Decrease in Visual Acuity in a 77-Year-old Woman with Age-Related Macular Degeneration after a SARS-CoV-2 Infection Treated with Hydroxychloroquine

Introduction

To date, hydroxychloroquine (HCQ) is a well-established antimalarial and immunomodulatory drug used as a treatment for several autoimmune and infectious diseases including rheumatoid arthritis, lupus erythematosus, and malaria [1], [2]. Recently, HCQ has been used as pre-/postexposure prophylaxis and treatment for the coronavirus disease 2019 (COVID-19) [3], [4], [5], [6]. However, despite the potential antiviral effects and its anti-inflammatory profile, the results based on clinical studies regarding HCQ as a treatment for SARS-CoV-2 are contradictory, and main concerns exist for its efficacy and safety profile [1], [2], [3], [7], [8]. In addition, studies have shown that the benefits of treating SARS-CoV-2 patients are limited and do not seem to outweigh side effects [2], [3], [5], [7]. Thus, the World Health Organization (WHO) no longer recommends HCQ to prevent or treat patients with SARS-CoV-2 [9]. Among common side effects, HCQ can cause gastrointestinal discomfort, headache, and dizziness, but also more severe side effects such as cardiotoxicity and ocular toxicity [1], [3], [6]. Regarding ocular toxicity, manifestations can be corneal deposits, ciliary body dysfunction, posterior subcapsular lens opacity, and retinopathy [10], [11]. Symptoms of an HCQ retinopathy can include blurred vision, loss of night vision, and partial central or peripheral loss of vision [10].

In the last decade, spectral-domain and swept-source optical coherence tomography (SD-OCT and SS-OCT) have been established as noninvasive imaging technologies to assess structural changes of the retina in several ocular diseases and can help to assess the progression of an HCQ retinopathy [12], [13], [14], [15], [16], [17].

As HCQ can deposit in melanin-containing tissues such as the RPE (retinal pigment epithelium), the function of the RPE gets disrupted, leading to a reduction of lysosomal degradation of shed outer segments. With the progression of the disease, a degeneration of RPE as well as a disruption of the ellipsoid zone can result in complete atrophy of the RPE and outer retina (cRORA) [1], [18].

These changes are visible in SD-OCT. The disruption of the ellipsoid zone and the loss of the outer nuclear layer (ONL) [11], [19] cause a collapse of the parafoveal retina, which can lead to a “flying saucer” appearance of the fovea [20]. These structural changes in the outer retina usually correlate with functional changes shown in multifocal electroretinograms (mERGs) and changes in the visual field [10], [11].

Geographic atrophy (GA), as a subset manifestation of cRORA, can appear as a sign of advanced age-related macular degeneration (AMD), causing irreversible vision loss without any treatment possibility known to date. The growth rate of GA plays a key role in determining the prognosis of a patient with AMD. Regarding the progression of GA, previous studies have shown that outer retinal tubulations (ORTs) could be associated with a slower progression of GA.

Autofluorescence (AF) or scanning laser ophthalmoscopy (SLO) en face images are used to measure GA at baseline and at each follow-up visit to determine a growth rate per year or more years. The literature describes growth rates of GA between 1.78 and 6.4 mm² over 5 years and growth rates of 1.52, 1.61, and 2.2 mm² per year [21], [22].

In this case, we aimed to present a case of a 77-year-old woman with a diagnosis of advanced dry AMD who experienced a drop in her visual acuity (VA) after she had a SARS-CoV-2 infection, and was treated with HCQ. GA in SLO en face OCT images were used to measure the progression of GA within 7 years (follow-up).

Publikationsverlauf

Eingereicht: 27. September 2021

Angenommen: 06. Februar 2022

Artikel online veröffentlicht:
26. April 2022

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