Pericentral Plaquenil Retinopathy: Why Eye Damage Starts in a Different Place for Some Patients
Pericentral Plaquenil Retinopathy at a Glance
Plaquenil (hydroxychloroquine) can slowly harm the retina, the light-sensing layer at the back of your eye. In most patients of European background, the first damage sits in a ring close to the center of sight. Doctors call that the parafoveal pattern. In many patients of East Asian background, the first damage starts farther out, near the large blood vessels that arc across the retina. The American Academy of Ophthalmology's 2025 screening update describes this farther-out pattern, called pericentral, as the usual starting place in eyes of East Asian patients1. The drug is the same. The place your eye doctor needs to look is not.
Here is why that matters, and why it is fixable. A scan aimed only at the center can miss damage that begins farther out. A wider scan sees it. So the useful step is small: ask whether your screening covers the wider area. Most people on this drug never develop retinopathy, and those who do are usually found by a scan first.
Ancestry does not change what the drug does. It seems to change where the retina gives way first. In a series of 201 patients with hydroxychloroquine retinopathy, pericentral damage on its own was reported in about 50 of every 100 Asian patients, compared with about 2 of every 100 white patients2. A later analysis of 4,677 long-term users from the same health system found a similar split, with about 54 of every 100 cases in Asian patients showing the pericentral pattern compared with about 5 of every 100 cases in white patients3. That is a difference in geography inside the eye, not in how dangerous the drug is.
You need one question answered, not a course in retinal imaging. Ask whether your screening includes wide imaging and a wider visual field test, not only the standard center-focused pair. The 2025 Academy revision recommends macular OCT and wide-pattern autofluorescence imaging as the main screening tests, and notes that a 10-2 visual field shows parafoveal damage well while wider 24-2 or 30-2 patterns are needed to show pericentral damage1. If your eye doctor already screens this way, you have your answer.
How Plaquenil Affects the Retina in the First Place
Plaquenil is a prescription medicine used for autoimmune conditions including lupus, rheumatoid arthritis, and Sjogren's syndrome, and it works by lowering immune system inflammation4. Why the retina is affected is still being worked out. Researchers describe several proposed mechanisms for the retinal injury, including binding to melanin, interference with the cell's recycling process by making internal compartments less acidic, and disruption of the retinal cycle that renews the light-sensing pigment5. None is settled, which is part of why the pattern difference is unexplained.
For decades the textbook picture of this problem was a bull's eye: a doughnut of damage circling the very center of the retina. That parafoveal pattern sits roughly 2 to 6 degrees out from the fovea, the pinpoint at the center of sharpest sight, and it is what most eyes of patients of European heritage show5. Screening habits grew up around that picture, and a narrow, high-detail scan of the center is excellent at catching it.
The pericentral pattern is the same disease in a different place. Pericentral retinopathy is defined as retinal change 8 degrees or more from the fovea, out toward the major retinal blood vessels, rather than the 2 to 6 degree ring of parafoveal disease6. The two compare like this:
| What differs | Parafoveal (classic) | Pericentral |
|---|---|---|
| Where damage starts | Close to the center, about 2 to 6 degrees out | Farther out, 8 degrees or more from the center |
| Who shows it more often | Most patients of European background | Many patients of East Asian background |
| Tests that show it best | Narrow central scan plus a 10-2 visual field | Wide scan, wide autofluorescence, plus a 24-2 or 30-2 field |
Advanced disease can involve both zones, whichever one it started in5. The two patterns are starting points, not separate diseases.
Why Some Patients Get the Pericentral Pattern
The evidence comes from two settings, and it is worth being precise about that. In a 201-patient series drawn from one large American health system, pericentral damage was linked with longer drug use before detection, 19.5 years on average compared with 15.0 years for parafoveal cases, and those patients were found at a more advanced stage2. The 4,677-patient analysis came from that same health system and found Asian patients considerably more likely than white patients to show the pericentral subtype, with Black patients also showing a raised likelihood of it3. An independent group of 218 Korean patients screened in Korea gives the separate check: 9 were found to have retinopathy, and 8 of those 9 had a mainly pericentral pattern7.
No genetic variation has been consistently linked with hydroxychloroquine retinopathy, and while genetic factors may underlie the difference in how the disease presents in eyes of European and Asian patients, no specific genes have been identified1. So the pattern difference is a well-described observation without a confirmed cause. Because nobody can test you for a gene that predicts your pattern, the practical response is to screen for both.
