Prevention and detection of hydroxychloroquine-induced retinopathy in patients with systemic autoimmune diseases

Abstract

IntroductionHydroxychloroquine (HCQ) is prescribed in systemic autoimmune diseases for disease-modifying benefits. However, long-term HCQ use can cause irreversible retinal toxicity.Areas coveredKey articles were identified through searches of publications in PubMed and Embase from January 2000 to May 2025. Data indicate that retinopathy risk is low during the first 5-10 years of therapy but rises with longer exposure. High daily dose ( >5 mg/kg real weight), long-term use ( >5 years), renal impairment, and tamoxifen use are key risk factors. Guidelines emphasize weight-based dosing (<= 5 mg/kg/day) and regular ophthalmologic screening. The American Academy of Ophthalmology (AAO) recommends baseline fundus exam and annual screening after 5 years of HCQ use if no high-risk features, using spectral-domain optical coherence tomography (SD-OCT) and automated visual fields as primary tests. Four recommended screening modalities by AAO and Royal College of Ophthalmologists include SD-OCT, fundus autofluorescence, automated visual fields, and multifocal electroretinography.Expert opinionDespite advancements in understanding and detecting HCQ retinopathy, challenges remain in defining a truly safe dose, achieving early detection, and ensuring adherence to screening guidelines. Ongoing research into imaging biomarkers, genetic susceptibility, and AI-driven tools aims to enhance early detection and personalize screening, ultimately improving outcomes and reducing vision loss.