Plaquenil Eye Screening: What the OCT and Visual Field Test Are Actually Looking For
Plaquenil Eye Screening at a Glance
Your eye doctor is looking for very early damage to the retina, the light-sensing layer at the back of your eye. Plaquenil can harm it in a small number of long-term users1. The damage starts in a ring around your sharpest vision, not in the middle of it. So you can have it and not feel it yet.
The scan and the field test find that ring first. The American Academy of Ophthalmology says the retina usually still looks normal to the naked eye when these tests first pick up damage2.
Most people on this drug never get retinal damage. Pooled results from 19 screening studies covering 15,338 adults found damage in about 1 of every 1,000 people in the first five years, rising to about 56 of every 1,000 by 15 years1.
Early Plaquenil damage is silent. It sits just off center, in the part of the retina you do not read with. A bull's-eye pattern a doctor can see just by looking into your eye is a late sign, and the Academy states it should no longer occur when screening is done properly2.
That is the logic of the schedule. The Academy reports that damage caught at a mild stage usually settles within about a year of stopping the drug, with a very low risk of losing central vision2.
You need one baseline visit soon after starting the drug, then yearly checks once screening has begun.
The Academy recommends a baseline exam soon after the drug is begun, with retinal photos, an OCT scan, and a wide-pattern autofluorescence photo2. Annual screening is recommended during treatment, though it may be deferred through the first five years for people with no significant risk factors, and it begins at once for people who have them2. If you are unsure where you sit, ask at your next visit.
What Hydroxychloroquine Can Do to the Retina
Plaquenil retinopathy is damage to the photoreceptors, the cells that turn light into signals, and in more severe disease to the pigment layer beneath them2. Plaquenil is the brand name; the drug itself is hydroxychloroquine.
It builds up in the retina over years, usually showing in a band around the fovea, the pinpoint at the dead center of the retina that handles reading and faces. EyeWiki describes the earliest change as disruption of the parafoveal ellipsoid zone, the bright band on the scan that marks healthy photoreceptors3.
The Academy states the damage is largely irreversible and that there is no proven therapy other than stopping the drug or lowering the dose2. That is a hard sentence to read, and it is exactly why the yearly schedule exists: found early, most cases stay mild.
Uncommon early, and still uncommon later when the dose stays in the recommended range. Pooled analysis of 19 screening studies found that a daily dose above 5.0 mg per kilogram of real body weight was a principal risk factor, along with chronic kidney disease, female sex, and Asian descent1.
In one health-system cohort of 3,325 long-term users, retinopathy by 15 years was found in about 27 of every 1,000 people in the lowest weight-based dose group, at or below that same threshold, and about 216 of every 1,000 in the highest group4. Most cases there were mild: of 81 people with retinopathy, 56 were graded mild, 17 moderate, and 8 severe4. The dose decision belongs to the doctor who prescribes it, not to your eye doctor and not to this page.
A few things raise the odds enough that your eye doctor may start yearly screening sooner.
In a cohort of 4,677 long-term users with masked review of results, retinopathy was more common in people who began the drug at age 65 or older, in women, in people with stage 3 or worse chronic kidney disease, and in people also taking tamoxifen5. The Academy likewise lists renal disease, tamoxifen use, and older age at the start of therapy among the main risk factors beyond dose and duration2.
| Risk factor | Why your eye doctor asks |
|---|---|
| Higher weight-based daily dose | The strongest changeable factor; your prescriber sets it |
| Years on the drug | Risk builds rather than leveling off |
| Reduced kidney function | The drug clears partly through the kidneys |
| Tamoxifen at the same time | Linked to higher risk in long-term users |
| Asian ancestry | Shifts which part of the retina is checked |
Having one of these does not mean damage is on its way. It means the schedule tightens, which is the point.
How to Get Ready for Your Screening Visit
Bring three facts: your current daily dose, the date you started the drug, and your latest kidney result if you have it.
A joint statement from the American College of Rheumatology, the American Academy of Dermatology, the Rheumatologic Dermatology Society, and the American Academy of Ophthalmology stresses direct communication between the prescriber and the eye care provider6. You are the fastest link in that chain, and these three facts are what your eye doctor needs from the other end of it.
You do not need to stop your Plaquenil before screening, and you do not need to fast. Screening measures damage that builds over years, so an ordinary dosing day is what your doctor wants to see.
Wear your glasses or bring them, and pack sunglasses in case your pupils are widened. The field test asks you to focus on a target in the center while small dim lights appear around it, and to press a button whenever you see one7. If you wear contact lenses, ask whether to keep them in.
