Intended for healthcare professionals

Endgames Picture Quiz

Blurred vision: targeting a diagnosis

BMJ 2013; 347 doi: (Published 12 September 2013) Cite this as: BMJ 2013;347:f5209
  1. Charlotte P Buscombe, foundation year 2 doctor ,
  2. Siying Lin, specialist registrar in ophthalmology,
  3. Nicholas J Wilson-Holt, consultant ophthalmologist
  1. 1Royal Cornwall Hospital, Truro TR1 3LJ, UK
  1. charlotte.buscombe{at}

A 68 year old woman with a longstanding history of non-specific inflammatory arthritis (which had been extensively investigated) was referred to the ophthalmologist with a three month history of flashing lights and blurred vision. Her regular drugs included meloxicam, omeprazole, amitriptyline, and 400 mg hydroxychloroquine, which she had been taking daily for 15 years. She was of normal body weight.

Ophthalmological assessment showed a reduced visual acuity at 6/18 in the right eye and 6/12 in the left eye, with mild depression in colour vision on Ishihara plate testing. Early cataracts were present, and fundal examination identified bilateral changes in epithelial retinal pigment at both posterior poles.Visual field testing showed bilateral annular scotomas.

She was referred for further investigations, including colour fundus photography, which show bilateral disturbance of retinal pigments at both maculas giving a “bull’s eye” appearance (fig 1)

Fig 1 Colour fundal photography of both eyes at presentation


  • 1 What is the likely underlying diagnosis?

  • 2 What are the predisposing risk factors for this condition?

  • 3 How should this condition be investigated?

  • 4 What measures should be taken to aid early detection of this condition?


1 What is the likely underlying diagnosis?

Short answer

The central visual field loss suggests macular disease, and fundus photography shows characteristic “bull’s eye” retinopathy. Because this patient is being treated with hydroxychloroquine, this finding is strongly suggestive of a toxic retinopathy secondary to this drug.

Long answer

Hydroxychloroquine is commonly used to treat inflammatory and …

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