# Subtle Presentations and Diagnostic Complexities of Hydroxychloroquine Retinopathy: A Case Series

## TL;DR

This paper presents three cases where retinal damage from long-term hydroxychloroquine use was missed until later stages, highlighting the need for better screening and awareness.

## Contribution

The study emphasizes the diagnostic challenges of early hydroxychloroquine retinopathy and advocates for improved interdisciplinary coordination and adherence to screening guidelines.

## Key findings

- Early signs of retinal toxicity were overlooked in three patients on long-term hydroxychloroquine therapy.
- Diagnostic evaluations using advanced imaging failed to detect retinopathy until later stages.
- The cases highlight the need for structured, multimodal screening and improved clinician awareness.

## Abstract

Hydroxychloroquine (HCQ) is widely used in managing autoimmune disorders but carries a notable risk of retinal toxicity, particularly with prolonged therapy. Early detection remains critical yet challenging, given the subtlety of initial clinical and imaging findings. We report a case series of three female patients (aged 68, 49, and 48 years), all of whom were on long-term HCQ therapy for rheumatoid arthritis and inflammatory polyarthritis.

Early retinal toxicity indicators such as subtle ellipsoid zone disruption, perifoveal pigmentary alterations, and initial visual field defects were overlooked in all three patients, leading to delayed recognition of HCQ-induced retinopathy. Despite robust screening recommendations and guidelines and comprehensive diagnostic evaluations including spectral-domain optical coherence tomography and multifocal electroretinography, practical challenges like inconsistent follow-ups and uncertainty in clinical decision-making complicated timely intervention.

These cases underscore the necessity of vigilant, structured, multimodal screening for HCQ retinopathy, emphasizing early recognition and proactive management. Improved clinician awareness, strict adherence to screening guidelines, and robust interdisciplinary coordination between ophthalmologists and prescribing physicians are essential to prevent irreversible visual impairment associated with HCQ use.