What Happens During the OCT Scan and the Visual Field Test
The OCT is a camera that takes a cross-section picture of your retina using light. Nothing touches your eye.
It is a non-invasive imaging test that uses light waves to take cross-section pictures of the retina, letting the doctor see and measure each retinal layer8. You rest your head on a support to hold it still, the machine scans your eye without touching it, and scanning takes about 5 to 10 minutes8. It is quiet and painless; the hardest part is not over-blinking.
The field test measures what your retina can detect, rather than what it looks like.
You look into a bowl-shaped device called a perimeter and focus on a central target. Small dim lights appear in different places, you press a button whenever you see one, and the machine records the lights you do not perceive7. You may blink normally, and you may pause the test if you need a break7.
Most people find it tiring rather than uncomfortable. If your attention drifts, use the pause. Reliability matters more here than speed.
You may also get a wide photo showing how your retina glows under a particular color of light.
The Academy's current guidance names OCT together with wide-pattern fundus autofluorescence as the primary screening tools, with the photo reaching beyond the vessel arcades, roughly 30 degrees and ideally out to 50 or 55 degrees2. Autofluorescence can reveal early damage as a bright area that may appear before thinning shows on the scan3. It takes seconds, and having it added is not a sign anything is wrong.
Two people on the same drug can be handed different tests, and that is deliberate.
The Academy recommends a 10-2 field pattern for the parafoveal area, and a 24-2, 30-2, or 24-2C pattern when pericentral damage further out is the concern2. EyeWiki notes the area at risk sits typically 2 to 6 degrees from fixation in non-Asian patients, and that wider 24-2 or 30-2 patterns are recommended for patients of Asian descent, because damage may extend beyond the central macula3.
| Pattern | Where it sits | Field test used |
|---|---|---|
| Parafoveal | A ring close to the center of vision | 10-2 |
| Pericentral | A wider ring out near the vessel arcades | 24-2, 30-2, or 24-2C |
Your ancestry, your risk factors, and your last scan all shape which tests you get.
What the OCT Is Actually Looking For in Your Retina
On the scan, healthy photoreceptors appear as bright, continuous lines near the outer retina.
The one that matters here is the band where light-sensing cells pack their energy machinery (clinical: the ellipsoid zone, or EZ). Toxicity shows as focal granular fragmentation, thinning, or loss of that ellipsoid zone, and disruption of the external limiting membrane signals a more advanced stage2. Your doctor compares this year's lines against your earlier ones, which is why the baseline scan matters even though it is almost always normal.
This is the classic pattern, and it explains why damage stays invisible to you for so long.
Here the outer retina thins in the parafovea first, and the preserved central ellipsoid zone set against thinned tissue on either side produces a bright line under the fovea2. EyeWiki calls the same appearance the flying saucer sign: outer retinal layers stay intact under the fovea while the ellipsoid zone is lost on both sides3. This was the more common of the two patterns, seen in 102 of the 125 people who developed retinopathy in a 4,677 person cohort5.
Some people develop damage in a wider ring, well outside the small central zone a 10-2 field covers.
In this pattern there is marked thinning and loss of the marker lines beyond the parafovea, confirmed on wide-pattern autofluorescence2. In the same cohort, 23 of the 125 cases were pericentral, and among Asian patients with retinopathy, 54 of every 100 cases followed that pattern5.
Ancestry shifts the odds here rather than settling them. In that same cohort the pericentral subtype accounted for about 54 of every 100 retinopathy cases among Asian patients, which leaves the remaining cases, roughly 46 of every 100, following the parafoveal pattern instead5. That is why wide imaging is now standard, and why your own pattern is not assumed in advance.
What the Visual Field Test Is Actually Looking For
The field test hunts for a patch where your retina is less sensitive than it should be (clinical: a scotoma).
Visual field testing measures how wide an area your eye can see while you focus on a central point, and it detects blind spots called scotomas7. In early hydroxychloroquine retinopathy the typical finding is a paracentral scotoma, in the zone roughly 2 to 6 degrees out from fixation in non-Asian patients3. You do not feel a spot that small, because your other eye and your constant small eye movements paper over it all day.
Field results are plotted flipped relative to the retina, which is why the printout looks back to front.
The Academy notes early field defects are typically superonasal, meaning in the upper inner part of the field, corresponding to damage in the lower outer retina, and it recommends reading the pattern deviation plot from standard white testing2. If your printout shows a cluster of dark squares up and toward the nose side, that is the region your doctor will re-check on the scan.
