Michael Easterbrook

Ocular effects and safety of antimalarial agents

The clinical experiences with 1,500 patients receiving chloroquine or hydroxychloroquine over a 15-year period are reviewed. Forty-six patients with confirmed irreversible, bilateral, early chloroquine retinopathy have been followed prospectively since 1980. Patients presenting with normal color vision and relative paracentral scotomas appear not to progress over short-term follow-up of five years. Retinopathy in patients presenting with less than 20/20 vision, abnormal color vision, and positive fluorescein angiography may progress even if treatment with the medication is discontinued. The Amsler grid is an effective method of screening patients taking antimalarial agents for early relative paracentral scotomas. Color vision testing and fluorescein angiography are useful in elderly patients with age-related macular disease when visual field testing is unreliable.

The Ocular Safety of Hydroxychloroquine

The insert currently supplied with hydroxychloroquine states that patients should have an initial ophthalmological assessment and then regular assessments every 3 months. The rheumatologist should expect a report from the ophthalmologist, which includes a corneal assessment of tissue dose, a reference to visual field defects if present on the Amsler grid, and a comment concerning the status of the patients color vision. Daily dose is more important than duration of dose, regarding maculopathy. The visual prognosis of retinopathy is excellent if the diagnosis is made at an early stage of the disease. This report suggests that ophthalmological review need only occur initially and on a yearly basis if the daily dose of hydroxychloroquine is less than 6.5 mg/kg/d and the duration of therapy is less than 9 years.

Eye Injuries in Athletics and Recreation

Sports-related eye injuries represent a significant eye health hazard worldwide. In the USA, it is estimated that eye injuries from sports account for more than 100,000 physician visits per year at the cost of greater than

Detection of color vision defects in chloroquine retinopathy1

175 million. The sports responsible for the greatest number of injuries are baseball, ice hockey, and racquet sports. In the USA there are over 189 million participants in these sports with a disproportionate number (one-third) of injuries involving the pediatric population. The most common injuries are abrasions and contusions, followed by more serious injuries, including hyphema. Substantial reduction in the incidence of eye injuries through prevention has been demonstrated in the sport of hockey which can serve as a model for other sports. Specific criteria for protective eyewear must be developed. Polycarbonate plastic lenses and frames which are sturdy and impact resistant provide optimal protection. Lensless goggles, street wear and spectacle correction glasses do not provide adequate eye protection. The ophthalmologists role in preventing sports-related eye injuries includes addressing particular sports participants needs, identifying one-eyed athletes, and informing patients of the need for protective eyewear.

The Use of Amsler Grids in Early Chloroquin Retinopathy

OBJECTIVE The effect of chloroquine toxicity on color vision is unclear. The authors identified the color defects seen in chloroquine retinopathy and determined the sensitivity and specificity of clinical color vision tests for detecting the presence of previously diagnosed chloroquine retinopathy. DESIGN Case-control study. PARTICIPANTS Chloroquine retinopathy was defined using previously published criteria. Data from 30 patients with retinopathy and 25 patients using chloroquine but with no evidence of retinal toxicity were collected. METHODS All patients were tested with the following six clinical color vision tests: Ishihara, Farnsworth D-15, and Adams Desaturated-15 (Dsat-15), City University 2nd Edition (CU), Standard Pseudoisochromatic Plates Part 2 (SPP-2), and American Optical Hardy Rand Rittler (AO HRR). MAIN OUTCOME MEASURES The number of failures was determined for each test. The types of color vision defects were classified as blue-yellow (BY), red-green (RG), or mixed RG and BY (mixed). RESULTS Of the 30 patients with retinopathy, 28 (93.3%) of 30 patients failed at least 1 color vision test, demonstrating predominantly mixed defects. Five (25%) of 25 of the control subjects failed at least 1 test, and these defects were predominantly BY. The sensitivity and specificity of the tests are as follows: SPP-2 (93.3%, 88%), AO HRR (76.7%, 88%), Ishihara (43.3%, 96%), Dsat-15 (33.3%, 84%), D-15 (16.7%, 96%), and CU (20%, 92%). CONCLUSIONS Color vision can be affected by chloroquine and should be tested routinely with a color vision test designed to detect both mild BY and protan RG defects to maximize sensitivity for toxicity. The SPP-2 and AO HRR are two tests that meet these criteria. The Ishihara has a low sensitivity, as do the D-15 tests and CU. All of the tests have similar specificity for chloroquine toxicity. If color vision defects are detected in patients at risk of developing chloroquine retinopathy, additional testing is indicated to rule out toxicity.

Eye Injuries in Squash and Racquetball Players: An Update

A survey of Canadian ophthalmologists and rheumatologists suggests that there is a significant incidence of definite chloroquine retinopathy in their patients. As hydroxychloroquine and chloroquine appear to be better tolerated and less toxic than some other drugs used in the treatment of rheumatoid arthritis and systemic lupus erythematosus, there is a need for a simple, patient-administered test for early diagnosis of chloroquine retinopathy. The Amsler grid and smaller Yannuzzi modified Amsler grid are simple, inexpensive, and correlate well with scotomas found with static and kinetic perimetry.

Eye Injuries in Racket Sports: A Continuing Problem

In brief From the summer of 1978 to May 1981 there were 154 eye injuries from squash and 91 from racquetball reported to the eye surgeons of Canada. The ball caused 90% of the most serious racquetball injuries and 67% of those in squash. Fifty-two players reported eye injuries that occurred while wearing open eye guards. Only two injuries occurred involving protectors with plastic in front of the eye. Players who wear prescription lenses are particularly at risk during play, because the glasses cannot withstand balls and rackets traveling at speeds of up to 127 mph.

Eye Protection in Racket Sports: An Update.

In brief: Hyphema was the most common serious injury in this review of 67 squash and 18 racquetball eye injuries. Several patients had corneal lacerations and retinal detachments, and many had lid contusions, small lacerations, and subconjunctival hemorrhages. Eight sustained severe loss of vision. Open eye guards did not protect all players who wore them, and all types of prescription lenses were breakable. Since these patients had several years of experience, competitive players may be at higher risk. Carefully chosen eye guards and defensive playing could solve much of the problem.

Eye Protection for Squash and Racquetball Players

In brief: A growing number of eye injuries in squash and racquetball in the late 1970s triggered research on eye protectors for these sports. The investigations showed that lensless eye guards were ineffective and that the frames of some lensed eye guards shattered when hit by a ball. Subsequently, Canadian and US organizations set standards for eye guards, requiring that the devices protect the eye from a ball traveling at 90 mph. Seven commercially available eye guards now meet the Canadian or US standard or both. Polycarbonate is the best lens material for eye guards. There is no substitute for approved eye guards; neither experience nor ordinary prescription glasses nor lensless eye guards provide good protection.

Getting patients to protect their eyes during sports

In brief: The author discusses 19 ocular injuries in squash and racquetball players who wore eye guards with an opening between the upper and lower rim. The more recently developed eye guards that protect the eye with thick plastic should prevent direct injury from rackets or balls.