Special AAO Report: Recommendations on Screening for Hydroxychloroquine Retinopathy (2025 Revision)

Clinical Snapshot

Key Findings

• P Value: Not applicable for guideline

• Effect Size: Not applicable for guideline

• Primary Outcome: Updated screening recommendations for hydroxychloroquine retinopathy

• Nnt Or Sensitivity: OCT and fundus autofluorescence recommended as primary screening tools with high sensitivity for early detection

• Confidence Interval: Not applicable for guideline

Clinical Application

High - uses widely available imaging technologies (OCT, fundus autofluorescence) in most ophthalmology practices Highly relevant to Australian practice where hydroxychloroquine is PBS-listed for rheumatoid arthritis and lupus. Aligns with RANZCO screening practices and Medicare item numbers for OCT imaging All patients receiving hydroxychloroquine therapy, with specific considerations for different ethnic groups

Abstract

BACKGROUND: The American Academy of Ophthalmology recommendations on screening for hydroxychloroquine (HCQ) retinopathy are now a decade old. This revision provides an update based on current knowledge. Major points and changes are as follows. NATURE OF TOXICITY: The retina typically remains clinically normal for many years on HCQ, but there is an unpredictable point at which signs of toxicity may develop. PATTERN OF TOXICITY: Most eyes of patients of European heritage have a parafoveal pattern of toxicity, whereas eyes of East Asian patients tend to present with pericentral toxicity, but there are many exceptions, and screening examinations should look for both patterns. DOSAGE: The recommended daily dosage remains unchanged at ≤5.0 mg/day/kg real weight. Keep under 400 mg/day for severely obese patients. RISK FACTORS: Beyond dose and duration, concurrent renal disease and tamoxifen use increase risk, as does initiation of HCQ therapy at an older age. CLINICAL TESTS: The primary screening tool should be OCT, along with wide-pattern fundus autofluorescence (FAF). Visual field (VF) and multifocal electroretinography (mfERG) are secondary confirmatory tests. Newer VF algorithms such as 24-2C can screen parafoveal and pericentral regions simultaneously. SCREENING: A baseline screening examination, including fundus, OCT, and FAF, is advised soon after HCQ is begun, not only to rule out preexisting conditions but also for comparison with later results. Annual screening with OCT and FAF is recommended while using HCQ, but may be deferred during the first 5 years if there are no significant risk factors. PROGRESSION: Mild retinopathy is unlikely to progress after discontinuation of HCQ, but severe retinopathy may continue to worsen for many years. IMPLICATIONS OF EARLY SIGNS OF TOXICITY: With earlier recognition comes greater need to communicate with patients and their medical providers regarding options to stop HCQ or continue with cautious monitoring. NEW TECHNOLOGY: There have been experimental advances in imaging and artificial intelligence analysis for HCQ screening, but none have been validated for general use or are widely available at this time. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found after the references.

References

1. 1.Marmor, M. F., Ahn, S. J., Ehlers, J. P., Melles, R. B., Mieler, W. F., Sarraf, D., & Yusuf, I. H. (2025). Special AAO Report: Recommendations on Screening for Hydroxychloroquine Retinopathy (2025 Revision). Ophthalmology. https://doi.org/10.1016/j.ophtha.2025.11.001