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

Introduction: Hydroxychloroquine (HCQ) is prescribed in systemic autoimmune diseases for disease-modifying benefits. However, long-term HCQ use can cause irreversible retinal toxicity.

Areas covered: Key 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 opinion: Despite 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.