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Microaneurysms are seen in inferior temporal region and a small temporal macula area (arrows). Hypo-and hyperfluorescent images of the fovea (asterisk) are not modified during the angiogram.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Synthetic antimalarials in the treatment of systemic lupus erythematosus (SLE) have been a major therapeutic advance and serve as immunomodulators and inhibitors of thrombosis, with few side effects, prolonging the quality of life of patients. Their withdrawal leaves the patient with SLE at the mercy of the side effects of corticosteroids and immunosuppressants, and increases the risk of flares.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Hydroxychloroquine can cause severe retinal toxicity, requiring discontinuation of therapy, although there are few cases of cloroquine retinopathy, always related to very high cumulative drug dose.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Synthetic antimalarial toxicity is detected by ophthalmic screening protocols focused on development of macular pathology.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> One must not forget that the patient with SLE is predisposed to retinal ischemia that may be confused with macular damage due to cloroquine. We present a case in which the ocular findings represented a challenge in the therapeutic decision.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Case Report</span><p id="par0020" class="elsevierStylePara elsevierViewall">A 50-year-old woman with SLE was treated with a umulative dose of 365<span class="elsevierStyleHsp" style=""></span>g of hydroxychloroquine for 13 years, with mild lupus nephritis and hypertension controlled 5 years prior; during her screening for ocular toxicity she presented moderate loss of vision, presenting a corrected visual acuity of 0.7 in the right eye and 1 in the left eye. In the right fundus we observed irregular areas of hyperpigmentation and depigmentation in the macula, without apparent serous uprising, and some arcades microhemorrhages. The left fundus appeared normal. 10-2 the visual field was normal in both eyes. Optical coherence tomography (OCT) of the right eye showed hyperreflective foveal thickening and hyporreflective cavities in deep layers (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). The OCT of the left eye was normal. Fluorescein angiography (FA) showed no bull's-eye pattern, but microaneurysms in both eyes (not detected on fundoscopy), sectoral distribution and hyper-and hypofluorescence late macular leakage (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). In the multifocal electroretinogram (mfERG) there were low amplitude responses in both peripheral retinas, low power density in the foveal region of the right eye and normal foveolar activity in the left eye (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>). The alteration of the N95 wave of the electroretinogram pattern reflected a dysfunction of the ganglion cells of both retinas, probably causing the disease.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">The neurophysiological findings, the OCT and FA suggested a vascular origin rather than a toxic effect, so it toxicity was ruled out and hydroxychloroquine retinopathy was diagnosed as lupus, recommending the maintenance of the antimalarial but with close monitoring of the patient to prevent maculopathy as a risk factor. In subsequent visits the patient maintained her visual acuity and had improved lupus symptoms with hydroxychloroquine maintenance treatment, which confirmed the suspected end diagnosis.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Discussion</span><p id="par0030" class="elsevierStylePara elsevierViewall">In the early alterations of the visual field as a sign of cloroquine maculopathy 10-2, central mfERG, OCT and autofluorescence have recently been added as diagnostic tests, with their use recommended for routine screening.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Central mfERG shows very early alterations,<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> but its availability is scarce.</p><p id="par0035" class="elsevierStylePara elsevierViewall">The field of view of our patient was normal in both eyes, which ruled cloroquine maculopathy. The mfERG showed macular dysfunction only in the right eye and asymmetry is rare in drug toxicity. The results of the AGF and the rest of neurophysiological studies suggested an episode of retinal ischemia. The OCT image was reminiscent of a rare form of central serous chorioretinopathy, lupus<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> choroidopathy, while microaneurysms in cuneiform distributions were more typical of hypertensive episodes.