Letters
6. Barry P, Cordovés L, Gardner S. ESCRS guidelines for prevention and treatment of endophthalmitis following cataract surgery: data, dilemmas and conclusions, 2013. http://www.escrs.org/downloads/endophthalmitis-guidelines .pdf. Accessed June 10, 2014. 7. Yin VT, Weisbrod DJ, Eng KT, et al. Antibiotic resistance of ocular surface flora with repeated use of a topical antibiotic after intravitreal injection. JAMA Ophthalmol. 2013;131(4):456-461. 8. Bhavsar AR, Googe JM Jr, Stockdale CR, et al; Diabetic Retinopathy Clinical Research Network. Risk of endophthalmitis after intravitreal drug injection when topical antibiotics are not required: the Diabetic Retinopathy Clinical Research Network laser-ranibizumab-triamcinolone clinical trials. Arch Ophthalmol. 2009; 127(12):1581-1583.
In Reply We agree that there are limited evidence-based data indicating that perioperative topical antibiotics reduce rates of endophthalmitis following cataract surgery.1 As previously discussed, the use of perioperative topical povidoneiodine, an eyelid speculum and drape with isolation of the eyelids and eyelashes, and meticulous sterile preparation and procedures is effective in limiting the incidence of endophthalmitis in these patients.2 It is unlikely that a large-scale randomized prospective trial to evaluate the use of perioperative topical antibiotics could be performed because the rates of endophthalmitis are very low. Furthermore, other risk factors including rupture of the posterior capsule, anterior vitrectomy, diabetes mellitus, and older age may be more important for the development of postoperative endophthalmitis. In a somewhat similar model used by vitreoretinal specialists, periprocedural topical antibiotics do not appear to reduce the risk of endophthamitis following intravitreal injections.3 Topical antibiotics may promote the emergence of antimicrobial resistance, leading to the potential of endophthalmitis caused by more virulent organisms.4 Andrew M. Schimel, MD Eduardo Alfonso, MD Harry W. Flynn Jr, MD Author Affiliations: Center for Excellence in Eye Care, Miami, Florida (Schimel); Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, Florida (Alfonso, Flynn). Corresponding Author: Harry W. Flynn Jr, MD, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, 900 NW 17th St, Miami, FL 33136 ([email protected]). Published Online: January 2, 2015. doi:10.1001/jamaophthalmol.2014.5326. Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Flynn reported having received grants from the National Eye Institute, Research to Prevent Blindness, and the US Department of Defense outside this work. No other disclosures were reported. 1. Gower EW, Lindsley K, Nanji AA, Leyngold I, McDonnell PJ. Perioperative antibiotics for prevention of acute endophthalmitis after cataract surgery. Cochrane Database Syst Rev. 2013;7:CD006364. 2. Schimel AM, Alfonso EC, Flynn HW Jr. Endophthalmitis prophylaxis for cataract surgery: are intracameral antibiotics necessary? [published online August 14, 2014]. JAMA Ophthalmol. doi:10.1001/jamaophthalmol.2014.2052. 3. Storey P, Dollin M, Pitcher J, et al; Post-Injection Endophthalmitis Study Team. The role of topical antibiotic prophylaxis to prevent endophthalmitis after intravitreal injection. Ophthalmology. 2014;121(1):283-289. 4. Kim SJ, Toma HS. Antimicrobial resistance and ophthalmic antibiotics: 1-year results of a longitudinal controlled study of patients undergoing intravitreal injections. Arch Ophthalmol. 2011;129(9):1180-1188. jamaophthalmology.com
