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 Table of Contents  
ADR FORUM (CASE REPORT)
Year : 2021  |  Volume : 59  |  Issue : 4  |  Page : 404-406

Reversible blurred vision with hydroxychloroquine in a COVID-19 patient


1 Department of Pharmacology, Dr. D Y Patil Medical College, Navi Mumbai, Maharashtra, India
2 MGM School of Physiotherapy, Navi Mumbai, Maharashtra, India

Date of Submission04-Nov-2020
Date of Decision26-Jun-2021
Date of Acceptance28-Jun-2021
Date of Web Publication21-Dec-2021

Correspondence Address:
Dr. Pramila Yadav
Department of Pharmacology, Dr D Y Patil Medical College, Nerul, Navi Mumbai, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/tjosr.tjosr_165_20

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  Abstract 


Among the umbrella of drugs postulated for COVID-19 treatment, chloroquine and hydroxychloroquine (HCQ) are currently being used in the management of COVID-19–positive patients in India. Hydroxychloroquine (HCQ) retinopathy is a known but a rare adverse effect when used in autoimmune diseases. However, advanced age, comorbidities (such as diabetes, obesity and cardiovascular disease), and patients taking subsequent comedications could be potentially more susceptible. We present a unique case history of patient suffering from reversible blurred vision probably due to HCQ in a COVID-19 patient.

Keywords: Blurred vision, COVID-19, hydroxychloroquine


How to cite this article:
Yadav P, Deolekar P, Mehandarkar H, Singh A. Reversible blurred vision with hydroxychloroquine in a COVID-19 patient. TNOA J Ophthalmic Sci Res 2021;59:404-6

How to cite this URL:
Yadav P, Deolekar P, Mehandarkar H, Singh A. Reversible blurred vision with hydroxychloroquine in a COVID-19 patient. TNOA J Ophthalmic Sci Res [serial online] 2021 [cited 2022 Jan 27];59:404-6. Available from: https://www.tnoajosr.com/text.asp?2021/59/4/404/333162




  Introduction Top


Since the advent of COVID-19 pandemic, cases have been on a rise in all continents.[1] One of the treatment options being suggested were chloroquine (CQ) and hydroxychloroquine (HCQ).[1]

The adverse effect profile of HCQ in malaria and autoimmune disease is well established. COVID-19 patients because of their advanced age with associated comorbidities and on multiple medications could be more susceptible to adverse effects.[2],[3],[4] Within the eye, HCQ can adversely impact the cornea, ciliary body, and retina.[5],[6],[7] The incidence of HCQ retinopathy is very low at 0.5% incidence of retinal toxicity after 5 years of therapy.[8] In contrast, the case report takes into consideration one of the rare side effects of HCQ. The case report aims to make primary care physician aware of this and factors that should be considered before prescribing HCQ.


  Case Report Top


A 48-year-old man with a history of diabetes weight 98 kg had history of high-grade fever, dry cough, headache, body pain, and sore throat for the past 7 days. He took medications (Paracetamol, cetirizine) for the same prescribed by a local general practitioner. He showed no clinical improvement and hence RT-PCR was done next day which reported positive. The above symptoms continued with additional loss of appetite and breathlessness. Oxygen saturation was maintained between 95% and 97%. Laboratory tests were: C-reactive protein: positive (25 mg/l), fasting blood sugar - 277 mg/dl, postprandial blood sugar - 375 mg/dl, and HbA1C - 54 mmol/mol. He was advised home isolation with following medications by the physician.

Hydroxychloroquine 200 mg, 2 tablets twice on 1st day, and then 1 tablet twice for 7 days. Paracetamol 500 mg SOS, dexamethasone 0.5 mg OD (till the symptom subside), Vitamin C 500 mg BD, Vitamin D 60,000 IU (once a week), cough syrup containing combination of dextromethorphan +chlorpheniramine, azithromycin 500 mg OD for 5 days, montelukast 10 mg OD for 5 days, pantoprazole-D 40 mg on empty stomach BD, and zinc sulfate 20 mg BD were advised for 21 days.

On the next day, he started experiencing blurred vision with difficulty in reading his blood reports and other activities that require accommodation. The severity of blurred vision remained constant throughout for the next few days. There is not much information about intensity of blurred vision, as the patient stopped reading. Since the patient was home quarantined and the physician was more concerned on treating the COVID aspect, there was not much focus on blurred vision. The blurred vision also returned back to normal before the fever subsided. The return to normal could be some days prior, but it went unnoticed. The patient also complained of symptoms of gastritis, i.e. nausea and vomiting, giddiness, excessive sleep, and extreme weakness. No ophthalmic check-up was done for the same as he was COVID positive; therefore, assessment on the visual loss could not be confirmed.

Patient gave no history of dimished central vision, color blindness and central blind spots. He gave no history of halos around light or photophobia. He currently uses reading glasses but has had no ophthalmic examination in the recent past. He is presently under treatment with oral antidiabetics. None of the other drugs except HCQ could have a temporal association with this adverse event. The patient did not have any known risk factors, such as renal disease liver disease, concomitant retinotoxic agents, or coexisting retinal disease.


  Discussion Top


The Royal College of Ophthalmologists has emphasized the safe dose (<5 mg/kg/day) and safe duration (for <5 years) of CQ and HCQ. The daily doses of HCQ exceed the daily safe doses but may be considered relatively safe from irreversible retinal toxicity perspective.[9]

HCQ has established binding affinity with melanin in retinal pigment epithelium with proven toxicity to the photoreceptor layer and outer nuclear layer of the retina. Light absorption and metabolism of cone cells may also contribute to the damages, causing characteristic “bull's eye” maculopathy.[9],[10]

It is however unknown whether exposure to high dose over a short period may also effect similar cellular level damages as seen in chronic exposure.[11] Given that patients with COVID-19 could be older, it is possible that these patients could have preexisting age-related macular degeneration.[12]

In this patient, history was elicited after disease state was over; hence, though a bit sketchy, we could definitely link the blurred vision to HCQ. The concomitant drugs the patient was taking are not associated with visual disturbances. A major limitation of this case report was that because of COVID-19 lockdown situation in the area that time, the patient could not get an ophthalmic examination done.