Field testing leans on your attention and stamina, so results are read in context rather than one at a time.
The Academy's guidance is that questionable results should be repeated or validated with additional procedures, so valuable medication is not stopped unnecessarily2. The current revision positions visual fields and multifocal electroretinography as secondary, confirmatory tests alongside the primary scan and wide photo2. So an abnormal field on its own usually leads to a repeat test, not to a decision about your drug.
Making Sense of Your Results
A normal screening means no damage was detectable today, with the tests you had.
It does not mean you are permanently in the clear, because risk builds with years of use. Pooled screening data show the figure rising from roughly 1 of every 1,000 users at five years to roughly 56 of every 1,000 at fifteen years1. That is an argument for keeping the yearly appointment, not for worrying in between.
Expect a repeat, not a verdict. Multifocal electroretinography, which measures the electrical response of the retina point by point, is used for objective corroboration when results are unclear2.
The four-society joint statement warns against stopping hydroxychloroquine casually for borderline findings, describing it as a valuable drug that should not be avoided for fear of retinopathy6. A suspicious result usually buys closer watching, not an overnight change.
Not the eye doctor alone, and not you alone. The joint statement says the decision to discontinue should be reached through shared decision-making involving the patient, the prescribing physician, and the eye care provider, weighing disease severity against the estimated risk to vision6.
Stage shapes what comes next: where damage is mild and the external limiting membrane is intact, mild progression may continue about a year after stopping and then usually settles, while damage already involving that membrane or the pigment layer is described as likely to progress toward central vision loss even after the drug is stopped2. That difference is the whole argument for screening on schedule.
The Limits and Risks of Screening Itself
Neither test touches your eye, and neither uses radiation.
The scan is non-invasive and the machine scans your eye without touching it8. The realistic downsides are a few hours of dilation blur, tired eyes after the field test, and the time the visit takes.
Several familiar eye tests are specifically not recommended for this screening.
The Academy lists fundus exam and photography on their own, OCT angiography, time-domain OCT, fluorescein angiography, full-field electroretinography, the Amsler grid, color vision testing, and the electro-oculogram as not recommended for hydroxychloroquine screening2. If someone handed you an Amsler grid for home use, ask what it is meant for. It has a real role in other retinal conditions, and it is not the tool that finds this problem early.
The honest population picture is reassuring without being a promise.
In that health-system cohort, most retinopathy found was mild, with 56 of the 81 cases graded mild4. None of that forecasts your individual result; it describes what happens across large groups screened the way the guideline describes.
When to Call Your Eye Doctor Between Screenings
Screening is built for silence, so any change you actually notice is worth reporting.
- Words or letters dropping out mid-line while you read
- A blurry or blank patch near, but not exactly at, the center of your vision
- Colors looking washed out or duller than they used to
- Needing much more light to read than a year ago
- Trouble adjusting when you walk into a dim room
Any of these can have ordinary explanations, including a change in your glasses or a cataract. Call your eye doctor, say what changed and when, and ask whether your screening should move up.
For most people on this drug, routine means one screening visit a year once screening has started.
The Academy recommends annual screening with the scan and wide-pattern autofluorescence during treatment, beginning at once for people who carry significant risk factors2. Book it the same month each year and tie it to another annual task so it does not quietly slip.
An eye doctor with the right equipment, in contact with whoever prescribes the drug.
The four-society statement divides the work: the rheumatologist, dermatologist, or other non-ophthalmic clinician is responsible for proper prescribing, and the ophthalmologist or other eye care professional for detecting toxicity through screening6. When you book, say the words hydroxychloroquine screening, so the office schedules the scan and the field test rather than a glasses check.
Questions Patients Ask About Plaquenil Eye Screening
No, and nothing touches your eye. You rest your head on a support, look at a target, and the machine scans with light while you hold still. The Academy describes the scan as non-invasive, says the machine scans the eye without touching it, and puts scanning at about 5 to 10 minutes8. The usual complaint is that holding still feels awkward. If drops were used, the blur afterward lasts a few hours.
Often yes, but plan as though the answer is no the first time. Whether you get dilating drops depends on the equipment and on what your doctor wants to see, and the Academy notes an OCT may or may not require dilating drops, which widen the pupil8. Drops blur near vision and make daylight feel harsh for a few hours, so arrange a ride and bring sunglasses.
