Evaluating adherence to AAO hydroxychloroquine screening guidelines

• Excessive testing observed in early hydroxychloroquine therapy. • Missed screenings noted in long-term hydroxychloroquine users. • Study underscores the need for improved guideline adherence. • Real body weight should be used for hydroxychloroquine dosing. • Collaboration between ophthalmologists and rheumatologists is crucial. Hydroxychloroquine (HCQ) is commonly prescribed for autoimmune disorders but carries a risk of retinal damage, which increases over time. The American Academy of Ophthalmology (AAO) issued updated guidelines in 2016 to optimize screening for HCQ retinopathy, recommending dosing based on real body weight and specific visual field (VF) testing patterns. This study aimed to assess adherence to the AAO guidelines for HCQ retinopathy screening in a clinical setting and to identify deviations in the implementation of these guidelines. We employed a large, single-center retrospective case series study design. We conducted a retrospective analysis of 391 patients treated with HCQ at a single academic center from 2017 to 2019. The study focused on the appropriateness of screening tests, specifically optical coherence tomography (OCT) and VF testing, based on the duration of HCQ therapy. Our analysis showed that over-testing with OCT and VF was prevalent among patients on HCQ for five years or less, occurring in 56% and 48% of encounters, respectively. Conversely, there were missed screenings in patients on HCQ for more than five years, with 12% and 16% of encounters lacking OCT and VF testing, respectively. Notably, adherence to VF testing guidelines for Asian patients was poorly implemented, with the recommended wide pattern VF testing conducted in only two of nine cases. Additionally, there were significant instances where HCQ dosages exceeded recommended levels without subsequent adjustments, despite ophthalmologists' recommendations. The study highlights a critical need for improved guideline adherence to prevent unnecessary testing costs and undetected retinopathy in long-term HCQ users. It underscores the importance of using real body weight for dosing decisions and enhancing collaboration between ophthalmologists and rheumatologists to manage the delicate balance between disease control and the risk of retinopathy. Further multi-center studies are warranted to evaluate adherence variations and develop strategies for guideline implementation. This study assesses adherence to the 2016 AAO guidelines for HCQ retinopathy screening. Findings reveal excessive testing in early therapy and occasional missed screenings in long-term users, highlighting the need for guideline compliance.