscopy, and fluorescein angiography[J]. Graefe's Arch Clin Exp Ophthalmol, 2012, 250(3): 319-325. DOI: 10.1007/s00417-011-1753-2.
32.	Borrelli E, Battista M, Cascavilla ML, et al. Impact of structural changes on multifocal electroretinography in patients with use of hydroxychloroquine[J]. Invest Ophthalmol Vis Sci, 2021, 62(12): 28. DOI: 10.1167/iovs.62.12.28.
33.	Tsang AC, Ahmadi S, Hamilton J, et al. The diagnostic utility of multifocal electroretinography in detecting chloroquine and hydroxychloroquine retinal toxicity[J]. Am J Ophthalmol, 2019, 206: 132-139. DOI: 10.1016/j.ajo.2019.04.025.
34.	Molina-Martín A, Piñero DP, Pérez-Cambrodí RJ. Decreased perifoveal sensitivity detected by microperimetry in patients using hydroxychloroquine and without visual field and fundoscopic anomalies[J/OL]. J Ophthalmol, 2015, 2015: 437271[2015-03-12]. https://pubmed.ncbi.nlm.nih.gov/25861463/. DOI: 10.1155/2015/437271.
35.	Chen E, Brown DM, Benz MS, et al. Spectral domain optical coherence tomography as an effective screening test for hydroxychloroquine retinopathy (the "flying saucer" sign)[J]. Clin Ophthalmol, 2010, 4: 1151-1158. DOI: 10.2147/opth.S14257.
36.	Godinho G, Madeira C, Falcão M, et al. Longitudinal retinal changes induced by hydroxychloroquine in eyes without retinal toxicity[J]. Ophthalmic Res, 2021, 64(2): 290-296. DOI: 10.1159/000511592.
37.	Bulut M, Erol MK, Toslak D, et al. A new objective parameter in hydroxychloroquine-induced retinal toxicity screening test: macular retinal ganglion cell-inner plexiform layer thickness[J]. Arch Rheumatol, 2018, 33(1): 52-58. DOI: 10.5606/ArchRheumatol.2018.6327.
38.	Gil P, Nunes A, Farinha C, et al. Structural and functional characterization of the retinal effects of hydroxychloroquine treatment in healthy eyes[J]. Ophthalmologica, 2019, 241(4): 226-233. DOI: 10.1159/000495308.
39.	Kan E, Yakar K, Demirag MD, et al. Macular ganglion cell-inner plexiform layer thickness for detection of early retinal toxicity of hydroxychloroquine[J]. Int Ophthalmol, 2018, 38(4): 1635-1640. DOI: 10.1007/s10792-017-0635-y.
40.	Casado A, López-de-Eguileta A, Fonseca S, et al. Outer nuclear layer damage for detection of early retinal toxicity of hydroxychloroquine[J]. Biomedicines, 2020, 8(3): 54. DOI: 10.3390/biomedicines8030054.
41.	Ugwuegbu O, Uchida A, Singh RP, et al. Quantitative assessment of outer retinal layers and ellipsoid zone mapping in hydroxychloroquine retinopathy[J]. Br J Ophthalmol, 2019, 103(1): 3-7. DOI: 10.1136/bjophthalmol-2018-312363.
42.	Ahn SJ, Joung J, Lee BR. Evaluation of hydroxychloroquine retinopathy using ultra-widefield fundus autofluorescence: peripheral findings in the retinopathy[J]. Am J Ophthalmol, 2020, 209: 35-44. DOI: 10.1016/j.ajo.2019.09.008.
43.	Tarakcioglu HN, Ozkaya A, Yigit U. Is optical coherence tomography angiography a useful tool in the screening of hydroxychloroquine retinopathy?[J]. Int Ophthalmol, 2021, 41(1): 27-33. DOI: 10.1007/s10792-020-01549-4.
44.	Ahn SJ, Ryu SJ, Lim HW, et al. Toxic effects of hydroxychloroquine on the choroid: evidence from multimodal imaging[J]. Retina, 2019, 39(5): 1016-1026. DOI: 10.1097/iae.0000000000002047.
45.	Ledingham J, Gullick N, Irving K, et al. BSR and BHPR guideline for the prescription and monitoring of non-biologic disease-modifying anti-rheumatic drugs[J]. Rheumatology (Oxford), 2017, 56(6): 865-868. DOI: 10.1093/rheumatology/kew479.
46.	Yusuf IH, Ledingham JM, MacPhie E, et al. Monitoring for retinal toxicity in patients taking hydroxychloroquine and chloroquine[J]. Rheumatology (Oxford), 2019, 58(1): 3-4. DOI: 10.1093/rheumatology/key024.