Premium Intraocular Lens Effect on the Immediate Sequential Cataract Surgery Physician Perspective Cost-Analysis Model To the Editor The Invited Commentary by Naseri and McLeod1 on immediate sequential cataract surgery (ISCS) compared with delayed sequential cataract surgery (DSCS) based on my physician perspective cost-analysis model2 is an excellent analysis that discusses how premium intraocular lens (IOL) use may affect this model. It also reviews various factors affecting physician decision making. The model omitted potential physician reimbursement from premium IOLs.2 A 2013 Market Scope survey found that premium IOLs composed less than 10% of IOL procedures for 52% of surgeons and 10% to 30% of IOL procedures for 37% of surgeons.3 For most surgeons, premium IOLs currently encompass a small percentage of their surgical practice; thus, exclusion from the model was appropriate. Naseri and McLeod1 calculated a 6% reduction in physician revenue with ISCS using the national average presbyopia correction surgery fee ($2185/eye). To clarify this issue in the context of the model I used,2 a comparison of cost differences between ISCS and DSCS for both presbyopia-correcting and astigmatism-correcting IOLs was performed. Unlike the analysis by Naseri and McLeod, this model in calculating physician revenue removed the premium IOL costs and adjusted for regional fee differences. West Tennessee Medicare cataract surgery physician reimbursement ($698.61) is lower than the national average cataract surgery physician reimbursement ($760.74). The West Tennessee presbyopia correction surgery fee is $2000/eye (national average, $2185/eye) and the astigmatism correction surgery fee is $1000/eye (national average, $1221/eye). Medicare requires that the surgical facility supply the IOL and be paid directly by the patient, while also allowing a small handling fee ($25-$50).4 The premium IOL cost used the Alcon Restor IOL ($895/eye) and the Alcon Toric IOL ($495/ eye) minus the Medicare IOL reimbursement of $150/eye plus a $50 premium IOL handling fee per eye, resulting in an adjusted Restor IOL cost of $795/eye and an adjusted Toric IOL cost of $395/eye. No adjustments were made for discounts, additional physician and technician time requirements, or enhancement costs. Use of ISCS resulted in revenue decreases of 9.2% and 13.4% for presbyopia-correcting and astigmatismcorrecting surgery, less narrowing than the 6% decrease that Naseri and McLeod predicted. The real dollar loss from converting to ISCS does not change in either method; only the percentage of revenue difference between DSCS and ISCS changes, varying with the size of the total surgical fee. Second, I agree that physicians will include multiple factors in their decision-making process including safety, liability, access, societal benefit, and other considerations, but I was able to highlight only some potentially negative financial aspects of physician decision making, such as gaming and supplier-induced demand, in the cost-analysis model2 owing to space restrictions. Sean T. Neel, MD, MSc Author Affiliation: Eye Clinic PC, Jackson, Tennessee.
(Reprinted) JAMA Ophthalmology April 2015 Volume 133, Number 4
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://archopht.jamanetwork.com/ by a Cornell University User on 09/19/2016
491
Letters
Corresponding Author: Sean T. Neel, MD, MSc, Eye Clinic PC, 668 Skyline Dr, Jackson, TN 38301 ([email protected]). Published Online: January 8, 2015. doi:10.1001/jamaophthalmol.2014.5333. Conflict of Interest Disclosures: The author has completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported. 1. Naseri A, McLeod S. Benefits of and barriers to immediate sequential cataract surgery [published online September 18, 2014]. JAMA Ophthalmol. doi:10.1001 /jamaophthalmol.2014.3637. 2. Neel S. A cost and policy analysis comparing immediate sequential cataract surgery and delayed sequential cataract surgery from the physician perspective in the United States [published online September 18, 2014]. JAMA Ophthalmol. doi:10.1001/jamaophthalmol.2014.3335. 3. Ingenito K. Premium cataract surgery goes mainstream: finding opportunity in a slow economy and changing reimbursement climate. Cataract Refract Surg Today. October 2013:51-52. 4. Ellis S. Are you billing for your PC/AC IOL cataract cases correctly? http://www .beckersasc.com/asc-coding-billing-and-collections/are-you-billing-for-your -pcac-iol-cataract-cases-correctly.html. Accessed September 30, 2014.