Scientific literature does not support the above observation in terms dose and duration. According to literature references HCQ causes irreversible visual defects on long term use. This patient experienced blurred vision on short-term use which was reversible. This could suggest the new possibility of HCQ causing blurred vision even on short term use.

The adverse event has been reported: By consumer on ADR PvPi app India.

Routine baseline ocular examination can be considered provided there are enough workforces with extreme precautions during the examination, although it is not an absolute mandate for patients with COVID-19 who are undergoing treatment with HCQ. However, a comprehensive history of ocular disease, particularly macular disease, in COVID-19–positive cases who are more than 50 years of age, before initiation of HCQ treatment, to rule out age-related macular degeneration or other macular abnormalities is relevant.[13]

Treatment guidelines of Belgium mention preexisting retinal pathology, a contraindication of using HCQ therapy in patients with COVID-19.[13] As treatment with HCQ is of unproven benefit, rather can be harmful instead, using other treatment modalities in patients with the preexisting disease could be appropriate.[14] The patients should also be informed to visit the ophthalmologists if they encounter any abnormal visual symptoms, postrecovery from COVID-19 with the treatment using HCQ.[12] At the time of publication of this article HCQ is not used in treatment of Covid 19. But caution needs to be advocated when prescribing HCQ for others conditions as well.


  Conclusion Top


The adverse event of blurred vision in this patient could be attributed to HCQ. It was mild, reversible in contrast with the literature. Further, considering a plethora of drugs being used of COVID 19, caution needs to be applied with the use of HCQ in patients with eye diseases or taking ocular toxic concomitant drugs.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understand that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Cortegiani A, Ingoglia G, Ippolito M, Giarratano A, Einav S. A systematic review on the efficacy and safety of chloroquine for the treatment of COVID-19. J Crit Care 2020;57:279-83.  Back to cited text no. 1
    
2.
Gautret P, Lagier JC, Parola P, Hoang VT, Meddeb L, Mailhe M, et al. Hydroxychloroquine and azithromycin as a treatment of COVID-19: Results of an open-label non-randomized clinical trial. Int J Antimicrob Agents 2020;56:105949.  Back to cited text no. 2
    
3.
Department of Medical Services Ministry of Public Health Thailand. Thai Treatment Guideline for COVID-19; 2020. Available from: https://ddc.moph.go.th/viralpneumonia/file/g_health_care/G2_new3_1.pdf. [Last accessed on 2020 Oct].  Back to cited text no. 3
    
4.
Gbinigie K, Frie K. Should chloroquine and hydroxychloroquine be used to treat COVID-19? A rapid review. BJGP Open 2020;4:bjgpopen20X101069. DOI: https://doi.org/10.3399/bjgpopen20X101069.  Back to cited text no. 4
    
5.
Yam JC, Kwok AK. Ocular toxicity of hydroxychloroquine. Hong Kong Med J 2006;12:294-304.  Back to cited text no. 5
    
6.
Easterbrook M. Long-term course of antimalarial maculopathy after cessation of treatment. Can J Ophthalmol 1992;27:237-9.  Back to cited text no. 6
    
7.
Elman A, Gullberg R, Nilsson E, Rendahl I, Wachtmeister L. Chloroquine retinopathy in patients with rheumatoid arthritis. Scand J Rheumatol 1976;5:161-66.  Back to cited text no. 7
    
8.
Mavrikakis M, Papazoglou S, Sfikakis PP, Vaiopoulos G, Rougas K. Retinal toxicity in long term hydroxychloroquine treatment. Ann Rheum Dis 1996;55:187-9.  Back to cited text no. 8
    
9.
Murray JJ, Lee MS. Re: Marmor. et al.: American academy of ophthalmology statement: Recommendations on screening for chloroquine and hydroxychloroquine retinopathy (2016 Revision). (Ophthalmology 2016;123:1386-1394). Ophthalmology 2017;124:e28-9.  Back to cited text no. 9
    
10.
Easterbrook M. Ocular effects and safety of antimalarial agents. Am J Med 1988;85:23-9.  Back to cited text no. 10
    
11.
Yusuf IH, Sharma S, Luqmani R, Downes SM. Hydroxychloroquine retinopathy. Eye (Lond) 2017;31:828-45.  Back to cited text no. 11
    
12.
Ruamviboonsuk P, Lai TYY, Chang A, Lai CC, Mieler WF, Lam DS, et al. Chloroquine and Hydroxychloroquine Retinal Toxicity Consideration in the Treatment of COVID-19. Asia Pac J Ophthalmol (Phila) 2020;9:85-7.  Back to cited text no. 12
    
13.
Institute of Tropical Medicine Antewerp, Universiteit Antwerpen, CHU Saint-Pierre, et al. Interim Clinical Guidance for Patients Suspected of/Confirmed With Covid-19 in Belgium; 2020. p. 1-3. Available from: https://epidemio.wiv-isp.be/ID/Documents/Covid19/COVID-19_InterimGuidelines_Treatment_ENG.pdf. [Last accessed on 2020 Mar 23].  Back to cited text no. 13
    
14.
Guastalegname M, Vallone A. Could chloroquine hydroxychloroquine be harmful in Coronavirus Disease 2019 (COVID-19) treatment? Clin Infect Dis 2020;71:888-9.  Back to cited text no. 14
    




 

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