#LetsLearnOphthal

What are the latest 2026 guidelines for patients on Hydroxychloroquine?

𝐀𝐦𝐞𝐫𝐢𝐜𝐚𝐧 𝐀𝐜𝐚𝐝𝐞𝐦𝐲 𝐨𝐟 𝐎𝐩𝐡𝐭𝐡𝐚𝐥𝐦𝐨𝐥𝐨𝐠𝐲 (𝐀𝐀𝐎) 𝟐𝟎𝟐𝟔 𝐠𝐮𝐢𝐝𝐞𝐥𝐢𝐧𝐞𝐬 𝐟𝐨𝐫 𝐇𝐲𝐝𝐫𝐨𝐱𝐲𝐜𝐡𝐥𝐨𝐫𝐨𝐪𝐮𝐢𝐧𝐞(𝐇𝐂𝐐) 𝐑𝐞𝐭𝐢𝐧𝐨𝐩𝐚𝐭𝐡𝐲:

The guidelines update the 2016 version with new evidence on:

◾Risk factors

◾Patterns

◾Imaging(screening)

◾ Progression

ℝ𝕚𝕤𝕜 𝔽𝕒𝕔𝕥𝕠𝕣𝕤 𝕗𝕠𝕣 ℝ𝕖𝕥𝕚𝕟𝕒𝕝 𝕋𝕠𝕩𝕚𝕔𝕚𝕥𝕪

⚫ Exceeding the daily dose

⚫ Prolonged duration

⚫ Concurrent renal disease

⚫ Concomitant tamoxifen use

⚫ Initiation of HCQ therapy at older ages

𝔻𝕠𝕤𝕒𝕘𝕖 ℝ𝕖𝕔𝕠𝕞𝕞𝕖𝕟𝕕𝕒𝕥𝕚𝕠𝕟𝕤

The safe daily dosage threshold remains ≤𝟓.𝟎 𝐦𝐠/𝐤𝐠 𝐫𝐞𝐚𝐥 𝐛𝐨𝐝𝐲 𝐰𝐞𝐢𝐠𝐡t (unchanged from prior guidelines).

𝘍𝘰𝘳 𝘴𝘦𝘷𝘦𝘳𝘦𝘭𝘺 𝘰𝘣𝘦𝘴𝘦 𝘱𝘢𝘵𝘪𝘦𝘯𝘵𝘴, weight-based calculations may lead to overdosing—𝘴𝘵𝘢𝘳𝘵 𝘸𝘪𝘵𝘩 𝘢 𝘭𝘰𝘸𝘦𝘳 𝘥𝘰𝘴𝘦 𝘢𝘯𝘥 𝘤𝘢𝘱 𝘢𝘵 𝘢 𝘮𝘢𝘹𝘪𝘮𝘶𝘮 𝘰𝘧 400 𝘮𝘨/𝘥𝘢𝘺.

ℙ𝕒𝕥𝕥𝕖𝕣𝕟𝕤 𝕠𝕗 𝔻𝕚𝕤𝕖𝕒𝕤𝕖:

♦️ Patients of 𝐄𝐮𝐫𝐨𝐩𝐞𝐚𝐧 𝐚𝐧𝐜𝐞𝐬𝐭𝐫𝐲 most commonly exhibit a 𝐩𝐚𝐫𝐚𝐟𝐨𝐯𝐞𝐚𝐥 𝐩𝐚𝐭𝐭𝐞𝐫𝐧 of toxicity (𝐜𝐥𝐚𝐬𝐬𝐢𝐜 𝐛𝐮𝐥𝐥'𝐬-𝐞𝐲𝐞 𝐦𝐚𝐜𝐮𝐥𝐨𝐩𝐚𝐭𝐡𝐲).

♦️ Those of 𝐄𝐚𝐬𝐭 𝐀𝐬𝐢𝐚𝐧 𝐚𝐧𝐜𝐞𝐬𝐭𝐫𝐲 more frequently show a 𝐩𝐞𝐫𝐢𝐜𝐞𝐧𝐭𝐫𝐚𝐥 𝐩𝐚𝐭𝐭𝐞𝐫𝐧.