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Faced with a maculopathy in a patient with SLE treated with hydroxychloroquine, we must not forget that they are patients exposed to thrombotic events that can generate retinal confusion, so that additional tests may be necessary to make an adequate differential diagnosis, because without maculopathy there is no need for drug withdrawal, even to assess an increase in dosage.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Ethical disclosures</span><p id="par0050" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Protection of human and animal subjects.</span> The authors declare that no experiments were performed on humans or animals for this investigation.</p><p id="par0055" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Confidentiality of Data.</span> The authors declare that they have followed the protocols of their work centre on the publication of patient data and that all the patients included in the study have received sufficient information and have given their informed consent in writing to participate in that study.</p><p id="par0060" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Right to privacy and informed consent.</span> The authors have obtained the informed consent of the patients and /or subjects mentioned in the article. The author for correspondence is in possession of this document.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conflict of Interest</span><p id="par0045" class="elsevierStylePara elsevierViewall">The authors have no disclosures to make.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:2 [ "identificador" => "xres125902" "titulo" => "Abstract" ] 1 => array:2 [ "identificador" => "xpalclavsec113196" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres125901" "titulo" => "Resumen" ] 3 => array:2 [ "identificador" => "xpalclavsec113197" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Case Report" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Discussion" ] 7 => array:2 [ "identificador" => "sec0025" "titulo" => "Ethical disclosures" ] 8 => array:2 [ "identificador" => "sec0020" "titulo" => "Conflict of Interest" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2011-09-09" "fechaAceptado" => "2011-12-08" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec113196" "palabras" => array:4 [ 0 => "Lupus erythematosus" 1 => "Hydroxychloroquine" 2 => "Central serous chorioretinopathy" 3 => "Multifocal electroretinography" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec113197" "palabras" => array:4 [ 0 => "Lupus eritematoso" 1 => "Hidroxicloroquina" 2 => "Coriorretinopatía central serosa" 3 => "Electrorretinografía multifocal" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">A 50-year-old woman with systemic lupus erythematosus treated for 13 years with hydroxychloroquine developed nephropathy and high blood pressure 5 years ago as well as moderate loss of vision in her right eye. Fundoscopy showed alterations of macular pigmentation only in the right eye. Visual fields 10-2 were normal in both eyes. Optical coherence tomography showed hyperreflective foveal thickening with a hyporreflective cavity underlying in the right macula, and was normal in left macula. Fluorescein angiography showed no bulls-eye pattern, but did show microaneurysms in vascular arcades. Multifocal central electroretinogram was diminished in right eye and the electroretinogram pattern was diminished in both eyes. We concluded that the alterations of the right eye were suggestive of ischemic maculopathy, not chloroquine toxicity.</p>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Una mujer de 50 años con lupus eritematoso sistémico, tratada 13 años con hidroxicloroquina y desde hace 5 años con nefropatía e hipertensión arterial, refirió en la revisión periódica pérdida moderada de visión en el ojo derecho. La fundoscopia mostró solo alteraciones de la pigmentación macular en el ojo derecho. El campo visual 10-2 fue normal en ambos ojos. La tomografía de coherencia óptica mostró en la mácula derecha un engrosamiento foveal hiperreflectivo, con cavidad hiporreflectiva subyacente, y fue normal en la mácula izquierda. La angiografía fluoresceínica no mostró patrón en ojo de buey, sino microaneurismas en arcadas vasculares. El electrorretinograma multifocal central estaba disminuido en el ojo derecho y el electrorretinograma patrón moderadamente disminuido en ambos ojos. En conclusión, las alteraciones del ojo derecho fueron indicativas de maculopatía isquémica, pero no de toxicidad cloroquínica.</p>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara">Please cite this article as: Rodríguez-Hurtado FJ, et al. Maculopatía en paciente con lupus eritematoso sistémico tratado con hidroxicloroquina. Reumatol Clin. 2012. <span class="elsevierStyleInterRef" href="doi:10.1016/j.reuma.2011.12.012">doi:10.1016/j.reuma.2011.12.012</span></p>" ] ] "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 3493 "Ancho" => 3167 "Tamanyo" => 1151768 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Optical coherence tomography of the right eye of the patient showing discrete thickening of the fovea, with a hyporeflective space in the outer layers of the retina (arrows).