Mircoperimetric Sensitivity in Patients on Plaquenil Therapy
Mircoperimetric Sensitivity in Patients on Plaquenil Therapy
The mean age of the patients was 54.5±10.3 years (range, 37–76 years) with 15 female subjects and 1 male subject. Twelve (75%) of the subjects were African American, 3 (19%) were Hispanic, and 1 (6%) was Asian. Of the 16 patients with a history of Plaquenil usage, 11 had a diagnosis of SLE, 4 with RA, and 1 with dermatomyositis ( Table 1 ). The mean age of the visually normal control subjects was 53.4±11.9 years (range, 31–65 years). The mean age of the patients did not differ significantly from that of the controls (P=0.81).
The duration of Plaquenil exposure ranged from 5–25 years (median, 11 years). The average maximum daily dose for the study population was 4 mg/kg/day (range, 1.77–6.67 mg/kg/day) with an average cumulative dose of 1485 g (range, 255–3650 g). The BCVA ranged from −0.07 to 0.15 logMAR (Snellen acuity equivalent of20/20 to 20/25). The funduscopic exam was normal in all subjects, as were the results from color vision testing. The 10–2 HVF results were graded by three authors independently (MAG, CCC, and RVJ). There was no evidence of retinopathy based on the pattern deviation maps, but, overall sensitivity was reduced slightly for the patients based on the mean deviation value. One patient had scattered outer rim defects on her visual field that were considered to be within the normal range. Both FAF and SD-OCT exams, graded by the retina specialists independently (MAG, CCC, and WFM), showed normal autofluorescence and retinal structures and thickness, respectively. Two patients were noted to have few extrafoveal drusen outside the Polar 3 test grid, on FAF and SD-OCT that correlated with their funduscopic exams. Of the 14 patients who underwent mfERG testing, a qualitative analysis of the results indicated that all had a normal waveform shape ( Table 2 ).
The overall mean sensitivity values for the right eye (15.0±1.1 dB) and left eye (14.6±1.2 dB) of the 15 patients who had measurements in both eyes were not significantly different (t=0.87, P=0.40). Consequently, data from the left eye were converted to right eye format and the data from the two eyes of each patient were averaged. All further analysis was based on the mean sensitivity value of the two eyes. The microperimetry sensitivity data are shown in Figure 1 for the controls (open circles) and the patients (filled circles). The bars represent the 5th and 95th percentiles for the controls (dark bars) and the patients (light bars), and the horizontal lines indicate the mean for each group. A three-way ANOVA indicated a significant difference (P<0.001) only for the main effect of subject group (overall mean sensitivities of 16.5±2.1 and 14.7±1.9 dB for the controls and patients, respectively). The overall microperimetry value was below the 5th percentile of the controls for 5 of the 16 patients (first set of bars in Figure 1). For the inner ring (second set of bars), the microperimetry value for each patient fell within the 5th and 95th percentiles of the controls. For the middle ring (third set of bars), six patients were below the 5th percentile of the controls, and three patients were below the 5th percentile for the outer ring (fourth set of bars). Bonferroni-corrected follow-up comparisons indicated that the mean sensitivity values within the inner (Figure 1: second pair of bars), middle (Figure 1: third pair of bars), and outer (Figure 1: fourth pair of bars) rings were significantly less for the patients, as compared with the controls (P=0.001, P=0.004, P=0.003, for the inner, middle, and outer rings, respectively). The sensitivity values for the patients did not significantly differ at the three eccentricities (mean sensitivities of 15.8±2.3, 15.7±1.9, and 14.9±2.3 dB for the inner, middle, and outer rings, respectively) or among the retinal locations within a ring.
(Enlarge Image)
Figure 1.
Mean sensitivity for the control subjects (open circles) and patients (filled circles) for the overall mean and each of the three rings. The bars represent the 5th and 95th percentiles, and the horizontal bars represent the mean for each group.
The overall mean thickness for right eye (281.0±14.2 μm) and left eye (279.6±24.3 μm) of the 15 patients who had measurements in both eyes was not significantly different (t=0.34, P=0.74). Consequently, data from the left eye were converted to right eye format and the data from the two eyes of each patient were averaged. The overall mean thickness of the controls (287.2±14.0 μm) was not significantly different from that of the patients (280.3±18.3 μm) (P=0.32). Bonferroni-corrected follow-up comparisons indicated that the mean thickness values within the inner, middle, and outer rings were not significantly different for the patients, as compared with the controls (P=0.17, P=0.07, P=0.99, for the inner, middle, and outer rings, respectively).
