She suffered from Sjogren syndrome and inflammatory arthritis and was currently treated with prednisone and methotrexate. She was previously treated with hydroxychloroquine (Plaquenil) 200mg bid (6.5mg/kg) for 10 years, which was stopped one year prior to presentation. Plaquenil and double vision Chloroquine diphophate salt Alopecia with plaquenil Rheumatologists use hydroxychloroquine sulfate Plaquenil, Concordia Pharmaceuticals to treat autoimmune diseases, namely discoid or systemic lupus erythematosus, rheumatoid arthritis, Sjögren syndrome, and malaria. When taken at high doses and for long durations, hydroxychloroquine has been known to cause parafoveal retinal toxicity. The changes are most often permanent, but in some cases, vision has improved. Most rheumatologists recommend patients undergo a baseline eye examination prior to starting Plaquenil and be re-examined in the future depending on their risk for developing the condition. Risk factors include advanced age and having pre-existing retinal disease. The current maximum daily HCQ dose recommended by the AAO is 5 mg/kg of real weight. The 2011 guidelines suggested a maximum dose of 6.5 mg/kg of ideal weight. The biggest difference between the. Review of systems: Blurred vision, halos, dry eye, dry mouth, gastroesophageal reflux, joint pain Pupils: Reactive to light in each eye from 5 mm in the dark to 2 mm in the light. Extraocular movements: Full, both eyes (OU) Confrontation visual fields: Full OU Intra-ocular pressure The optic nerves appeared healthy with a 0.3 cup-to-disc ratio. Past Ocular History: None Medical History: Sjogren syndrome and inflammatory arthritis, supraventricular tachycardia, anxiety, depression, peptic ulcer disease Medications: prednisone, methotrexate, amitriptyline, ranitidine, estradiol, tizanidine, diltiazem, Restasis Allergies: codeine, droperidol Family History: heart disease, arthritis, cancer Social History: occasional alcohol but no tobacco or intravenous drug use. Plaquenil retinal testing guidelines My Take on New Ocular Screening Guidelines for Plaquenil., Plaquenil Side Effects on Your Eyes and Vision Desethyl chloroquineStopping plaquenil beforesurgeryVisual defects hydroxychloroquinePlaquenil evaluation eyesWhat are side effects of hydroxychloroquine Bull’s Eye Retinopathy Early macular toxicity can cause stippling or mottling of the RPE Next, granular pigmentation and loss of the normal foveal reflex can occur It’s believed but not proven that if early macular changes are detected and the medication is stopped, any toxicity that has occurred can be reversed.1 If the maculopathy continues to progress, concentric zones of. Early Plaquenil Toxicity Detected without Bull’s Eye.. Despite Plaquenil dosing recommendations, retinal toxicity.. Hydroxychloroquine And Chloroquine Screening 2016 AAO.. If any abnormality is detected by Humphrey 10-2 testing or retinal examination, follow up 62 with the previously mentioned objective testing is imperative. 63 64 If toxicity is suspected or demonstrated, ideally the HCQ should be stopped. Newer guidelines state that daily dose 5mg/kg of real weight/day can lead to toxicity. Retinal toxicity is irreversible and can progress after cessation of hydroxychloroquine, thus early screening is important to limit potential vision loss. Baseline screening and annual screening after five years is recommended. In particular, chloroquine and hydroxychloroquine Plaquenil are two such medications, with the potential for retinal toxicity. Given that the retinal damage from these medications is largely irreversible, screening by a retinal specialist is critical to detect early retinal toxicity to try and limit the extent of visual loss.