Prevention of Hydroxychloroquine-Related Retinal Toxic Effects To the Editor We commend Mititelu et al1 on their recent study of hydroxychloroquine toxic effects but take issue with their conclusion. We believe prevention rather than early detection is best practice. Hydroxychloroquine is dosed by lean (“ideal”) body weight, which is based purely on height and sex. It is a hypothetical concept that excludes body fat in determining a person’s weight. Hence, shorter patients will have a lower lean body weight. The default hydroxychloroquine dosage on many electronic prescribing systems and most commonly encountered in practice is 200 mg twice daily. Hydroxychloroquine should be dosed at 6.5 mg/kg lean body weight daily. The default dosage of 200 mg twice daily (400 mg/d) is acceptable for a patient with a lean body weight of more than 61.54 kg (135 lbs; 6.5 mg/kg × 61.54 kg = 400 mg). There are a variety of published formulas for calculating lean body weight, but their difference is marginal.2 Men shorter than 1.63 m (5 ft 4 in) and women shorter than 1.68 m (5 ft 6 in) will have a lean body weight lower than 64.54 kg. Therefore, the default hydrochloroquine dosage of 200 mg twice daily is too high for these patients. In the study by Mititelu and colleagues, all the women with retinal toxic effects were shorter than 1.68 m but had received a dosage of 400 mg/d. We conducted a retrospective record review that was Health Insurance Portability and Accountability Act of 1996 compliant and institutional review board approved.3 We reviewed the electronic medical record of a large, multicenter health maintenance organization for all patients taking hydroxychloroquine in 2009. We identified 675 patients; based on their sex, height, and dosage, it was determined that 370 of 662 females (56%) and 6 of 13 males (46%) were receiving higher than the recommended dosage for their lean body weight. Pautler4 addressed the issue of lean body weight dosing in a letter to the editor in the September 2007 issue of Archives of Ophthalmology. Consistent with our findings, Michaelides et al5 found that 9 of 16 women (56%) were receiving hydroxychloroquine dosages greater than the recommended daily dosage based on lean body weight. 492
With the epidemic of obesity facing us, the best practice for the busy clinician may be to routinely note the height for patients prescribed hydroxychloroquine. We recommend that men shorter than 1.63 m and women shorter than 1.68 m have their daily dosage lowered from the default of 200 mg twice daily (400 mg/d) to prevent retinal toxic effects. Matthew D. Walvick, DO Chau H. Ngo, PharmD Author Affiliations: John Muir Medical Group, Walnut Creek, California (Walvick); Sutter Solano Medical Center, Vallejo, California (Ngo). Corresponding Author: Matthew D. Walvick, DO, John Muir Medical Group, 1450 Treat Blvd, Ste 250B, Walnut Creek, CA 94598 (matthew.walvick_d.o [email protected]). Published Online: January 2, 2015. doi:10.1001/jamaophthalmol.2014.3254. Conflict of Interest Disclosures: None reported. 1. Mititelu M, Wong BJ, Brenner M, Bryar PJ, Jampol LM, Fawzi AA. Progression of hydroxychloroquine toxic effects after drug therapy cessation: new evidence from multimodal imaging. JAMA Ophthalmol. 2013;131(9):1187-1197. 2. Pai MP, Paloucek FP. The origin of the “ideal” body weight equations. Ann Pharmacother. 2000;34(9):1066-1069. 3. Lahey JM, Lehmer JM, Walvick MD, Kolarik E, Lam DH. Incidence and characteristics of Plaquenil toxicity in a large population-based study. Poster presented at: 2008 Annual Meeting of the American Academy of Ophthalmology; November 10, 2008; Atlanta, GA. 4. Pautler SE. Hydroxychloroquine dosages should be calculated using lean body mass. Arch Ophthalmol. 2007;125(9):1303-1304. 5. Michaelides M, Stover NB, Francis PJ, Weleber RG. Retinal toxicity associated with hydroxychloroquine and chloroquine: risk factors, screening, and progression despite cessation of therapy. Arch Ophthalmol. 2011;129(1):30-39.
In Reply We thank Walvick and Ngo for their comments regarding the importance of dosing by ideal body weight in patients using hydroxychloroquine. First, we emphasize that our study was not designed or appropriate to address the question of prevention since we were mainly interested in the course of retinopathy following discontinuation. As alluded to by Walvick and Ngo, in our study we also found that at the time toxic effects were diagnosed, most patients were receiving dosages above the daily recommendations based on their ideal body weight (corrected for their height).1 The question of dosing has been addressed in previous studies, prompting the revised recommendations by the American Academy of Ophthalmology.2 Because the current recommended American Academy of Ophthalmology practice for screening includes a baseline examination, perhaps it is at that point we as ophthalmologists can impact the lives of these patients, paying attention to the question of dosing. Further, as a specialty, we are in need of a concerted effort to create better algorithms for follow-up. For example, with our first patient who developed toxic effects despite receiving a dosage much lower than the recommended dosage, would it have been more appropriate to closely follow a young patient with renal disease from baseline at a more stringent 6-month regimen or should we, in similar situations, recommend against the use of hydroxychloroquine altogether? If we follow such patients more closely, are we going to then face an onslaught of patients who need frequent screening?