Figures 2 and 3 summarize the OCT, microperimetry, HVF pattern deviation, and FAF results for two representative patients.
(Enlarge Image)
Figure 2.
Test results of a 60-year-old Hispanic female on Plaquenil for 6 years for treatment of dermatomyositis (maximum daily dose of 4.63 mg/kg/day and cumulative dose of 876 g, BCVA 20/20). (a) Microperimetry Polar 3 test grid superimposed on the scanning laser ophthalmoscope infrared image showing reduced mean retinal sensitivity (13.4 dB). Small white crosses indicate fixation. (b) Corresponding spectral-domain optical coherence tomography thickness at each of the 28 Polar 3 tested points shows no retinal thinning. (c) Automated 10–2 Humphrey visual field shows a normal pattern deviation. (d) Fundus autofluorescence shows no retinal pigment epithelium abnormalities. (e) Spectral-domain optical coherence tomography B-scan image shows normal retinal thickness and an intact inner segment–outer segment junction of the photoreceptors.
(Enlarge Image)
Figure 3.
Test results of a 59-year-old African American female with a 17-year history of Plaquenil use for treatment of rheumatoid arthritis (maximum daily dose of 6.77 mg/kg/day and cumulative dose of 2482 g, BCVA 20/20). (a) Microperimetry Polar 3 test grid superimposed on the scanning laser ophthalmoscope infrared image showing reduced mean retinal sensitivity (14.1 dB). (b) Corresponding spectral-domain optical coherence tomography thickness at each of the 28 Polar 3 tested points shows no retinal thinning. (c) Automated 10–2 Humphrey visual field shows a normal pattern deviation. (d) Fundus autofluorescence shows no retinal pigment epithelium abnormalities. (e) Spectral-domain optical coherence tomography B-scan image shows normal retinal thickness and an intact inner segment–outer segment junction of the photoreceptors.
Results
Demographic Characteristics
The mean age of the patients was 54.5±10.3 years (range, 37–76 years) with 15 female subjects and 1 male subject. Twelve (75%) of the subjects were African American, 3 (19%) were Hispanic, and 1 (6%) was Asian. Of the 16 patients with a history of Plaquenil usage, 11 had a diagnosis of SLE, 4 with RA, and 1 with dermatomyositis ( Table 1 ). The mean age of the visually normal control subjects was 53.4±11.9 years (range, 31–65 years). The mean age of the patients did not differ significantly from that of the controls (P=0.81).
The duration of Plaquenil exposure ranged from 5–25 years (median, 11 years). The average maximum daily dose for the study population was 4 mg/kg/day (range, 1.77–6.67 mg/kg/day) with an average cumulative dose of 1485 g (range, 255–3650 g). The BCVA ranged from −0.07 to 0.15 logMAR (Snellen acuity equivalent of20/20 to 20/25). The funduscopic exam was normal in all subjects, as were the results from color vision testing. The 10–2 HVF results were graded by three authors independently (MAG, CCC, and RVJ). There was no evidence of retinopathy based on the pattern deviation maps, but, overall sensitivity was reduced slightly for the patients based on the mean deviation value. One patient had scattered outer rim defects on her visual field that were considered to be within the normal range. Both FAF and SD-OCT exams, graded by the retina specialists independently (MAG, CCC, and WFM), showed normal autofluorescence and retinal structures and thickness, respectively. Two patients were noted to have few extrafoveal drusen outside the Polar 3 test grid, on FAF and SD-OCT that correlated with their funduscopic exams. Of the 14 patients who underwent mfERG testing, a qualitative analysis of the results indicated that all had a normal waveform shape ( Table 2 ).