</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 2361 "Ancho" => 3153 "Tamanyo" => 688538 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Central multifocal electroretinogram with 100 hexagons. We observe a moderate decrease in the rpower density of the foveal region of the right eye (no white areas).</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1248 "Ancho" => 1493 "Tamanyo" => 174326 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Angiography of the right eye. Microaneurysms are seen in inferior temporal region and a small temporal macula area (arrows). Hypo-and hyperfluorescent images of the fovea (asterisk) are not modified during the angiogram.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "A long-term study of hydroxychloroquine withdrawal on exacerbations in systemic lupus erythematosus. The Canadian Hydroxychloroquine Study Group" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "E. Tsakonas" 1 => "L. Joseph" 2 => "J.M. Esdaile" 3 => "D. Choquette" 4 => "J.L. Senécal" 5 => "A. 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Year/Month | Html | Total | |
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2024 November | 15 | 16 | 31 |
2024 October | 59 | 42 | 101 |
2024 September | 61 | 22 | 83 |
2024 August | 67 | 45 | 112 |
2024 July | 58 | 30 | 88 |
2024 June | 70 | 43 | 113 |
2024 May | 61 | 44 | 105 |
2024 April | 51 | 22 | 73 |
2024 March | 64 | 27 | 91 |
2024 February | 55 | 24 | 79 |
2024 January | 52 | 22 | 74 |
2023 December | 53 | 32 | 85 |
2023 November | 60 | 46 | 106 |
2023 October | 49 | 49 | 98 |
2023 September | 111 | 43 | 154 |
2023 August | 121 | 20 | 141 |
2023 July | 70 | 20 | 90 |
2023 June | 81 | 37 | 118 |
2023 May | 69 | 25 | 94 |
2023 April | 67 | 6 | 73 |
2023 March | 59 | 33 | 92 |
2023 February | 81 | 30 | 111 |
2023 January | 48 | 34 | 82 |
2022 December | 71 | 41 | 112 |
2022 November | 117 | 37 | 154 |
2022 October | 92 | 47 | 139 |
2022 September | 127 | 41 | 168 |
2022 August | 107 | 34 | 141 |
2022 July | 44 | 45 | 89 |
2022 June | 89 | 35 | 124 |
2022 May | 60 | 49 | 109 |
2022 April | 85 | 48 | 133 |
2022 March | 74 | 57 | 131 |
2022 February | 81 | 41 | 122 |
2022 January | 60 | 38 | 98 |
2021 December | 50 | 41 | 91 |
2021 November | 65 | 48 | 113 |
2021 October | 81 | 56 | 137 |
2021 September | 73 | 40 | 113 |
2021 August | 83 | 37 | 120 |
2021 July | 63 | 25 | 88 |
2021 June | 84 | 32 | 116 |
2021 May | 78 | 46 | 124 |
2021 April | 128 | 70 | 198 |
2021 March | 122 | 34 | 156 |
2021 February | 80 | 27 | 107 |
2021 January | 53 | 19 | 72 |
2020 December | 55 | 27 | 82 |
2020 November | 45 | 27 | 72 |
2020 October | 38 | 13 | 51 |
2020 September | 57 | 35 | 92 |
2020 August | 28 | 33 | 61 |
2020 July | 37 | 42 | 79 |
2020 June | 44 | 27 | 71 |
2020 May | 41 | 18 | 59 |
2020 April | 61 | 20 | 81 |
2020 March | 32 | 16 | 48 |
2020 February | 1 | 0 | 1 |
2020 January | 4 | 0 | 4 |
2019 September | 4 | 0 | 4 |
2019 June | 1 | 0 | 1 |
2019 May | 1 | 0 | 1 |
2019 March | 1 | 0 | 1 |
2019 January | 1 | 0 | 1 |
2018 December | 2 | 0 | 2 |
2018 May | 5 | 1 | 6 |
2018 April | 90 | 8 | 98 |
2018 March | 62 | 6 | 68 |
2018 February | 46 | 3 | 49 |
2018 January | 37 | 5 | 42 |
2017 December | 45 | 7 | 52 |
2017 November | 52 | 5 | 57 |
2017 October | 31 | 10 | 41 |
2017 September | 51 | 7 | 58 |
2017 August | 66 | 13 | 79 |
2017 July | 68 | 12 | 80 |
2017 June | 97 | 11 | 108 |
2017 May | 89 | 13 | 102 |
2017 April | 78 | 12 | 90 |
2017 March | 62 | 16 | 78 |
2017 February | 55 | 8 | 63 |
2017 January | 55 | 14 | 69 |
2016 December | 87 | 19 | 106 |
2016 November | 82 | 9 | 91 |
2016 October | 118 | 11 | 129 |
2016 September | 164 | 10 | 174 |
2016 August | 80 | 8 | 88 |
2016 July | 49 | 13 | 62 |
2016 May | 1 | 0 | 1 |
2016 February | 1 | 0 | 1 |
2016 January | 3 | 0 | 3 |
2015 December | 2 | 0 | 2 |
2015 November | 1 | 0 | 1 |
2015 October | 1 | 0 | 1 |
2015 September | 1 | 21 | 22 |
2015 August | 1 | 0 | 1 |
2015 July | 28 | 5 | 33 |
2015 June | 74 | 6 | 80 |
2015 May | 71 | 17 | 88 |
2015 April | 58 | 7 | 65 |
2015 March | 65 | 7 | 72 |
2015 February | 58 | 5 | 63 |
2015 January | 57 | 10 | 67 |
2014 December | 64 | 15 | 79 |
2014 November | 75 | 8 | 83 |
2014 October | 68 | 12 | 80 |
2014 September | 68 | 14 | 82 |
2014 August | 56 | 14 | 70 |
2014 July | 62 | 21 | 83 |
2014 June | 72 | 10 | 82 |
2014 May | 59 | 18 | 77 |
2014 April | 68 | 17 | 85 |
2014 March | 88 | 21 | 109 |
2014 February | 60 | 18 | 78 |
2014 January | 65 | 23 | 88 |
2013 December | 64 | 10 | 74 |
2013 November | 68 | 10 | 78 |
2013 October | 62 | 15 | 77 |
2013 September | 53 | 11 | 64 |
2013 August | 56 | 14 | 70 |
2013 July | 45 | 10 | 55 |
2013 June | 59 | 10 | 69 |
2013 May | 48 | 14 | 62 |
2013 April | 53 | 12 | 65 |
2013 March | 42 | 22 | 64 |
2013 February | 42 | 10 | 52 |
2013 January | 55 | 20 | 75 |
2012 December | 47 | 15 | 62 |
2012 November | 47 | 19 | 66 |
2012 October | 18 | 18 | 36 |