JAMA Ophthalmology April 2015 Volume 133, Number 4 (Reprinted)
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://archopht.jamanetwork.com/ by a Cornell University User on 09/19/2016
jamaophthalmology.com
6. Barry P, Cordovés L, Gardner S. ESCRS guidelines for prevention and treatment of endophthalmitis following cataract surgery: data, dilemmas and conclusions, 2013. http://www.escrs.org/downloads/endophthalmitis-guidelines .pdf. Accessed June 10, 2014. 7. Yin VT, Weisbrod DJ, Eng KT, et al. Antibiotic resistance of ocular surface flora with repeated use of a topical antibiotic after intravitreal injection. JAMA Ophthalmol. 2013;131(4):456-461. 8. Bhavsar AR, Googe JM Jr, Stockdale CR, et al; Diabetic Retinopathy Clinical Research Network. Risk of endophthalmitis after intravitreal drug injection when topical antibiotics are not required: the Diabetic Retinopathy Clinical Research Network laser-ranibizumab-triamcinolone clinical trials. Arch Ophthalmol. 2009; 127(12):1581-1583.
In Reply We agree that there are limited evidence-based data indicating that perioperative topical antibiotics reduce rates of endophthalmitis following cataract surgery.1 As previously discussed, the use of perioperative topical povidoneiodine, an eyelid speculum and drape with isolation of the eyelids and eyelashes, and meticulous sterile preparation and procedures is effective in limiting the incidence of endophthalmitis in these patients.2 It is unlikely that a large-scale randomized prospective trial to evaluate the use of perioperative topical antibiotics could be performed because the rates of endophthalmitis are very low. Furthermore, other risk factors including rupture of the posterior capsule, anterior vitrectomy, diabetes mellitus, and older age may be more important for the development of postoperative endophthalmitis. In a somewhat similar model used by vitreoretinal specialists, periprocedural topical antibiotics do not appear to reduce the risk of endophthamitis following intravitreal injections.3 Topical antibiotics may promote the emergence of antimicrobial resistance, leading to the potential of endophthalmitis caused by more virulent organisms.4 Andrew M. Schimel, MD Eduardo Alfonso, MD Harry W. Flynn Jr, MD Author Affiliations: Center for Excellence in Eye Care, Miami, Florida (Schimel); Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, Florida (Alfonso, Flynn). Corresponding Author: Harry W. Flynn Jr, MD, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, 900 NW 17th St, Miami, FL 33136 ([email protected]). Published Online: January 2, 2015. doi:10.1001/jamaophthalmol.2014.5326. Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Flynn reported having received grants from the National Eye Institute, Research to Prevent Blindness, and the US Department of Defense outside this work. No other disclosures were reported. 1. Gower EW, Lindsley K, Nanji AA, Leyngold I, McDonnell PJ. Perioperative antibiotics for prevention of acute endophthalmitis after cataract surgery. Cochrane Database Syst Rev. 2013;7:CD006364. 2. Schimel AM, Alfonso EC, Flynn HW Jr. Endophthalmitis prophylaxis for cataract surgery: are intracameral antibiotics necessary? [published online August 14, 2014]. JAMA Ophthalmol. doi:10.1001/jamaophthalmol.2014.2052. 3. Storey P, Dollin M, Pitcher J, et al; Post-Injection Endophthalmitis Study Team. The role of topical antibiotic prophylaxis to prevent endophthalmitis after intravitreal injection. Ophthalmology. 2014;121(1):283-289. 4. Kim SJ, Toma HS. Antimicrobial resistance and ophthalmic antibiotics: 1-year results of a longitudinal controlled study of patients undergoing intravitreal injections. Arch Ophthalmol. 2011;129(9):1180-1188. jamaophthalmology.com