These are the predominant patterns, but exceptions are common—toxicity is not exclusive to one pattern.

𝘚𝘤𝘳𝘦𝘦𝘯𝘪𝘯𝘨 𝘱𝘳𝘰𝘵𝘰𝘤𝘰𝘭𝘴 𝘮𝘶𝘴𝘵 𝘵𝘩𝘦𝘳𝘦𝘧𝘰𝘳𝘦 𝘦𝘷𝘢𝘭𝘶𝘢𝘵𝘦 𝘣𝘰𝘵𝘩 𝘱𝘢𝘳𝘢𝘧𝘰𝘷𝘦𝘢𝘭 𝘢𝘯𝘥 𝘱𝘦𝘳𝘪𝘤𝘦𝘯𝘵𝘳𝘢𝘭 𝘳𝘦𝘨𝘪𝘰𝘯𝘴 𝘵𝘰 𝘢𝘷𝘰𝘪𝘥 𝘮𝘪𝘴𝘴𝘪𝘯𝘨 𝘤𝘢𝘴𝘦𝘴.

ℂ𝕝𝕚𝕟𝕚𝕔𝕒𝕝 𝕋𝕖𝕤𝕥𝕤 𝕗𝕠𝕣 𝕊𝕔𝕣𝕖𝕖𝕟𝕚𝕟𝕘:

𝐏𝐫𝐢𝐦𝐚𝐫𝐲 𝐭𝐨𝐨𝐥𝐬:

✅ 𝐒𝐩𝐞𝐜𝐭𝐫𝐚𝐥-𝐝𝐨𝐦𝐚𝐢𝐧 𝐨𝐩𝐭𝐢𝐜𝐚𝐥 𝐜𝐨𝐡𝐞𝐫𝐞𝐧𝐜𝐞 𝐭𝐨𝐦𝐨𝐠𝐫𝐚𝐩𝐡𝐲 (𝐒𝐃-𝐎𝐂𝐓) - ear;y signs of subtle outer nuclear layer thinning, ellipsoid zone disruption

✅ 𝐖𝐢𝐝𝐞-𝐩𝐚𝐭𝐭𝐞𝐫𝐧 𝐟𝐮𝐧𝐝𝐮𝐬 𝐚𝐮𝐭𝐨𝐟𝐥𝐮𝐨𝐫𝐞𝐬𝐜𝐞𝐧𝐜𝐞 (𝐅𝐀𝐅)

.𝐀𝐝𝐣𝐮𝐧𝐜𝐭 𝐭𝐞𝐬𝐭𝐬:

🟠 𝐀𝐮𝐭𝐨𝐦𝐚𝐭𝐞𝐝 𝐯𝐢𝐬𝐮𝐚𝐥 𝐟𝐢𝐞𝐥𝐝𝐬 (𝐕𝐅)

Newer VF protocols like 24-2C are highlighted for their ability to assess both parafoveal and pericentral areas effectively.

🟠 𝐌𝐮𝐥𝐭𝐢𝐟𝐨𝐜𝐚𝐥 𝐞𝐥𝐞𝐜𝐭𝐫𝐨𝐫𝐞𝐭𝐢𝐧𝐨𝐠𝐫𝐚𝐩𝐡𝐲 (𝐦𝐟𝐄𝐑𝐆)

𝕊𝕔𝕣𝕖𝕖𝕟𝕚𝕟𝕘 𝕊𝕔𝕙𝕖𝕕𝕦𝕝𝕖

𝐂𝐨𝐦𝐩𝐫𝐞𝐡𝐞𝐧𝐬𝐢𝐯𝐞 𝐛𝐚𝐬𝐞𝐥𝐢𝐧𝐞 𝐞𝐱𝐚𝐦 (𝐢𝐧𝐜𝐥𝐮𝐝𝐢𝐧𝐠 𝐎𝐂𝐓 𝐚𝐧𝐝 𝐅𝐀𝐅)

Soon after starting HCQ; ideally within the first year. The aim is to:

💠 Exclude pre-existing maculopathy

💠 Establish reference images for future comparison

𝐀𝐧𝐧𝐮𝐚𝐥 𝐬𝐜𝐫𝐞𝐞𝐧𝐢𝐧𝐠 is recommended during ongoing use of HCQ.