Microperimetry Data
The overall mean sensitivity values for the right eye (15.0±1.1 dB) and left eye (14.6±1.2 dB) of the 15 patients who had measurements in both eyes were not significantly different (t=0.87, P=0.40). Consequently, data from the left eye were converted to right eye format and the data from the two eyes of each patient were averaged. All further analysis was based on the mean sensitivity value of the two eyes. The microperimetry sensitivity data are shown in Figure 1 for the controls (open circles) and the patients (filled circles). The bars represent the 5th and 95th percentiles for the controls (dark bars) and the patients (light bars), and the horizontal lines indicate the mean for each group. A three-way ANOVA indicated a significant difference (P<0.001) only for the main effect of subject group (overall mean sensitivities of 16.5±2.1 and 14.7±1.9 dB for the controls and patients, respectively). The overall microperimetry value was below the 5th percentile of the controls for 5 of the 16 patients (first set of bars in Figure 1). For the inner ring (second set of bars), the microperimetry value for each patient fell within the 5th and 95th percentiles of the controls. For the middle ring (third set of bars), six patients were below the 5th percentile of the controls, and three patients were below the 5th percentile for the outer ring (fourth set of bars). Bonferroni-corrected follow-up comparisons indicated that the mean sensitivity values within the inner (Figure 1: second pair of bars), middle (Figure 1: third pair of bars), and outer (Figure 1: fourth pair of bars) rings were significantly less for the patients, as compared with the controls (P=0.001, P=0.004, P=0.003, for the inner, middle, and outer rings, respectively). The sensitivity values for the patients did not significantly differ at the three eccentricities (mean sensitivities of 15.8±2.3, 15.7±1.9, and 14.9±2.3 dB for the inner, middle, and outer rings, respectively) or among the retinal locations within a ring.
(Enlarge Image)
Figure 1.
Mean sensitivity for the control subjects (open circles) and patients (filled circles) for the overall mean and each of the three rings. The bars represent the 5th and 95th percentiles, and the horizontal bars represent the mean for each group.
SD-OCT Data/Thickness Map
The overall mean thickness for right eye (281.0±14.2 μm) and left eye (279.6±24.3 μm) of the 15 patients who had measurements in both eyes was not significantly different (t=0.34, P=0.74). Consequently, data from the left eye were converted to right eye format and the data from the two eyes of each patient were averaged. The overall mean thickness of the controls (287.2±14.0 μm) was not significantly different from that of the patients (280.3±18.3 μm) (P=0.32). Bonferroni-corrected follow-up comparisons indicated that the mean thickness values within the inner, middle, and outer rings were not significantly different for the patients, as compared with the controls (P=0.17, P=0.07, P=0.99, for the inner, middle, and outer rings, respectively).
Figures 2 and 3 summarize the OCT, microperimetry, HVF pattern deviation, and FAF results for two representative patients.
(Enlarge Image)
Figure 2.
Test results of a 60-year-old Hispanic female on Plaquenil for 6 years for treatment of dermatomyositis (maximum daily dose of 4.63 mg/kg/day and cumulative dose of 876 g, BCVA 20/20). (a) Microperimetry Polar 3 test grid superimposed on the scanning laser ophthalmoscope infrared image showing reduced mean retinal sensitivity (13.4 dB). Small white crosses indicate fixation. (b) Corresponding spectral-domain optical coherence tomography thickness at each of the 28 Polar 3 tested points shows no retinal thinning. (c) Automated 10–2 Humphrey visual field shows a normal pattern deviation. (d) Fundus autofluorescence shows no retinal pigment epithelium abnormalities. (e) Spectral-domain optical coherence tomography B-scan image shows normal retinal thickness and an intact inner segment–outer segment junction of the photoreceptors.
(Enlarge Image)
Figure 3.
Test results of a 59-year-old African American female with a 17-year history of Plaquenil use for treatment of rheumatoid arthritis (maximum daily dose of 6.77 mg/kg/day and cumulative dose of 2482 g, BCVA 20/20). (a) Microperimetry Polar 3 test grid superimposed on the scanning laser ophthalmoscope infrared image showing reduced mean retinal sensitivity (14.1 dB). (b) Corresponding spectral-domain optical coherence tomography thickness at each of the 28 Polar 3 tested points shows no retinal thinning. (c) Automated 10–2 Humphrey visual field shows a normal pattern deviation. (d) Fundus autofluorescence shows no retinal pigment epithelium abnormalities. (e) Spectral-domain optical coherence tomography B-scan image shows normal retinal thickness and an intact inner segment–outer segment junction of the photoreceptors.
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