Bull's Eye Maculopathy in Near-Infrared Reflectance as An Early Sign of Hydroxychloroquine Toxicity

Hydroxychloroquine (HCQ) ocular toxicity is rare but severe, and progression can occur even after termination of therapy. Case reports have suggested that a bull's eye maculopathy detected by near-infrared reflectance (NIR) may indicate early HCQ toxicity. This retrospective cross-sectional study evaluated patients treated with HCQ who underwent routine screening with optical coherence tomography (OCT), fundus autofluorescence (FAF) and 10-2 perimetry. NIR images captured alongside OCT were subsequently graded independently by 2 masked graders for the presence of bull's eye maculopathy, and the result was compared to the outcome of the screening. A total of 123 participants (246 eyes) were included, and 101 (90%) were female. The patients' mean age was 55.2 ± 13.8 years. The mean time of HCQ usage was 84.0 ± 72.3 months, and the mean weekly dose was 2327 ± 650 mg. Two eyes showed toxicity in all 3 routine screening exams, with one patient suspending HCQ. The prevalence of bull´s eye lesions in NIR was 13% (33 eyes) with substantial intergrader agreement, a 71.3% specificity and 88.0% negative predictive value for HCQ toxicity. We suggest that NIR changes may be a sign of early HCQ toxicity. The detection of NIR bull´s eye lesions may warrant an increased screening frequency.