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 kidney stones Hydroxychloroquine 200 mg tab tablet The number of reported cases of likely toxicity begins to increase sharply after approximately 5 years of use. 10 A cumulative dose of 1000 g HCQ is reached in 7 years with a typical daily dose of 400 mg, and a cumulative dose of 460 g CQ is reached in 5 years with a typical daily dose of 250 mg. Although the incidence of macular toxicity is infrequent with Plaquenil use at a dosage of 200mg or 400mg q.d. its visual impact can be devastating. 2,3. The associated classic retinal toxicity is described as a bull’s eye maculopathy ring of depigmented retinal pigment epithelium that spares the foveal area. A cumulative dose of 1000g of hydroxychloroquine or 460g of chloroquine was likely the largest risk factor, which was typically achieved after 5-7 years of a typical dosage 8, 10. However, there have been case reports of patients with hydroxychloroquine toxicity as early as 1.9 months after starting treatment 11. 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. Chloroquine maculopathy cumulative dose H35.381-383 Toxic Maculopathy Of Retina - Decision-Maker PLUS, New Plaquenil Guidelines Plaquenil for scalpPlaquenil macular toxicityChloroquine and prime Cumulative dose 1000 g total HCQ 460 g total CQ Daily Dose Hydroxychloroquine HCQ Chloroquine CQ 400 mg/day 6.5 mg/kg ideal body weight for short individuals 250 mg/day 3.0 mg/kg ideal body weight for short individuals Age Elderly Systemic disease Kidney or liver dysfunction Ocular disease Retinal disease or maculopathy Early Plaquenil Toxicity Detected without Bull’s Eye.. Hydroxychloroquine Plaquenil Toxicity and.. Long-term continuation of chloroquine-induced retinal.. Feb 27, 2019 The retinopathy is related to the total cumulative dose and is more marked with chloroquine. Patients present with decreased vision which may be severe in end-stage chloroquine maculopathy - less than 6/60 - and characterised by a 'bull's-eye' macular lesion a well-defined red centre surrounded by a mottled yellow periphery, abnormal colour. The study reads “One often cited side effect is chloroquine retinopathy, which can result in permanent vision loss after high cumulative doses of chloroquine. “However, retinal damage is extremely. A cumulative dose of 1000g HCQ is reached in 7 years with a typical daily dose of 400 mg. In the same study, toxicity was not related to age, weight or daily dose but was related to duration of use and increased rapidly after 5 to 7 years; thus, it is important to be aware of the risk factors and use more effective protocols of screening on all the patients who exceed 5 years of exposure.