Audit of Retinal Screening Protocol Adherence Among Patients Receiving Hydroxychloroquine at the Department of Rheumatology, Gulab Devi Teaching Hospital, Pakistan.

introductionHydroxychloroquine (HCQ) is a widely used drug for various rheumatological conditions. Long-term use may be associated with retinal toxicity, which is often asymptomatic in the early stages and may lead to irreversible vision loss. Regular retinal screening is recommended in patients on long-term HCQ therapy. This audit assessed compliance with HCQ retinal screening protocols and evaluated changes in adherence following targeted interventions. MATERIALS AND

methodsA two-cycle clinical audit was conducted in the Department of Rheumatology, Gulab Devi Teaching Hospital, Lahore, Pakistan. The first cycle (August-October 2025) included 50 patients receiving HCQ therapy. Data were collected using a structured proforma through review of medical records and patient interviews. Three indicators, based on the 2016 American Academy of Ophthalmology (AAO) recommendations, were assessed: baseline retinal screening within one year of HCQ initiation, annual screening in patients on HCQ for ≥5 years, and early screening in high-risk patients (<5 years of therapy). High-risk patients were defined as those with one or more recognized risk factors for HCQ retinopathy, including an HCQ dose >5 mg/kg/day based on actual body weight, renal impairment, pre-existing macular disease, or concurrent tamoxifen use, and receiving HCQ for less than five years. Documentation of ophthalmology referral was also assessed. Interventions included patient counselling, educational leaflets, mandatory ophthalmology referral, structured documentation of high-risk status, and improved coordination with ophthalmology services. The second cycle (February-April 2026) included 50 new, non-overlapping patients assessed using the same methodology.

resultsIn Phase 1, baseline retinal screening was documented in 12.0% (6/50), while 88.0% (44/50) had no record of screening. Annual screening in long-term users was 15.4% (4/26), and high-risk early screening was 9.1% (1/11). Ophthalmology referral was documented in 18.0% (9/50). Following interventions, baseline screening improved to 100% (50/50; p < 0.001). Annual screening improved to 76.0% (19/25; p < 0.001), and high-risk screening improved to 75.0% (9/12; p = 0.003). Ophthalmology referral improved to 100% (50/50; p < 0.001).

conclusionBaseline adherence to HCQ retinal screening was poor initially. Following structured interventions including counselling, referral pathways, and improved documentation, significant improvement was observed across all indicators. Some gaps remain in follow-up screening, particularly annual and high-risk monitoring, highlighting the need for continued reinforcement of guideline-based practice.