Blue Sclera and Retinal Hyperpigmentation in a Patient With Long-term Minocycline Use

A woman in her 80s complained of mildly distorted vision in both eyes for several months. Best-corrected visual acuity was 20/25 OD and 20/40 OS. Intraocular pressure was 16 mm Hg OD and 17 mm Hg OS. Her medical history included rheumatoid arthritis treated with minocycline, 100 mg twice daily, for more than 10 years. External examination revealed blue-gray discoloration of the nail beds and bilateral sclera (Figure, A). Ophthalmoscopic and optical coherence tomography findings demonstrated a bluish appearance to the macula with associated pigmented retinal pigment epithelium deposits (Figure, B) consistent with minocycline-induced retinal hyperpigmentation.¹ The lack of choroidal hyperreflectivity suggested no associated pigmented choroidal nevus. Given the unknown, long-term visual relevance of minocycline-induced retinal hyperpigmentation, the patient was switched from minocycline to methotrexate, 10 mg weekly, with supplementation of folic acid to manage her rheumatoid arthritis.^2- 4