47.	Yusuf IH, Foot B, Lotery AJ. The royal college of ophthalmologists recommendations on monitoring for hydroxychloroquine and chloroquine users in the United Kingdom (2020 revision): executive summary[J]. Eye (Lond), 2021, 35(6): 1532-1537. DOI: 10.1038/s41433-020-01380-2.

1. Chandler LC, Yusuf IH, McClements ME, et al. Immunomodulatory effects of hydroxychloroquine and chloroquine in viral infections and their potential application in retinal gene therapy[J]. Int J Mol Sci, 2020, 21(14): 4972. DOI: 10.3390/ijms21144972.
2. Gordon C, Amissah-Arthur MB, Gayed M, et al. The british society for rheumatology guideline for the management of systemic lupus erythematosus in adults[J]. Rheumatology (Oxford), 2018, 57(1): e1-e45. DOI: 10.1093/rheumatology/kex286.
3. Fanouriakis A, Tziolos N, Bertsias G, et al. Update οn the diagnosis and management of systemic lupus erythematosus[J]. Ann Rheum Dis, 2021, 80(1): 14-25. DOI: 10.1136/annrheumdis-2020-218272.
4. Nicolò M, Ferro Desideri L, Bassetti M, et al. Hydroxychloroquine and chloroquine retinal safety concerns during COVID-19 outbreak[J]. Int Ophthalmol, 2021, 41(2): 719-725. DOI: 10.1007/s10792-020-01593-0.
5. Doyno C, Sobieraj DM, Baker WL. Toxicity of chloroquine and hydroxychloroquine following therapeutic use or overdose[J]. Clin Toxicol (Phila), 2021, 59(1): 12-23. DOI: 10.1080/15563650.2020.1817479.
6. Lotery A, Burdon M. Monitoring for hydroxychloroquine retinopathy[J]. Eye (Lond), 2020, 34(8): 1301-1302. DOI: 10.1038/s41433-020-0795-2.
7. Marmor MF, Carr RE, Easterbrook M, et al. Recommendations on screening for chloroquine and hydroxychloroquine retinopathy: a report by the American Academy of Ophthalmology[J]. Ophthalmology, 2002, 109(7): 1377-1382. DOI: 10.1016/s0161-6420(02)01168-5.
8. Yusuf IH, Foot B, Galloway J, et al. The royal college of ophthalmologists recommendations on screening for hydroxychloroquine and chloroquine users in the United Kingdom: executive summary[J]. Eye (Lond), 2018, 32(7): 1168-1173. DOI: 10.1038/s41433-018-0136-x.
9. Eo DR, Lee MG, Ham DI, et al. Frequency and clinical characteristics of hydroxychloroquine retinopathy in Korean patients with rheumatologic diseases[J]. J Korean Med Sci, 2017, 32(3): 522-527. DOI: 10.3346/jkms.2017.32.3.522.
10. Jorge A, Ung C, Young LH, et al. Hydroxychloroquine retinopathy-implications of research advances for rheumatology care[J]. Nat Rev Rheumatol, 2018, 14(12): 693-703. DOI: 10.1038/s41584-018-0111-8.
11. Allahdina AM, Chen KG, Alvarez JA, et al. Longitudinal changes in eyes with hydroxychloroquine retinal toxicity[J]. Retina, 2019, 39(3): 473-484. DOI: 10.1097/iae.0000000000002437.
12. Pham BH, Marmor MF. Sequential changes in hydroxychloroquine retinopathy up to 20 years after stopping the drug: implications for mild versus severe toxicity[J]. Retina, 2019, 39(3): 492-501. DOI: 10.1097/iae.0000000000002408.
13. Xu C, Zhu L, Chan T, et al. Chloroquine and hydroxychloroquine are novel inhibitors of human organic anion transporting polypeptide 1A2[J]. J Pharm Sci, 2016, 105(2): 884-890. DOI: 10.1002/jps.24663.
14. Yusuf IH, Sharma S, Luqmani R, et al. Hydroxychloroquine retinopathy[J]. Eye (Lond), 2017, 31(6): 828-845. DOI: 10.1038/eye.2016.298.
15. Li JH, Xu ZY, Li MJ, et al. LC-MS based metabolomics reveals metabolic pathway disturbance in retinal pigment epithelial cells exposed to hydroxychloroquine[J/OL]. Chem Biol Interact, 2020, 328: 109212[2020-09-01]. https://linkinghub.elsevier.com/retrieve/pii/S0009-2797(20)30475-0. DOI: 10.1016/j.cbi.2020.109212.
