What is the next step in managing a patient with seropositive rheumatoid arthritis on methotrexate, hydroxychloroquine, and sulfasalazine who develops blurred vision?

Immediate Ophthalmology Referral for Hydroxychloroquine Retinal Toxicity Evaluation

The next step is to immediately refer this patient to an ophthalmologist for comprehensive retinal screening with spectral-domain optical coherence tomography (SD-OCT) and automated visual field testing to evaluate for hydroxychloroquine-induced retinopathy, while continuing all current RA medications until definitive evidence of retinal toxicity is established. 1

Urgent Ophthalmologic Assessment Required

• Blurred vision in a patient on hydroxychloroquine (HCQ) requires prompt ophthalmologic evaluation with modern screening techniques, specifically SD-OCT and automated visual field testing of the central 10 degrees. 1

• The ophthalmologist should perform best corrected distance visual acuity (BCVA), automated threshold visual field testing, and SD-OCT to detect early anatomic changes in the retina. 1

• OCT retinal scans should be prioritized as the initial screening tool, as anatomic changes are more specific for detecting toxicity than subjective visual field tests. 1

Critical Decision Point: Do NOT Stop HCQ Prematurely

• HCQ should NOT be discontinued based on symptoms alone without definitive evidence of retinopathy from objective testing. 1

• Questionable or borderline findings on initial screening should be rechecked after a few months or the patient sent for retina consultation with additional tests such as multifocal electroretinography or fundus autofluorescence imaging. 1

• The decision to discontinue HCQ must involve shared decision-making between the patient, prescribing rheumatologist, and eye care provider, considering the severity of the rheumatic disease and estimated risk of visual loss if the drug is continued. 1

Risk Assessment for HCQ Retinopathy

Evaluate the following risk factors that increase likelihood of retinal toxicity: 1

• Daily HCQ dosage ≥5 mg/kg of actual body weight (not ideal body weight)
• Duration of use greater than 5 years
• Renal impairment
• Concurrent tamoxifen usage
• Preexisting macular disease
• Total cumulative dose >1000g 2

Alternative Causes of Blurred Vision to Consider

While awaiting ophthalmology evaluation, consider other potential causes of visual symptoms: 3

• Dry eye syndrome/keratoconjunctivitis sicca (most common ocular manifestation in RA patients) 2
• Corticosteroid-induced cataracts or glaucoma (if patient has had prior steroid exposure) 2
• Sulfasalazine-related visual disturbances (rare but possible)
• Methotrexate-related effects (uncommon)
• RA-related ocular inflammation (episcleritis, scleritis) 2

Management Algorithm Based on Ophthalmology Results

If definitive retinal toxicity is confirmed: 1

• Discontinue HCQ immediately
• Continue methotrexate 10mg weekly and sulfasalazine 500mg twice daily
• Optimize current DMARD therapy by increasing methotrexate dose to 15-25mg weekly if tolerated 1, 4
• Consider adding a biologic DMARD (TNF inhibitor, abatacept, tocilizumab, or rituximab) if disease activity remains moderate-to-high after 3-6 months of optimized conventional DMARD therapy 4, 5
• Monitor closely as retinal changes may progress even after HCQ cessation 1

If no retinal toxicity is found: 1

• Continue all three DMARDs (methotrexate, HCQ, sulfasalazine)
• Establish annual ophthalmologic screening with SD-OCT and visual field testing
• Address alternative causes of blurred vision identified during evaluation
• Ensure HCQ dosing does not exceed 5 mg/kg actual body weight 1, 3

Important Caveats

• Fundus examination and ophthalmoscopy alone are NOT adequate screening tools, as photoreceptor damage is detectable with OCT and visual field testing well before visible fundus changes appear. 1

• A "bull's-eye" lesion on fundoscopy indicates advanced, irreversible toxicity—screening aims to detect changes much earlier. 1

• Visual field testing can show considerable test-to-test variation and should not be considered definitive evidence of retinopathy until repeat testing shows a consistent partial or full ring scotoma. 1

• If retinopathy is detected early and HCQ is discontinued, damage can stabilize without serious visual loss. 1