For 𝐥𝐨𝐰-𝐫𝐢𝐬𝐤 𝐩𝐚𝐭𝐢𝐞𝐧𝐭𝐬 (safe dose, no major risk factors), 𝐚𝐧𝐧𝐮𝐚𝐥 𝐬𝐜𝐫𝐞𝐞𝐧𝐢𝐧𝐠 𝐦𝐚𝐲 𝐛𝐞 𝐝𝐞𝐟𝐞𝐫𝐫𝐞𝐝 𝐟𝐨𝐫 𝐭𝐡𝐞 𝐟𝐢𝐫𝐬𝐭 𝟓 𝐲𝐞𝐚𝐫𝐬.

ℙ𝕣𝕠𝕘𝕣𝕖𝕤𝕤𝕚𝕠𝕟 𝕠𝕗 𝕋𝕠𝕩𝕚𝕔𝕚𝕥𝕪

𝐄𝐚𝐫𝐥𝐲 𝐝𝐞𝐭𝐞𝐜𝐭𝐢𝐨𝐧 is critical. 𝘐𝘧 𝘏𝘊𝘘 𝘪𝘴 𝘥𝘪𝘴𝘤𝘰𝘯𝘵𝘪𝘯𝘶𝘦𝘥 𝘸𝘩𝘦𝘯 𝘖𝘊𝘛 𝘤𝘩𝘢𝘯𝘨𝘦𝘴 𝘢𝘳𝘦 𝘮𝘪𝘭𝘥 (𝘭𝘪𝘮𝘪𝘵𝘦𝘥 𝘰𝘶𝘵𝘦𝘳 𝘳𝘦𝘵𝘪𝘯𝘢𝘭 𝘪𝘯𝘷𝘰𝘭𝘷𝘦𝘮𝘦𝘯𝘵), significant further 𝘱𝘳𝘰𝘨𝘳𝘦𝘴𝘴𝘪𝘰𝘯 𝘪𝘴 𝘶𝘯𝘭𝘪𝘬𝘦𝘭𝘺.

In 𝐚𝐝𝐯𝐚𝐧𝐜𝐞𝐝 𝐜𝐚𝐬𝐞𝐬—with 𝘦𝘹𝘵𝘦𝘯𝘴𝘪𝘷𝘦 𝘰𝘶𝘵𝘦𝘳 𝘯𝘶𝘤𝘭𝘦𝘢𝘳 𝘭𝘢𝘺𝘦𝘳 (𝘖𝘕𝘓) 𝘵𝘩𝘪𝘯𝘯𝘪𝘯𝘨, 𝘦𝘭𝘭𝘪𝘱𝘴𝘰𝘪𝘥 𝘻𝘰𝘯𝘦 (𝘌𝘡) 𝘥𝘢𝘮𝘢𝘨𝘦, 𝘰𝘳 𝘳𝘦𝘵𝘪𝘯𝘢𝘭 𝘱𝘪𝘨𝘮𝘦𝘯𝘵 𝘦𝘱𝘪𝘵𝘩𝘦𝘭𝘪𝘶𝘮 (𝘙𝘗𝘌) 𝘪𝘯𝘷𝘰𝘭𝘷𝘦𝘮𝘦𝘯𝘵—retinopathy can 𝘤𝘰𝘯𝘵𝘪𝘯𝘶𝘦 𝘵𝘰 𝘸𝘰𝘳𝘴𝘦𝘯 𝘧𝘰𝘳 𝘺𝘦𝘢𝘳𝘴 𝘥𝘦𝘴𝘱𝘪𝘵𝘦 𝘤𝘦𝘴𝘴𝘢𝘵𝘪𝘰𝘯, sometimes relentlessly, leading to central vision loss.