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Plaquenil therapy and eye exams...

  I was told from the start by my rheumatologist I would have to have eye exams including visual field exams every six months due to the plaquenil therapy.  My first two exams did include these tests.  But my next six month appointment is coming up, and they told me I didn't need the visual field test this time so the appointment would be shorter.  So what is the deal?  After two normal visual field exams, does that mean further visual field testing need be done at less frequent intervals, despite continuing plaquenil therapy?  What tests should be done at the six month interval?  Certainly, I have had no problem whatsoever from the plaquenil...but even knowing plaquenil induced eye problems are rare...I would like to make sure they continue to follow the proper guidelines.  I am also on low dose prednisone, I have taken prrednisone daily for 18 months at levels ranging from 2.5 mg to 5 mg....with periodic boosts to 60 mg with a fast taper back down to 5 mg.  Could this level of prednisone lead to any eye problems?  I do have dry eyes.
  Question 2:  my daughter also has what is probably lupus.  She is 14.  She also has had Graves' Disease since age 8...and is on antithyroid medications.  the graves' is probably still active based on the enlargement of the thyroid....but has been well controlled on medication.  At 8, she had the bulging eyeballs, but this completely resolved within a few months of treatment.  After being found to have lupus like symptoms and positive ANA and positive antidsDNA, we were told she would need annual exams by an opthamologist since lupus can affect the eyes.  Other than "dry eyes" what kind of problems was our pediatrician talking about with eyes that would stem from the lupus.  Interestingly enough, I tried to have her monitored by opthamologist yearly following her bout with bulging eyeballs...but insurance wouldn't pay for it after her eyeballs resolved...despite the Graves still being active.  Yet they will pay for the yearly exam since she has a lupus diagnosis....why?  I'm glad they do...but what is it about lupus that would trigger the insurance company to be generous when they denied opthamologic follow up despite a history of Graves' induced bulging eyeballs?  thanks for your help!
The management of patients on plaquenil has been a controversial subject.  Alot of the concerns are related to the problems caused by chloroquine, the predecesor to hydroxychloroquine (Plaquenil).  It was much more toxic to the retina and much more likely to cause permanent visual problems.  Hydroxychloroquine, on the other hand, is much less toxic to the retina and there have been fewer reported eye problems.  In general, a baseline ophthalmic examination should be performed upon initiation of therapy.  In addition, a central visual field test and color photographs of the retina are usually taken at that time.  There are differing opinions regarding subsequent follow-up exams.  The most conservative opinion would include exams every 6 months with repeat visual fields every 6 to 12 months.  My general feeling is to perform annual exams with visual field testing.  One study determined that the risk of retina toxicity when patients are taking less than 6.5 mg per kilograms per day is rare.  This means that a person weighing 150 lbs is likely to be safe if they are taking 200 mg twice daily.  I calculate this number regularly and if the person is on more than 6.5 mg per kg per day than I will follow them more closely.
Lupus can cause eye or eyelid problems but fortunately serious ocular problems are not the rule.  Lupus may be cause corneal problems and 1/3 of patients may have an associated dry eye syndrome.  There is also a risk of retinal blood vessel problems which could lead to decreased vision.  Due to these potential eye problems, a yearly examination would be recommended.
With respect to your question regarding your insurance company, I would ask that you speak to your insurance company.  We deal with these frustrations on a regular basis and sometimes there is no logic behind what they do.  As far as I can see, this examination should be covered because your daughter has a medical condition that could be associated with potential serious eye problems if not detected early.  Good Luck.
This information is provided for general medical education purposes only.  Please consult your doctor regarding specific questions.
*Keywords: lupus, plaquenil ,retinal disease, dry eye syndrome

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