The Royal College of Ophthalmologists (RCOphth) guideline1 was published in response to emerging evidence of harm associated with HCQ, and that with current retinal imaging techniques it was possible to detect the earliest signs of pre-symptomatic retinal toxicity. The guidance was produced with the support of rheumatologists, dermatologists and ophthalmologists.
The CCEHC was subsequently approached by commissioning groups and providers asking for clarification on some aspects of the guidelines. To facilitate this, a working group was formed from CCEHC members and others involved in the commissioning of services. The group produced a series of questions covering the most frequently raised issues and have been working through these with Chair of the RCOphth Guideline Development Group (GDG).
The RCOphth is aware of the potential commissioning and delivery challenges that are involved with the implementation of this guideline.
The following points are intended to provide greater understanding and clarity around terminology and responsibilities.
Terminology - the guideline relates to monitoring and not screening. Uncertainties around the responsibility for commissioning the necessary service have arisen over the term “screening” used in the Guideline. The guideline recommendations are for monitoring for retinal toxicity as a side effect of HCQ prescribed for the management of a number of chronic systemic (non-ocular) diseases. The UK National Screening Committee has confirmed that this does not constitute screening.
Responsibility for commissioning services for monitoring HCQ retinopathy rests with those who commission the services that require the prescription of HCQ and the primary prescribers of HCQ, with advice from ophthalmologists for developing referral and monitoring pathways.
Responsibility for arranging monitoring assessment for HCQ retinopathy lies with the primary prescriber. This includes identification of the eligible patient population and arranging for monitoring at baseline and ongoing regular review.
Responsibility for providing the monitoring assessment lies with the provider of the monitoring service and ophthalmologist/lead service clinician. The RCOphth provides guidance on the clinical and diagnostic assessment required for retinal toxicity, including
equipment specifications. The volume of activity generated for the delivery of these monitoring assessments is posing significant additional burden on HES clinics that are already under considerable capacity pressures.
Summary and developments
- Terminology: The GDG is making the relevant changes to the terminology (monitoring rather than screening) used in the guideline and its associated resources.
- Equipment: The GDG is reviewing the need for visual fields for monitoring.
- Clinical activity: The GDG is awaiting peer review of new evidence emerging on the timing of baseline assessment against likely risk. This may better guide the appropriate starting point for regular monitoring which may delay but not eliminate the need to do so.
The CCEHC welcomes these developments; and that new evidence may be emerging which streamlines the monitoring pathway. It is important that commissioners and providers are made aware that service requirements may be subject to change in the near future.
Reference:
- RCOphth. Hydroxychloroquine and Chloroquine Retinopathy: Recommendations on Screening. January 2020.
CCEHC February 2020
ENDS