Premium Intraocular Lens Effect on the Immediate Sequential Cataract Surgery Physician Perspective Cost-Analysis Model To the Editor The Invited Commentary by Naseri and McLeod1 on immediate sequential cataract surgery (ISCS) compared with delayed sequential cataract surgery (DSCS) based on my physician perspective cost-analysis model2 is an excellent analysis that discusses how premium intraocular lens (IOL) use may affect this model. It also reviews various factors affecting physician decision making. The model omitted potential physician reimbursement from premium IOLs.2 A 2013 Market Scope survey found that premium IOLs composed less than 10% of IOL procedures for 52% of surgeons and 10% to 30% of IOL procedures for 37% of surgeons.3 For most surgeons, premium IOLs currently encompass a small percentage of their surgical practice; thus, exclusion from the model was appropriate. Naseri and McLeod1 calculated a 6% reduction in physician revenue with ISCS using the national average presbyopia correction surgery fee ($2185/eye). To clarify this issue in the context of the model I used,2 a comparison of cost differences between ISCS and DSCS for both presbyopia-correcting and astigmatism-correcting IOLs was performed. Unlike the analysis by Naseri and McLeod, this model in calculating physician revenue removed the premium IOL costs and adjusted for regional fee differences. West Tennessee Medicare cataract surgery physician reimbursement ($698.61) is lower than the national average cataract surgery physician reimbursement ($760.74). The West Tennessee presbyopia correction surgery fee is $2000/eye (national average, $2185/eye) and the astigmatism correction surgery fee is $1000/eye (national average, $1221/eye). Medicare requires that the surgical facility supply the IOL and be paid directly by the patient, while also allowing a small handling fee ($25-$50).4 The premium IOL cost used the Alcon Restor IOL ($895/eye) and the Alcon Toric IOL ($495/ eye) minus the Medicare IOL reimbursement of $150/eye plus a $50 premium IOL handling fee per eye, resulting in an adjusted Restor IOL cost of $795/eye and an adjusted Toric IOL cost of $395/eye. No adjustments were made for discounts, additional physician and technician time requirements, or enhancement costs. Use of ISCS resulted in revenue decreases of 9.2% and 13.4% for presbyopia-correcting and astigmatismcorrecting surgery, less narrowing than the 6% decrease that Naseri and McLeod predicted. The real dollar loss from converting to ISCS does not change in either method; only the percentage of revenue difference between DSCS and ISCS changes, varying with the size of the total surgical fee. Second, I agree that physicians will include multiple factors in their decision-making process including safety, liability, access, societal benefit, and other considerations, but I was able to highlight only some potentially negative financial aspects of physician decision making, such as gaming and supplier-induced demand, in the cost-analysis model2 owing to space restrictions. Sean T. Neel, MD, MSc Author Affiliation: Eye Clinic PC, Jackson, Tennessee.
(Reprinted) JAMA Ophthalmology April 2015 Volume 133, Number 4
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://archopht.jamanetwork.com/ by a Cornell University User on 09/19/2016
491
Letters
Corresponding Author: Sean T. Neel, MD, MSc, Eye Clinic PC, 668 Skyline Dr, Jackson, TN 38301 ([email protected]). Published Online: January 8, 2015. doi:10.1001/jamaophthalmol.2014.5333. Conflict of Interest Disclosures: The author has completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported. 1. Naseri A, McLeod S. Benefits of and barriers to immediate sequential cataract surgery [published online September 18, 2014]. JAMA Ophthalmol. doi:10.1001 /jamaophthalmol.2014.3637. 2. Neel S. A cost and policy analysis comparing immediate sequential cataract surgery and delayed sequential cataract surgery from the physician perspective in the United States [published online September 18, 2014]. JAMA Ophthalmol. doi:10.1001/jamaophthalmol.2014.3335. 3. Ingenito K. Premium cataract surgery goes mainstream: finding opportunity in a slow economy and changing reimbursement climate. Cataract Refract Surg Today. October 2013:51-52. 4. Ellis S. Are you billing for your PC/AC IOL cataract cases correctly? http://www .beckersasc.com/asc-coding-billing-and-collections/are-you-billing-for-your -pcac-iol-cataract-cases-correctly.html. Accessed September 30, 2014.
