Hydroxychloroquine Toxicity with Short Duration of Hydroxychloroquine Use and Unilateral Bull's Eye Maculopathy

To report the examination and multimodal imaging findings of a patient with unilateral bull's eye maculopathy.

A retrospective chart review of a 77-year-old patient with unilateral bull's eye maculopathy who presented to a tertiary retinal practice was performed. The patient's history, visual acuity, examination and multimodal imaging findings over five years of follow-up were described.

This 77-year-old Japanese female initially presented with decreased vision in the right eye that had been gradually progressive over years. She had a history of rheumatoid arthritis for which she was initially prescribed hydroxychloroquine 200mg for a five-year period over 20 years prior to presentation. Visual acuity at presentation was 20/30 OD and 20/25 OS with correction. Macular examination and optical coherence tomography revealed a striking bull's eye pattern with a parafoveal ring of atrophy OD, but only subtle and questionable retinal pigment epithelial alterations OS. Fundus autofluorescence did not disclose any abnormalities in the left eye, but the right eye showed a classic bull's eye pattern, with preservation of foveal autofluoresence, a parafoveal hypoautofluorescent ring, and a surrounding outer border of hyperautofluorescence. Follow-up after 5 years showed a stable posterior segment examination.

We report a case of unilateral bull's eye maculopathy after only a short duration of hydroxychloroquine use. While ocular screening of patients receiving hydroxychloroquine is important, retinal toxicity with a low dose and short duration of use remains rare. Clinicians must retain a broad differential diagnosis in the assessment of patients with bull's eye maculopathy.