Case of Bull’s-Eye Maculopathy Associated with long term use of hydroxychloroquine

Dr. Yasha S. Modi and Rishi P. Singh, at Cole Eye Institute, Cleveland, OH have reported a rare case of Bull’s-Eye Maculopathy due to Hydroxychloroquine. The case has appeared in the New England Journal of Medicine.

Bull’s eye maculopathy is rare dystrophy, also known as benign concentric annular macular dystrophy (BCAMD). It causes a dartboard, or ring-shaped, a pattern of damage around the macula. This characteristic damage can also be caused by other inherited retinal conditions, or by long-term use of drugs which suppress the immune system as part of treatment for lupus or rheumatoid arthritis. In the present case, it was induced by long term use of hydroxychloroquine.

It describes a number of different conditions in which there is a ring of pale-looking damage around a darker area of the macula. The macula can often appear to have circular bands of different shades of pink and orange. Age of onset and severity of sight loss varies, and it can be inherited in many ways. It appears to be an autosomal dominant condition, which means that any child of a person affected has a 50 per cent chance of inheriting it too

A 60-year-old woman presented to the ophthalmology clinic after noticing central blind spots in the visual fields of both eyes. She had a history of rheumatoid arthritis, which had been treated with hydroxychloroquine at a dose of 400 mg daily for 14 years. The visual acuity was 20/20 in both eyes. The retinal examination showed a bull’s-eye pattern of hypopigmentation in both the right eye (Panel A) and the left eye (Panel B).

Visual-field testing showed ring scotomas, and retinal imaging on optical coherence tomography showed corresponding loss of photoreceptors and retinal pigment epithelium, findings that are consistent with hydroxychloroquine toxicity. Hydroxychloroquine was switched to methotrexate, and 6 months later, the patient’s ocular condition remained stable.