Prevention of Hydroxychloroquine-Related Retinal Toxic Effects To the Editor We commend Mititelu et al1 on their recent study of hydroxychloroquine toxic effects but take issue with their conclusion. We believe prevention rather than early detection is best practice. Hydroxychloroquine is dosed by lean (“ideal”) body weight, which is based purely on height and sex. It is a hypothetical concept that excludes body fat in determining a person’s weight. Hence, shorter patients will have a lower lean body weight. The default hydroxychloroquine dosage on many electronic prescribing systems and most commonly encountered in practice is 200 mg twice daily. Hydroxychloroquine should be dosed at 6.5 mg/kg lean body weight daily. The default dosage of 200 mg twice daily (400 mg/d) is acceptable for a patient with a lean body weight of more than 61.54 kg (135 lbs; 6.5 mg/kg × 61.54 kg = 400 mg). There are a variety of published formulas for calculating lean body weight, but their difference is marginal.2 Men shorter than 1.63 m (5 ft 4 in) and women shorter than 1.68 m (5 ft 6 in) will have a lean body weight lower than 64.54 kg. Therefore, the default hydrochloroquine dosage of 200 mg twice daily is too high for these patients. In the study by Mititelu and colleagues, all the women with retinal toxic effects were shorter than 1.68 m but had received a dosage of 400 mg/d. We conducted a retrospective record review that was Health Insurance Portability and Accountability Act of 1996 compliant and institutional review board approved.3 We reviewed the electronic medical record of a large, multicenter health maintenance organization for all patients taking hydroxychloroquine in 2009. We identified 675 patients; based on their sex, height, and dosage, it was determined that 370 of 662 females (56%) and 6 of 13 males (46%) were receiving higher than the recommended dosage for their lean body weight. Pautler4 addressed the issue of lean body weight dosing in a letter to the editor in the September 2007 issue of Archives of Ophthalmology. Consistent with our findings, Michaelides et al5 found that 9 of 16 women (56%) were receiving hydroxychloroquine dosages greater than the recommended daily dosage based on lean body weight. 492
With the epidemic of obesity facing us, the best practice for the busy clinician may be to routinely note the height for patients prescribed hydroxychloroquine. We recommend that men shorter than 1.63 m and women shorter than 1.68 m have their daily dosage lowered from the default of 200 mg twice daily (400 mg/d) to prevent retinal toxic effects. Matthew D. Walvick, DO Chau H. Ngo, PharmD Author Affiliations: John Muir Medical Group, Walnut Creek, California (Walvick); Sutter Solano Medical Center, Vallejo, California (Ngo). Corresponding Author: Matthew D. Walvick, DO, John Muir Medical Group, 1450 Treat Blvd, Ste 250B, Walnut Creek, CA 94598 (matthew.walvick_d.o [email protected]). Published Online: January 2, 2015. doi:10.1001/jamaophthalmol.2014.3254. Conflict of Interest Disclosures: None reported. 1. Mititelu M, Wong BJ, Brenner M, Bryar PJ, Jampol LM, Fawzi AA. Progression of hydroxychloroquine toxic effects after drug therapy cessation: new evidence from multimodal imaging. JAMA Ophthalmol. 2013;131(9):1187-1197. 2. Pai MP, Paloucek FP. The origin of the “ideal” body weight equations. Ann Pharmacother. 2000;34(9):1066-1069. 3. Lahey JM, Lehmer JM, Walvick MD, Kolarik E, Lam DH. Incidence and characteristics of Plaquenil toxicity in a large population-based study. Poster presented at: 2008 Annual Meeting of the American Academy of Ophthalmology; November 10, 2008; Atlanta, GA. 4. Pautler SE. Hydroxychloroquine dosages should be calculated using lean body mass. Arch Ophthalmol. 2007;125(9):1303-1304. 5. Michaelides M, Stover NB, Francis PJ, Weleber RG. Retinal toxicity associated with hydroxychloroquine and chloroquine: risk factors, screening, and progression despite cessation of therapy. Arch Ophthalmol. 2011;129(1):30-39.
In Reply We thank Walvick and Ngo for their comments regarding the importance of dosing by ideal body weight in patients using hydroxychloroquine. First, we emphasize that our study was not designed or appropriate to address the question of prevention since we were mainly interested in the course of retinopathy following discontinuation. As alluded to by Walvick and Ngo, in our study we also found that at the time toxic effects were diagnosed, most patients were receiving dosages above the daily recommendations based on their ideal body weight (corrected for their height).1 The question of dosing has been addressed in previous studies, prompting the revised recommendations by the American Academy of Ophthalmology.2 Because the current recommended American Academy of Ophthalmology practice for screening includes a baseline examination, perhaps it is at that point we as ophthalmologists can impact the lives of these patients, paying attention to the question of dosing. Further, as a specialty, we are in need of a concerted effort to create better algorithms for follow-up. For example, with our first patient who developed toxic effects despite receiving a dosage much lower than the recommended dosage, would it have been more appropriate to closely follow a young patient with renal disease from baseline at a more stringent 6-month regimen or should we, in similar situations, recommend against the use of hydroxychloroquine altogether? If we follow such patients more closely, are we going to then face an onslaught of patients who need frequent screening?
JAMA Ophthalmology April 2015 Volume 133, Number 4 (Reprinted)
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://archopht.jamanetwork.com/ by a Cornell University User on 09/19/2016
jamaophthalmology.com
