Facts from the Foundation of the ASRS
Retina Health Series
Committed to improving the quality of life of all people with retinal disease

Hydroxychloroquine-Induced Retinal Toxicity

Hydroxychloroquine (HCQ), sold under the brand name Plaquenil, is a medication used to treat autoimmune diseases like rheumatoid arthritis and lupus. While it is very effective, long-term use can cause serious eye problems, including retinal damage and vision loss. About 7.5% of people on HCQ develop retinal issues, increasing to 20% after 20 years.

Download fact sheet

Symptoms

HCQ toxicity usually does not cause symptoms in the early stages. Patients typically do not notice any issues until the toxicity affects the central macula, a small area at the center of the retina where light is sharply focused to produce the detailed color vision needed for tasks such as reading and driving. When symptoms do appear, they include painless, progressive blurring of central vision.

Risk factors

Certain factors increase the risk of eye damage from HCQ: 

  • Daily dose over 6.5 mg/kg
  • Obesity
  • Use longer than 5 years 
  • Kidney or liver problems 
  • Age over 60
  • Existing retinal disease

Screening: Eye damage from HCQ can occur before symptoms appear (Figure 1). Early and regular eye exams are crucial. Guidelines suggest a baseline exam within the first few months of starting HCQ. If no other risks are present, follow-up exams are recommended yearly after the first 5 years.

Figure 1 Fundus photos of the right and left eyes show pigment loss around the center of the retina. Photo courtesy of Lejla Vajzovic, MD, FASRS

Figure 2 Simulated vision loss from HCQ retinal toxicity. *Vision loss looks different for each individual. Photo courtesy of Lejla Vajzovic, MD, FASRS

Diagnostic testing

  • Optical coherence tomography (OCT): Creates detailed images of the retina to detect early damage (Figure 3)
  • Visual field testing: Measures how well different parts of the retina respond to visual stimuli
  • Multifocal electroretinography (mfERG): Assesses retinal function in different areas of the retina
  • Fundus autofluorescence (FAF): Non-invasive test that shows changes in retinal cells (Figure 4)

Figure 3 OCT images of the right and left eyes show damage to the outer retina indicated by disruption with loss of some of the outer layers of the retina in the bottom of the cross section in a patient with HCQ-induced maculopathy. Photo courtesy of Lejla Vajzovic, MD, FASRS

Figure 4 Fundus autofluorescence (FAF) images show dark areas around the center, creating what is described as a bulls-eye maculopathy since it looks like the center of an archery target. Photo courtesy of Lejla Vajzovic, MD, FASRS

Treatment and prognosis

There is no treatment for HCQ-induced retinal damage. The best approach is early detection and stopping the medication if damage is found. Keeping the daily dose below 5.0 mg/kg can reduce the risk.

If eye damage is detected, switching to a different medication is recommended. After stopping HCQ, mild damage may improve. However, it is also possible that worsening could occur in the year following cessation, potentially leading to central vision loss.

Authors

THANK YOU TO THE RETINA HEALTH SERIES AUTHORS

  • Sophie J. Bakri, MD
  • Audina Berrocal, MD
  • Antonio Capone, Jr., MD
  • Netan Choudhry, MD, FRCS-C
  • Thomas Ciulla, MD, MBA
  • Pravin U. Dugel, MD
  • Geoffrey G. Emerson, MD, PhD
  • K. Bailey Freund, MD
  • Roger A. Goldberg, MD, MBA
  • Darin R. Goldman, MD
  • Dilraj Grewal, MD
  • Larry Halperin, MD
  • Vi S. Hau, MD, PhD
  • Suber S. Huang, MD, MBA
  • G. Baker Hubbard, MD
  • Mark S. Humayun, MD, PhD
  • Talia R. Kaden, MD
  • Peter K. Kaiser, MD
  • M. Ali Khan, MD

  • Ivana K. Kim, MD, FASRS

  • Eleonora Lad, MD, PhD

  • Anat Loewenstein, MD
  • Mathew J. MacCumber, MD, PhD
  • Maya Maloney, MD
  • Timothy G. Murray, MD, MBA
  • Hossein Nazari, MD
  • Oded Ohana, MD, MBA
  • Jonathan L. Prenner, MD
  • Gilad Rabina, MD
  • Carl D. Regillo, MD, FACS
  • Naryan Sabherwal, MD
  • Sherveen Salek, MD
  • Andrew P. Schachat, MD
  • Adrienne W. Scott, MD 
  • Michael Seider, MD
  • Janet S. Sunness, MD
  • Eduardo Uchiyama, MD
  • Lejla Vajzovic, MD, FASRS
  • Allen Z. Verne, MD
  • Christina Y. Weng, MD, MBA
  • Yoshihiro Yonekawa, MD

EDITOR

John T. Thompson, MD

Spanish Series Editors

  • J. Fernando Arevalo, MD, PhD
  • Gabriela Lopezcarasa Hernandez, MD
  • Andres Lisker, MD
  • Virgilio Morales-Canton, MD

CHINESE SERIES EDITORS

  • Albert Li, MD

MEDICAL ILLUSTRATOR

Tim Hengst

Copyright © The Foundation of the American Society of Retina Specialists. All rights reserved.