Novel ERG for Detection of Hydroxychloroquine Retinopathy

Study Overview
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Brief Summary
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The purpose of the study is to investigate novel electroretinography (ERG) devices in the detection of hydroxychloroquine retinopathy. Two devices (the RETEval full-field and flicker ERG and UTAS multifocal ERG) will be evaluated in this study, comparing device outputs to standard of care screening tests, in groups of participants characterised by presence or absence of hydroxychloroquine-related retinopathy.

Detailed Description
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Hydroxychloroquine (HCQ) is a widely used drug used to treat disorders of inflammation in the body with up to 320,000 people estimated to be on this drug in the UK alone. Retinopathy due to HCQ is a significant problem, necessitating yearly screening which can only realistically take place in hospital eye units where funding and capacity constraints limit the provision of services. Electroretinography is a non-invasive method of testing for eye retinal problems, which works by flashing light (in certain patterns and brightness) into eyes and measuring the electrical response through fine wires placed on the eye surface or behind the eyelid, and is considered by many authors to be a gold-standard test to detect HCQ retinopathy. Their use has been limited due to the high expertise required to undertake and interpret tests, limited availability of testing, and high test burden, however newer electroretinography devices have been developed by a company called LKC Technologies, which are faster to perform, use leads placed on the skin (rather than the eye surface) which are more comfortable, easier to use by healthcare technicians, and can be done without the need for dilating eyedrops. The two devices being tested in this study are: The RETEval = a handheld electroretinography testing device The UTAS multifocal ERG = a trolley-mounted electroretinography testing device These innovations may make testing far easier to develop in both hospital eye service, and potentially even general settings such as outpatient clinics, general practices, and optometrists. This study aims to evaluate the performance of devices to detect and classify participants in 4 main groups: Normative control participants (n=35) Patients taking HCQ but without retinopathy (n=35) Patients taking HCQ with indeterminate features of retinopathy (also known as POSSIBLE retinopathy) (n=35) Patients taking HCQ with definite retinopathy Device outputs will be analysed and compared with masked graded screening results (incorporating spectral-domain macular optical coherence tomography and autofluorescence as standard, taken on the same visit) to generate device- and device-output-specific sensitivities and specificities. If a signal is found, the feasibility outcomes from this study will inform the study methodology and timelines for a larger trial if necessary.

Official Title
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A Feasibility Study Using Novel, Portable Electroretinography Devices to Detect Hydroxychloroquine Retinopathy

Conditions
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Hydroxychloroquine Retinopathy

Intervention / Treatment
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* Diagnostic Test: Hand-Held Full-Field Skin-Electrode Electroretinography (Device to be evaluated)
* Diagnostic Test: Trolley-Mounted Multifocal Skin-Electrode Electroretinography (Device to be evaluated)
* Diagnostic Test: Spectral-Domain Optical Coherence Tomography (Standard of Care test)
* Diagnostic Test: Macular Autofluorescence (Standard of Care test)


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Age ≥18 years HCQ groups: a. HCQ use >5 years for patients without any high-risk factors, or >1 year in patients with one or more high-risk factors for HCQ retinopathy, namely: i. Dose >5mg/kg per day actual body weight (ABW) ii. Estimated glomerular filtration rate (eGFR) of <60mls/min/1.73m2 iii. Concomitant tamoxifen use Control group: No prior HCQ exposure Exclusion Criteria: Cataract grade ≥3 of any subtype Recent cataract surgery within 4 weeks of recruitment Significant media opacity or corneal disease including, but not limited to, corneal oedema, corneal scarring, keratoconus, previous corneal transplants, severe keratoconjunctivitis sicca (requiring the use of topical serum, immunosuppressive or analogous therapy, or procedural treatment). Significant macular co-pathology including, but not limited to, macular degeneration, macular scarring, cystic macular oedema (for any reason), staphyloma. Inherited retinal and/or macular dystrophies including colour vision deficiencies Active or previous posterior uveitis or pan-uveitis Aphakia High refractive error >6.00 dioptres Amblyopia Diabetes Retinal angiopathies including, but no limited to, retinal vein occlusion, retinal artery occlusion, ocular ischaemic syndrome, HIV retinopathy, Sickle cell disease, radiation retinopathy Visually significant surgical retinal disease including epiretinal membrane, macular hole, retinal detachment, retinal tear Previous retinal laser or intravitreal treatment Moderate or worse glaucoma Optic atrophy Photosensitive epilepsy Ungradable HCQ retinopathy screening images Periocular infection or rash (recruitment can be deferred until acute pathology has resolved) Unable or unwilling to undertake study activities Any active use or history of the following medications: Amiodarone Canthaxanthin Deferoxamine Digoxin Ethambutol Interferon-alpha Melatonin Nefazodone Sildenafil Vigabatrin Chloroquine Quinine