No, and year twelve is the wrong year to stop. Risk builds with duration rather than leveling off. Pooled results from 19 screening studies found damage in about 1 of every 1,000 users at five years, rising to about 56 of every 1,000 at fifteen years1. Annual screening is recommended during treatment, and the option to defer it applies only to the first five years, and only when there are no significant risk factors2. Normal results so far are good news about the years behind you, not a forecast.
Because the guidance changed. The Academy's 2025 revision, which replaced recommendations standing for about a decade, names the OCT scan together with wide-pattern fundus autofluorescence as the primary screening tools2. The reason is that some people develop damage in a ring further out than a central field test covers. The photo takes seconds and is not a sign anything is wrong.
Most often it means the field test needs repeating. Field testing depends on attention and stamina, and a single odd result is common. The Academy's guidance is that questionable results should be repeated or validated with additional procedures, so valuable medication is not stopped unnecessarily2. Your doctor may repeat the field or re-check the matching part of the scan.
What matters is the equipment and the protocol more than the letters after the name. The four-society joint statement assigns detection of toxicity to the ophthalmologist or other eye care professional, and proper prescribing to the rheumatologist, dermatologist, or other non-ophthalmic clinician6. Ask whether the office performs OCT and wide-pattern autofluorescence, and if it does not, ask for a referral.
More Questions About Results, Risk, and Next Steps
It depends heavily on the stage at which it was caught. The Academy describes mild retinopathy, found while the external limiting membrane is still intact, as showing mild progression for about a year after the drug is stopped and then usually settling, with a very low risk of losing central vision. Where that membrane or the pigment layer is already involved, the guidance describes progression toward central vision loss as likely even after stopping2. That gap between the two stages is what keeping the yearly appointment is for, and your eye doctor can tell you which side of it your own scan sits on.
It can, and it is worth raising directly. The Academy notes East Asian patients more often show pericentral damage near the vessel arcades rather than the parafoveal pattern, and recommends 24-2, 30-2, or 24-2C field patterns when pericentral damage is the concern2. In one cohort, 54 of every 100 Asian patients with retinopathy had the pericentral pattern5. A 10-2 field alone can miss damage sitting further out.
Not at present. The Academy states there is no proven therapy other than stopping the drug or reducing the dose, and that the damage is largely irreversible except possibly at the very earliest stages2. That is why screening exists and why the yearly appointment is worth protecting: catching it at a mild stage, before the pigment layer is involved, is what the guidance links to the milder course above.
Take this list to your next screening visit, or to whoever prescribes the drug.
- What is my current daily dose, and how does it compare with my body weight?
- Has my yearly screening clock started, or am I still inside the deferral window?
- Which visual field pattern did you use for me, and why that one?
- Did today's scan change compared with my baseline scan?
- Do my kidney results or other medications move me into a higher risk group?
- If anything looked borderline today, what is the plan and when do we repeat it?
- Who will pass today's results to my rheumatologist or dermatologist?
- Daftarian N et al., Arthritis Care & Research, doi:10.1002/acr.80033 (2026). Risk of Retinopathy with Long-Term Hydroxychloroquine in Rheumatic Disease: Systematic Review and Meta-Analysis (19 studies, 15,338 adults).
- American Academy of Ophthalmology clinical statement; also Marmor MF et al., Ophthalmology 2026;133(4):439-450 (2026). Recommendations on Screening for Hydroxychloroquine Retinopathy (2025 Revision, supersedes the 2016 revision).
- EyeWiki, American Academy of Ophthalmology (2025). Hydroxychloroquine Toxicity.
- Melles RB et al., Annals of Internal Medicine 2023;176(2):166-173 (2023). Hydroxychloroquine Dose and Risk for Incident Retinopathy: A Cohort Study (3,325 long-term users).
- Jorge AM et al., JAMA Network Open 2024;7(5):e2410677 (same health-system cohort as the 2023 dose analysis) (2024). Risk Factors for Hydroxychloroquine Retinopathy and Its Subtypes (4,677 long-term users).
- American College of Rheumatology, American Academy of Dermatology, Rheumatologic Dermatology Society and American Academy of Ophthalmology (2021). ACR, AAD, RDS and AAO 2020 Joint Statement on Hydroxychloroquine Use with Respect to Retinal Toxicity.
- American Academy of Ophthalmology, EyeSmart patient education (2024). Visual Field Testing.
- American Academy of Ophthalmology, EyeSmart patient education (2024). What Is Optical Coherence Tomography?.