16. Melles RB, Marmor MF. Pericentral retinopathy and racial differences in hydroxychloroquine toxicity[J]. Ophthalmology, 2015, 122(1): 110-116. DOI: 10.1016/j.ophtha.2014.07.018.
17. Martín-Iglesias D, Artaraz J, Ruiz-Irastorza G. Hydroxychloroquine retinal toxicity and its association with dosage[J]. J Rheumatol, 2021, 48(1): 150. DOI: 10.3899/jrheum.200843.
18. Lee DH, Melles RB, Joe SG, et al. Pericentral hydroxychloroquine retinopathy in Korean patients[J]. Ophthalmology, 2015, 122(6): 1252-1256. DOI: 10.1016/j.ophtha.2015.01.014.
19. Elhusseiny AM, Relhan N, Smiddy WE. Docetaxel-induced maculopathy possibly potentiated by concurrent hydroxychloroquine use[J/OL]. Am J Ophthalmol Case Rep, 2019, 16: 100560[2019-09-26]. https://linkinghub.elsevier.com/retrieve/pii/S2451-9936(19)30103-3. DOI: 10.1016/j.ajoc.2019.100560.
20. Grassmann F, Bergholz R, Mändl J, et al. Common synonymous variants in ABCA4 are protective for chloroquine induced maculopathy (toxic maculopathy)[J]. BMC Ophthalmol, 2015, 15: 18. DOI: 10.1186/s12886-015-0008-0.
21. Liu J, Lu W, Reigada D, et al. Restoration of lysosomal pH in RPE cells from cultured human and ABCA4(-/-) mice: pharmacologic approaches and functional recovery[J]. Invest Ophthalmol Vis Sci, 2008, 49(2): 772-780. DOI: 10.1167/iovs.07-0675.
22. Geerlings MJ, de Jong EK, den Hollander AI. The complement system in age-related macular degeneration: a review of rare genetic variants and implications for personalized treatment[J]. Mol Immunol, 2017, 84: 65-76. DOI: 10.1016/j.molimm.2016.11.016.
23. Katsman D, Sanfilippo C, Sarraf D. Panretinal degeneration associated with long-term hydroxychloroquine use and heterozygous USH2A mutation[J]. Retin Cases Brief Rep, 2017, 11 Suppl 1: S77-80. DOI: 10.1097/icb.0000000000000421.
24. Mack HG, Kowalski T, Lucattini A, et al. Genetic susceptibility to hydroxychloroquine retinal toxicity[J]. Ophthalmic Genet, 2020, 41(2): 159-170. DOI: 10.1080/13816810.2020.1747093.
25. Petri M, Elkhalifa M, Li J, et al. Hydroxychloroquine blood levels predict hydroxychloroquine retinopathy[J]. Arthritis Rheumatol, 2020, 72(3): 448-453. DOI: 10.1002/art.41121.
26. Marmor MF, Kellner U, Lai TY, et al. Recommendations on screening for chloroquine and hydroxychloroquine retinopathy (2016 revision)[J]. Ophthalmology, 2016, 123(6): 1386-1394. DOI: 10.1016/j.ophtha.2016.01.058.
27. Browning DJ. The prevalence of hydroxychloroquine retinopathy and toxic dosing, and the role of the ophthalmologist in reducing both[J]. Am J Ophthalmol, 2016, 166: ix-xi. DOI: 10.1016/j.ajo.2016.03.044.
28. Kim KE, Ryu SJ, Kim YH, et al. Visual field examinations using different strategies in Asian patients taking hydroxychloroquine[J]. Sci Rep, 2022, 12(1): 14778. DOI: 10.1038/s41598-022-19048-0.
29. Carter KL, Do DV. Hydroxychloroquine-induced retinal toxicity[J]. J Rheumatol, 2020, 47(4): 632. DOI: 10.3899/jrheum.190538.
30. Kim KE, Ahn SJ, Woo SJ, et al. Use of OCT retinal thickness deviation map for hydroxychloroquine retinopathy screening[J]. Ophthalmology, 2021, 128(1): 110-119. DOI: 10.1016/j.ophtha.2020.06.021.
31. Missner S, Kellner U. Comparison of different screening methods for chloroquine/hydroxychloroquine retinopathy: multifocal electroretinography, color vision, perimetry, ophthalmoscopy, and fluorescein angiography[J]. Graefe's Arch Clin Exp Ophthalmol, 2012, 250(3): 319-325. DOI: 10.1007/s00417-011-1753-2.
32. Borrelli E, Battista M, Cascavilla ML, et al. Impact of structural changes on multifocal electroretinography in patients with use of hydroxychloroquine[J]. Invest Ophthalmol Vis Sci, 2021, 62(12): 28. DOI: 10.1167/iovs.62.12.28.