Ages Eligible for Study
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Minimum Age: 18 Years

Sexes Eligible for Study
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All

Study Plan
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How is the study designed?
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Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Normative Controls<br>Age- and sex- matched normal controls | Diagnostic Test: Hand-Held Full-Field Skin-Electrode Electroretinography (Device to be evaluated)<br>* RETEval Complete hand-held electroretinogram<br>Diagnostic Test: Trolley-Mounted Multifocal Skin-Electrode Electroretinography (Device to be evaluated)<br>* UTAS multifocal electroretinogram<br>Diagnostic Test: Spectral-Domain Optical Coherence Tomography (Standard of Care test)<br>* Heidelberg Engineering Spectralis Spectral-Domain Optical Coherence Tomography (macular structural scan)<br>Diagnostic Test: Macular Autofluorescence (Standard of Care test)<br>* Heidelberg Engineering Spectralis Autofluorescence imaging (macular structural image)<br>|
| On Hydroxychloroquine, NO retinopathy<br>Participants over 18 years on hydroxychloroquine without hydroxychloroquine-related retinopathy | Diagnostic Test: Hand-Held Full-Field Skin-Electrode Electroretinography (Device to be evaluated)<br>* RETEval Complete hand-held electroretinogram<br>Diagnostic Test: Trolley-Mounted Multifocal Skin-Electrode Electroretinography (Device to be evaluated)<br>* UTAS multifocal electroretinogram<br>Diagnostic Test: Spectral-Domain Optical Coherence Tomography (Standard of Care test)<br>* Heidelberg Engineering Spectralis Spectral-Domain Optical Coherence Tomography (macular structural scan)<br>Diagnostic Test: Macular Autofluorescence (Standard of Care test)<br>* Heidelberg Engineering Spectralis Autofluorescence imaging (macular structural image)<br>|
| On Hydroxychloroquine, POSSIBLE retinopathy<br>Participants over 18 years on hydroxychloroquine with possible (indeterminate) hydroxychloroquine-related retinopathy | Diagnostic Test: Hand-Held Full-Field Skin-Electrode Electroretinography (Device to be evaluated)<br>* RETEval Complete hand-held electroretinogram<br>Diagnostic Test: Trolley-Mounted Multifocal Skin-Electrode Electroretinography (Device to be evaluated)<br>* UTAS multifocal electroretinogram<br>Diagnostic Test: Spectral-Domain Optical Coherence Tomography (Standard of Care test)<br>* Heidelberg Engineering Spectralis Spectral-Domain Optical Coherence Tomography (macular structural scan)<br>Diagnostic Test: Macular Autofluorescence (Standard of Care test)<br>* Heidelberg Engineering Spectralis Autofluorescence imaging (macular structural image)<br>|
| On Hydroxychloroquine, DEFINITE retinopathy<br>Participants over 18 years on hydroxychloroquine with definite hydroxychloroquine-related retinopathy | Diagnostic Test: Hand-Held Full-Field Skin-Electrode Electroretinography (Device to be evaluated)<br>* RETEval Complete hand-held electroretinogram<br>Diagnostic Test: Trolley-Mounted Multifocal Skin-Electrode Electroretinography (Device to be evaluated)<br>* UTAS multifocal electroretinogram<br>Diagnostic Test: Spectral-Domain Optical Coherence Tomography (Standard of Care test)<br>* Heidelberg Engineering Spectralis Spectral-Domain Optical Coherence Tomography (macular structural scan)<br>Diagnostic Test: Macular Autofluorescence (Standard of Care test)<br>* Heidelberg Engineering Spectralis Autofluorescence imaging (macular structural image)<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| The sensitivity and specificity of both devices to discriminate between NO, POSSIBLE and DEFINITE hydroxychloroquine retinopathy compared to standard screening tests | Primary Outcome | All tests required to determine sensitivity and specificity of both devices compared to standard retinal imaging will be completed in a single visit. Safety will be evaluated up to 1 week post-visit. | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| To compare the sensitivity and specificity of undilated versus dilated testing with the multifocal ERG device, for all categories of hydroxychloroquine retinopathy | Secondary Outcome | All tests required to determine this outcome will be completed at a single visit. Safety will be evaluated up to 1 week post-visit. | 
| To determine the patient acceptability of both devices evaluated using standardised, study-specific questionnaires | Feasibility Outcome | All tests required to determine this outcome will be completed at a single visit. Safety will be evaluated up to 1 week post-visit. | 
| To determine the proportion and recruitment rate of patients in each category of hydroxychloroquine retinopathy who consent to join this study. | Feasibility Outcome | All tests required to determine this outcome will be completed at a single visit. Safety will be evaluated up to 1 week post-visit. | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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Electroretinography, Diagnostic Evaluation