Ancestry shapes where damage appears. Other factors shape whether it appears at all. In the 4,677-patient analysis, chronic kidney disease of stage 3 or higher and use of tamoxifen were both associated with higher retinopathy risk, while older age and female sex predicted the parafoveal subtype but not the pericentral one3. The 2025 Academy revision likewise identifies reduced kidney function and tamoxifen use as risk factors, alongside how long you have taken the drug and your daily dose relative to your body weight1. Your rheumatologist sets your dose, and it is worth asking how yours was calculated.
This page could easily be misread, so let us be plain. East Asian ancestry is linked with a different location of damage among the people who develop retinopathy. It is not a statement that you are likely to develop it. In that 4,677-person analysis, 125 people developed retinopathy of any kind across up to 15 years of use3. Most long-term users never develop it, and those who do are usually picked up on a routine scan while their sight is still good.
Symptoms of Pericentral Retinopathy and Why They Arrive Late
Silence is the defining feature of this condition, and it is the reason screening exists. Most patients who develop hydroxychloroquine toxicity have no visual symptoms whatsoever1. People with retinal damage from Plaquenil are not aware at first that they are losing vision4. Waiting to feel something is the one strategy that reliably fails. The upside is that a scan does not need you to feel anything, which is why the yearly appointment does more for your sight than watching for symptoms.
When symptoms do arrive, they tend to be odd rather than dramatic. The most recognizable visual field pattern in moderate to severe hydroxychloroquine retinopathy is a complete or partial ring-shaped blind area (clinical: ring scotoma), and a review of this retinopathy notes the damage was once thought rare because it was typically caught late, at an advanced stage where central vision loss was already noticeable5. With the pericentral pattern that ring sits farther from the center, so any gaps it produces fall off to the side of where you are looking rather than in your reading vision. Published descriptions of what pericentral patients notice are still thin, which is another reason screening runs on imaging rather than on symptoms.
An eye chart measures the pinpoint at the dead center of your retina. Pericentral damage begins nowhere near it. The Academy's 2025 revision states that central visual acuity is usually retained in hydroxychloroquine retinopathy until the severe and late stages of damage1. Someone can read the bottom line of the chart on the same day a scan shows a clear pericentral change. That is why the chart is never the screening test. Imaging carries the load here.
How Eye Doctors Find Pericentral Damage
The default macular scan is a narrow, detailed slice through the center of the retina. Detecting pericentral disease calls for wider testing, meaning a 30-degree or 9 mm OCT scan, wider-field autofluorescence imaging, or a 24-2 or 30-2 visual field, instead of relying on the standard 6 mm macular scan6. A narrow scan reading as normal is good news about the center of your retina, but it is not information about the zone where a pericentral change would begin. Widening the scan is a settings change on equipment most eye clinics already own.
Two imaging tests do most of the work in current screening. The 2025 Academy revision names macular OCT and wide-pattern fundus autofluorescence as the primary, objective screening tests, keeps visual fields and multifocal electroretinography as confirmatory tests, and recommends autofluorescence imaging that extends well beyond the central macula, ideally out to about 50 to 55 degrees1. OCT is a cross-section photograph of the retinal layers; autofluorescence maps how the supporting cell layer is faring. Together they show change well before your sight would register it.
Visual field testing is the button-pressing test that maps your blind spots. The 10-2 field pattern has high resolution for parafoveal toxicity, but wider test patterns such as 24-2 or 30-2 are needed to show pericentral damage1. The 10-2 examines only the central 10 degrees, so it can read as normal while a wider field shows the pericentral ring. If you have had 10-2 fields for years, that is worth one conversation, not alarm.
The 2025 Academy revision advises a baseline examination close to the start of therapy, then annual screening with OCT and autofluorescence, with deferral of annual screening during the first five years considered reasonable when no significant risk factors are present1. Academy patient guidance describes the same shape: a baseline eye examination, then yearly screening after about five years, or sooner for people at higher risk4. Risk factors such as reduced kidney function can move that start date earlier, so your own schedule is set with your history in hand.
What Happens If Screening Finds Pericentral Retinopathy
A screening finding starts a conversation. It is not an automatic instruction to stop your medicine. The 2025 Academy revision directs that once probable or definite signs of retinopathy are recognized, the decision to stop hydroxychloroquine be considered in collaboration with the patient and the prescribing physician1. That wording is deliberate. Hydroxychloroquine controls serious disease, and stopping it carries its own risks. Your eye doctor supplies the retinal picture, your prescriber weighs it against what the drug is holding at bay, and you are in that room too.
