What eye problems can hydroxychloroquine cause? An essential guide

October 11, 2025 •

3 min read

The risk of retinal toxicity from long-term hydroxychloroquine use is estimated to be up to 7.5% after five years of treatment for many patients. Understanding what eye problems can hydroxychloroquine cause is critical for preserving vision.

Quick Summary

Hydroxychloroquine, used for autoimmune diseases, can lead to irreversible retinal damage and vision loss with long-term use. Annual screenings are vital for early detection.

Key Points

Retinal Toxicity Risk: Hydroxychloroquine, especially with a daily dose relative to body weight exceeding a certain threshold or long duration (>5 years), can cause irreversible damage to the retina.
Early Detection is Crucial: Retinal toxicity is often asymptomatic in its early stages, so relying on symptoms is not enough to prevent permanent vision loss.
Screening Protocol: The American Academy of Ophthalmology recommends a baseline eye exam followed by annual screenings, starting earlier for high-risk patients.
Key Diagnostic Tests: SD-OCT and Automated Visual Field tests are the primary tools used for screening to detect subtle retinal changes.
Damage Can Progress: Even after discontinuing the medication, retinal damage from hydroxychloroquine can continue to progress, emphasizing the need for ongoing monitoring.
Other Eye Issues: Less severe, and usually reversible, ocular side effects include corneal deposits (keratopathy) and ciliary body dysfunction, causing glare or focusing problems.

Understanding Hydroxychloroquine's Ocular Impact

Hydroxychloroquine (Plaquenil) is used for autoimmune diseases like rheumatoid arthritis, lupus, and Sjögren's syndrome. Long-term use can cause eye problems, primarily affecting the retina, and the most serious is retinal toxicity or hydroxychloroquine retinopathy, which can lead to permanent vision damage. The drug builds up in the retinal pigment epithelium (RPE), causing cell damage. Since this damage is related to dose and duration and is mostly irreversible, regular monitoring is crucial for long-term users.

Hydroxychloroquine Retinopathy: The Primary Concern

Hydorxychloroquine retinopathy is a serious side effect that progresses slowly and is often not noticed by patients early on. Screening tests are necessary as symptoms are unreliable for early detection. This condition damages the macula, which is essential for central vision.

Symptoms of Retinopathy

While early signs are often missed, later symptoms may include:

Night blindness
Blurry central vision
Blind spots near the center of vision, making reading hard
Reduced ability to see red colors
Visual distortions or flashing lights

The Bull's-Eye Maculopathy

Advanced damage can appear as bull's-eye maculopathy, a ring of damage around the central fovea, indicating significant and often irreversible harm. In some ethnic groups, like Asian patients, the pattern of retinopathy may differ, requiring specific screening methods.

Other Potential Ocular Side Effects

Besides retinopathy, hydroxychloroquine can cause other eye issues that usually resolve when the drug is stopped.

Corneal Deposits (Keratopathy): Swirl-like deposits on the cornea that can cause glare or halos, rarely affecting vision and usually disappearing after stopping the drug.
Ciliary Body Dysfunction: Rarely, it can affect focusing, causing blurry near vision.

Who is at Risk?

Factors increasing the risk of hydroxychloroquine retinopathy include:

High daily dose relative to body weight
Long-term use (risk increases significantly after five years)
Kidney or liver problems
Using tamoxifen at the same time (increases risk about five times)
Older age when starting treatment
Existing macular disease

Essential Eye Screening for Hydroxychloroquine Users

Early detection is vital for preventing severe vision loss. The American Academy of Ophthalmology (AAO) provides screening guidelines.

Baseline Exam: A full eye exam within the first year to check for existing issues and set a baseline.
Annual Screening: Recommended annually starting after five years for most patients, or earlier for those with major risk factors.

Diagnostic Tools for Monitoring

Modern screening uses tests to detect subtle changes before vision loss.

Spectral-Domain Optical Coherence Tomography (SD-OCT): Shows detailed images of the retina, detecting early signs like thinning.
Automated Visual Field Testing: Checks for blind spots. Different patterns are used for Asian patients.
Fundus Autofluorescence (FAF): Shows stress in RPE cells.
Multifocal Electroretinography (mfERG): Measures retinal electrical activity, sensitive to early dysfunction.

Comparison of Screening Schedules

AAO guidelines recommend different screening based on risk:


Screening Aspect	Normal Risk Profile	High Risk Profile
Baseline Exam	Within the first year	Within the first year
Annual Screening Start	After five years	From the first year
Required Annual Tests	SD-OCT and 10-2 Visual Field	SD-OCT and 10-2 Visual Field (wider field for Asian patients)
Additional Tests	As needed	May include FAF or mfERG
Risk Factors Present	None	High dose, duration >5 years, kidney/liver disease, tamoxifen, older age, macular disease

Managing Hydroxychloroquine Toxicity

If toxicity is suspected, the eye doctor will work with the prescribing doctor to determine the best plan, often stopping the medication. Damage can continue even after stopping the drug as it leaves the body slowly. There's no cure for established damage, making early detection key. Be aware of other medications like tamoxifen that increase risk. Discuss treatment and monitoring with your doctors. The American Academy of Ophthalmology website is a valuable resource.

Conclusion

Hydroxychloroquine use carries a risk of irreversible retinal damage, but this risk is manageable with proper screening. Regular eye exams using advanced tests are essential for detecting toxicity early. By understanding risks and working with doctors, patients can benefit from the medication while protecting their vision.

Frequently Asked Questions

No, the retinal damage caused by hydroxychloroquine is generally considered irreversible. While some reversal of functional loss in very early cases is possible, established retinopathy is permanent and can progress even after the drug is stopped.

The American Academy of Ophthalmology recommends a baseline eye exam within the first year of starting the medication. For most patients without major risk factors, annual screening should begin after five years of treatment.

Risk factors include the daily dose relative to body weight, the duration of treatment, kidney or liver disease, concurrent use of tamoxifen, older age, and pre-existing macular disease.

Early retinal toxicity is often asymptomatic. When symptoms do occur, they can include difficulty with night vision, slight changes in color perception, or small blind spots near the center of vision.

Yes, basing dosage on actual body weight means that obese individuals may be receiving a higher dose per kilogram of actual body weight, which increases the risk of toxicity. Risk should be calculated based on actual body weight.

Primary screening tests include Spectral-Domain Optical Coherence Tomography (SD-OCT) and Automated Visual Field (10-2) testing. Fundus Autofluorescence (FAF) and Multifocal Electroretinography (mfERG) may also be used.

Do not stop taking the medication on your own. If toxicity is suspected, your ophthalmologist will consult with your prescribing doctor (e.g., your rheumatologist) to weigh the risks and benefits before making a decision to stop or adjust the dose.