E003 A quality improvement project looking into retinopathy screening for patients taking hydroxychloroquine at the Princess of Wales Hospital
Authors: Anjum Aqeel Maqsood , Safdar Saqib , Duffill Suzanne , Jenkins Charlotte , Smale Shaun , Srinivasan Usha 
Published: April 2024

Abstract

Background/Aims
Hydroxychloroquine (HCQ) is widely used in various rheumatic and dermatological conditions and the risk of associated retinal toxicity is more common than previously considered; an overall prevalence of 7.5% in patients taking HCQ for greater than 5 years, rising to 20 to 50% after 20 years of treatment. The Royal College of Ophthalmologists (RCOphth) revised guidelines (2020) advise annual monitoring of all patients for retinopathy who have taken HCQ for &gt; 5 years. Patients with additional risk factors for retinal toxicity may be monitored annually after the initiation of therapy.

Methods
We reviewed relevant medical records of all the rheumatology patients at Princess of Wales Hospital (POWH) on HCQ from January 2017 to February 2022. Data was collected to include patient demographics and diagnosis, duration on HCQ, whether retinopathy referral was indicated and requested and whether these patients were subsequently seen in the ophthalmology clinic.

Results
In total we identified 216 patients, and the median age was 60 (range 27-96). All patients had been informed of potential associated retinopathy and were advised to undergo annual assessment by an optician. 60 of these 216 patients had stopped HCQ for various reasons while 156 remained on it. 79 of these 156 were eligible for referral as per the revised RCOphth guidelines as they had received treatment for at least 5 years. 40 of these 79 were referred to ophthalmology and 15 had been reviewed by the ophthalmology service. None of these 15 patients, however, have had further annual ophthalmology reviews after initial assessment. 39 patients had not been referred to ophthalmology despite being on hydroxychloroquine for more than 5 years. If those at high risk are considered, a further 30 of these 156 patients would be eligible for referral. 14 out of these 30 had been referred and none had yet been seen by ophthalmology.

Conclusion
Using the criteria defined by the revised guidance, approx. 50% of eligible patients had been referred to ophthalmology; 33% of patients have undergone review. Potential reasons for poor adherence to the RCOphth guidelines would likely include the significant changes in guidelines issued in 2017, 2018 and 2020, lack of resources to cope with additional demand in the ophthalmology service and the COVID-19 pandemic which has resulted in significant delays in outpatient services. Following this project, all eligible patients have been referred to ophthalmology and the findings were shared with the dermatology service who are now undertaking a similar audit project. Given the updated referral criteria, we intend to implement a standard referral proforma to ensure all those at risk of retinopathy are identified and will work closely with ophthalmology colleagues to address how best to improve waiting times for such patients to undergo full assessment.

Disclosure
A. Anjum: None. S. Safdar: None. S. Duffill: None. C. Jenkins: None. S. Smale: None. U. Srinivasan: None.