There is no drop, laser, or surgery that restores retinal cells lost to this drug. Vision loss from Plaquenil is not reversible4. The Academy states the retinopathy is generally not reversible, except possibly at the very earliest stages of toxicity1. Because the loss is permanent, the whole value of screening lies in catching change while the damaged area is still small, which is a target regular screening hits routinely.
Stopping the drug does not end the monitoring, because the retina is slow to settle. Among 80 eyes of 41 Korean patients followed for at least two years after the drug was stopped, 60 of those eyes had the pericentral pattern, and what happened next tracked with how far the damage had already gone: about one third of eyes with early pericentral damage progressed a little at first and then stayed stable or improved, most eyes with moderate damage kept progressing, and eyes with severe damage progressed throughout the follow-up8. So your eye doctor will keep imaging you for years afterward. That schedule is not a bad sign; it is how the team confirms things have settled.
Risks, Outlook, and What the Numbers Really Mean
The honest headline is that this is uncommon today. At recommended dosing, the Academy reports the likelihood of toxicity is below 1 in 100 within five years and stays below 2 in 100 even after ten years of use, and that even after twenty years the added risk in the following year is under 5 in 1001. A review of the wider literature reports a higher overall figure, roughly 7 or 8 of every 100 long-term users after more than five years of exposure5. Those figures come from different groups studied in different eras, and both are population averages, not a forecast for you.
The stage at which the problem is caught shapes what follows. Eyes with early and moderate retinopathy stayed stable for up to nine years after the drug was stopped, while eyes with severe retinopathy continued to worsen for as long as twenty years5. Progression can be halted by stopping the drug when toxicity is detected before damage reaches the retinal pigment epithelium, the supporting layer beneath the light-sensing cells, though some progression can still occur after stopping in advanced cases6. Early detection is the difference between those two outcomes.
It is easy to finish a page like this more frightened than the facts warrant. Retinal damage is described by the Academy as a rare side effect of the drug4. Screening usually finds trouble before symptoms appear, and the pericentral pattern is a reason to widen a test rather than to stop a medicine that is working for you. The most useful thing you can do is keep the screening appointments you are offered, in a format suited to your ancestry.
When to Call Your Eye Doctor or Rheumatologist
None of the changes below prove retinopathy, since ordinary eye conditions cause the same complaints. They do earn a prompt call to your eye doctor:
- A new patchy gap or blind area in your sight that does not clear when you blink
- New difficulty reading, or letters dropping out of words
- New trouble seeing in dim light or adjusting when you walk into a dark room
- Colors looking washed out or different between your two eyes
- A change in your sight that follows a change in your dose or your kidney function
A different set of symptoms is not about this drug at all and needs same-day care: sudden loss of vision, a dark curtain or shadow moving across your sight, a sudden shower of new floaters with flashing lights, or severe eye pain. Those point to other eye problems that are treated urgently, and treated quickly most of them do well.
Plenty belongs on a list for your next appointment rather than a phone call. Whether your screening covers the wider field, whether your dose suits your body weight, and when your next scan is due are routine agenda items. So are dry eyes, mild fluctuating focus, and the ordinary need for stronger reading glasses, none of which are features of this condition.
Two clinicians share this problem. The prescriber, usually a rheumatologist or dermatologist, owns the dose and the reason you take the drug. The eye doctor, an optometrist or ophthalmologist doing this screening, owns the imaging and its interpretation, and may refer complex findings to a retina specialist. Ask that your results be sent to your prescriber, and mention your ancestry to whoever books the tests, since that decides which visual field pattern is ordered.
Common Questions About the Pericentral Pattern
No, that is not what the research shows. East Asian ancestry is linked with where damage tends to start, not with a higher chance of severe sight loss on its own. The practical concern is different: pericentral damage sits outside the area a standard central scan covers, so it can go unnoticed longer if screening is not widened. Ask whether yours includes wide imaging and a 24-2 or 30-2 field.
No. It is more common in patients of East Asian background, but it turns up in other groups too. In the largest analysis published, Black patients also showed a raised likelihood of the pericentral pattern, and a small share of white patients had it as well. That is why current guidance is to screen in a way that catches either pattern in anyone, rather than picking the test by ethnicity.