33. Tsang AC, Ahmadi S, Hamilton J, et al. The diagnostic utility of multifocal electroretinography in detecting chloroquine and hydroxychloroquine retinal toxicity[J]. Am J Ophthalmol, 2019, 206: 132-139. DOI: 10.1016/j.ajo.2019.04.025.
34. Molina-Martín A, Piñero DP, Pérez-Cambrodí RJ. Decreased perifoveal sensitivity detected by microperimetry in patients using hydroxychloroquine and without visual field and fundoscopic anomalies[J/OL]. J Ophthalmol, 2015, 2015: 437271[2015-03-12]. https://pubmed.ncbi.nlm.nih.gov/25861463/. DOI: 10.1155/2015/437271.
35. Chen E, Brown DM, Benz MS, et al. Spectral domain optical coherence tomography as an effective screening test for hydroxychloroquine retinopathy (the "flying saucer" sign)[J]. Clin Ophthalmol, 2010, 4: 1151-1158. DOI: 10.2147/opth.S14257.
36. Godinho G, Madeira C, Falcão M, et al. Longitudinal retinal changes induced by hydroxychloroquine in eyes without retinal toxicity[J]. Ophthalmic Res, 2021, 64(2): 290-296. DOI: 10.1159/000511592.
37. Bulut M, Erol MK, Toslak D, et al. A new objective parameter in hydroxychloroquine-induced retinal toxicity screening test: macular retinal ganglion cell-inner plexiform layer thickness[J]. Arch Rheumatol, 2018, 33(1): 52-58. DOI: 10.5606/ArchRheumatol.2018.6327.
38. Gil P, Nunes A, Farinha C, et al. Structural and functional characterization of the retinal effects of hydroxychloroquine treatment in healthy eyes[J]. Ophthalmologica, 2019, 241(4): 226-233. DOI: 10.1159/000495308.
39. Kan E, Yakar K, Demirag MD, et al. Macular ganglion cell-inner plexiform layer thickness for detection of early retinal toxicity of hydroxychloroquine[J]. Int Ophthalmol, 2018, 38(4): 1635-1640. DOI: 10.1007/s10792-017-0635-y.
40. Casado A, López-de-Eguileta A, Fonseca S, et al. Outer nuclear layer damage for detection of early retinal toxicity of hydroxychloroquine[J]. Biomedicines, 2020, 8(3): 54. DOI: 10.3390/biomedicines8030054.
41. Ugwuegbu O, Uchida A, Singh RP, et al. Quantitative assessment of outer retinal layers and ellipsoid zone mapping in hydroxychloroquine retinopathy[J]. Br J Ophthalmol, 2019, 103(1): 3-7. DOI: 10.1136/bjophthalmol-2018-312363.
42. Ahn SJ, Joung J, Lee BR. Evaluation of hydroxychloroquine retinopathy using ultra-widefield fundus autofluorescence: peripheral findings in the retinopathy[J]. Am J Ophthalmol, 2020, 209: 35-44. DOI: 10.1016/j.ajo.2019.09.008.
43. Tarakcioglu HN, Ozkaya A, Yigit U. Is optical coherence tomography angiography a useful tool in the screening of hydroxychloroquine retinopathy?[J]. Int Ophthalmol, 2021, 41(1): 27-33. DOI: 10.1007/s10792-020-01549-4.
44. Ahn SJ, Ryu SJ, Lim HW, et al. Toxic effects of hydroxychloroquine on the choroid: evidence from multimodal imaging[J]. Retina, 2019, 39(5): 1016-1026. DOI: 10.1097/iae.0000000000002047.
45. Ledingham J, Gullick N, Irving K, et al. BSR and BHPR guideline for the prescription and monitoring of non-biologic disease-modifying anti-rheumatic drugs[J]. Rheumatology (Oxford), 2017, 56(6): 865-868. DOI: 10.1093/rheumatology/kew479.
46. Yusuf IH, Ledingham JM, MacPhie E, et al. Monitoring for retinal toxicity in patients taking hydroxychloroquine and chloroquine[J]. Rheumatology (Oxford), 2019, 58(1): 3-4. DOI: 10.1093/rheumatology/key024.
47. Yusuf IH, Foot B, Lotery AJ. The royal college of ophthalmologists recommendations on monitoring for hydroxychloroquine and chloroquine users in the United Kingdom (2020 revision): executive summary[J]. Eye (Lond), 2021, 35(6): 1532-1537. DOI: 10.1038/s41433-020-01380-2.

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