Chloroquine and Oculotoxicity

The use of 4-aminoquinolines is generally considered contraindicated in the presence of retinal or visual field changes, whether attributable to 4-aminoquinoline compounds or to any other etiology. However, in the treatment of acute attacks of malaria caused by susceptible strains of plasmodia, these agents may be considered if potential benefits are anticipated to outweigh the risks. 4-aminoquinolines are oculotoxic and can cause dose-related, irreversible retinal damage and vision loss during and up to several years after long-term or high-dose therapy (e.g., in the treatment of systemic lupus erythematosus or rheumatoid arthritis). Ophthalmologic monitoring, including visual acuity, expert slit-lamp, funduscopic, and visual field tests, is recommended at baseline and every three months during prolonged use. Therapy should be discontinued immediately if abnormalities develop in visual acuity, visual field, or retinal macular areas (e.g., pigmentary changes, loss of foveal reflex), or if the patient experiences visual symptoms such as light flashes and streaks that are not fully explainable by difficulties of accommodation or corneal opacities. Other common symptoms that may indicate retinopathy include nyctalopia, photophobia, blurred distance vision, difficulty reading or seeing (e.g., words or letters disappearing or parts of objects missing; misty vision; fog before the eyes), and missing or blacked out areas in the central or peripheral visual field. Retinal changes and visual disturbances may progress even after cessation of therapy. However, in a number of patients, early retinopathy (macular pigmentation sometimes with central field defects) diminished or regressed completely after therapy was discontinued. Paracentral scotoma to red targets, sometimes termed PREMACULOPATHY, is indicative of early retinal dysfunction and is usually reversible with cessation of therapy.