Not wrong, but possibly incomplete for you. The 10-2 examines the central 10 degrees in fine detail and is very good at showing parafoveal damage. Pericentral change starts beyond 8 degrees from the center, so a 10-2 can read as normal while a wider 24-2 or 30-2 shows a ring of loss. Raise it as a question. Many practices have already moved to wider patterns.
Most likely you would not, and that is the honest answer. Early hydroxychloroquine retinopathy generally causes no symptoms at all, and pericentral damage sits away from the center of sight, so reading vision and eye chart results often stay normal. Only imaging reliably shows it at that stage, which is why screening runs on a calendar rather than on symptoms.
Not automatically, and not by your eye doctor alone. Current guidance is that stopping is considered jointly by you, your eye doctor, and the doctor who prescribes the drug, because hydroxychloroquine is controlling a serious condition and stopping carries real risks of its own. Some people stop, some change dose, and some continue with closer monitoring, depending on the stage of the change.
Existing damage does not repair itself, but stopping early changes what happens next. When toxicity is caught before the supporting layer beneath the light-sensing cells is affected, progression can be halted. Eyes with early or moderate changes have stayed stable for years after stopping, while eyes already at a severe stage worsened for much longer. The goal of screening is not repair; it is stopping the clock early.
More Questions About Screening, Ancestry, and Next Steps
There is no test to ask for. No specific genes have been identified that explain why eyes of European and Asian patients tend to show different patterns, and no genetic variation has been consistently linked with this retinopathy at all. Researchers suspect genetics plays some part, but nothing has been pinned down that a laboratory could test for. The substitute is simple: screen for either pattern.
No rule splits by fraction of ancestry, and the published studies did not test one. What is reasonable is to mention your background to whoever orders your tests and ask for the wider visual field pattern, since a 24-2 or 30-2 covers the central zone as well as the outer one. Widening the test costs nothing but a slightly longer appointment, and it removes the guesswork.
Largely yes, early on. Risk of any retinopathy stays low through the first years of use at recommended dosing, which is why annual screening can reasonably be deferred through the first five years when you have no added risk factors. The pattern question matters more as years accumulate, and pericentral cases have tended to be found after longer use.
No, because risk climbs with cumulative exposure rather than falling with a run of clear results. Reassuring scans tell you about the retina you had on those days, not about the years ahead. Guidance is for screening to continue annually throughout treatment once the early period has passed. It is a short appointment once a year, and it is what keeps a permanent loss from creeping up unnoticed.
A written list gets you further than remembering one question at the door. These are worth asking:
- Does my screening include wide imaging and a 24-2 or 30-2 visual field, not only a 10-2?
- Given my ancestry, should my imaging extend farther out than the standard macular scan?
- How was my daily dose worked out, and does it still suit my current body weight?
- Does my kidney function or any other medicine I take raise my risk?
- How many years have I been on this drug, and when did my annual screening start?
- If a change turns up on a scan, who decides what happens to my prescription, and how quickly?
- American Academy of Ophthalmology, clinical statement (Ophthalmology 2026;133:439-450) (2025). Recommendations on Screening for Hydroxychloroquine Retinopathy (2025 Revision).
- Melles RB, Marmor MF. Ophthalmology, peer-reviewed retrospective case series (PMID 25182842) (2015). Pericentral Retinopathy and Racial Differences in Hydroxychloroquine Toxicity.
- Jorge AM, Melles RB, Marmor MF, et al. JAMA Network Open, peer-reviewed longitudinal cohort study (PMC11082687) (2024). Risk Factors for Hydroxychloroquine Retinopathy and Its Subtypes.
- American Academy of Ophthalmology (EyeSmart) patient information (2026). What Is Plaquenil?.
- Yusuf IH, Charbel Issa P, Ahn SJ. Frontiers in Pharmacology, peer-reviewed review (2023). Hydroxychloroquine-induced Retinal Toxicity.
- Ahn SJ. Diagnostics (Basel), peer-reviewed literature review (PMC11353870) (2024). Classification of Hydroxychloroquine Retinopathy: A Literature Review and Proposal for Revision.
- Lee DH, Melles RB, Joe SG, et al. Ophthalmology, peer-reviewed retrospective observational study (PMID 25712474) (2015). Pericentral Hydroxychloroquine Retinopathy in Korean Patients.
- Ahn SJ, Seo EJ, Kim KE, et al. Ophthalmology, peer-reviewed multicenter retrospective cohort study (PMID 33129843) (2021). Long-Term Progression of Pericentral Hydroxychloroquine Retinopathy.