Risk-Based screening and imaging strategies for hydroxychloroquine retinopathy: A prospective analysis from southern India

Abstract

Background: Hydroxychloroquine (HCQ) is a mainstay treatment in autoimmune diseases, but long-term use may result in irreversible retinal toxicity. This study aimed to evaluate the prevalence, risk factors, and optimal monitoring strategies for HCQ retinopathy.Materials and Methods: A prospective observational study was conducted among 210 patients receiving HCQ therapy at Al-Azhar Medical College, Kerala, from January to December 2020. All patients underwent ophthalmic evaluation, including 10-2 visual field, spectral-domain optical coherence tomography (SD-OCT), fundus autofluorescence (FAF), and multifocal electroretinography (mfERG). Risk stratification was performed based on duration, daily dose, renal function, and concomitant drug use. Associations were analyzed using logistic regression.Results: Mean age of participants was 52.6±11.4 years; 62.9% were female. Retinopathy prevalence was 8.1%, highest detection being with SD-OCT (8.1%), followed by visual fields (6.7%), FAF (6.2%), and mfERG (4.3%). Risk was significantly associated with daily dose >5.0 mg/kg (p = 0.008), HCQ duration >5 years (p = 0.001), and renal impairment (p = 0.034). Based on these findings, tailored monitoring strategies were developed for low-, moderate-, and high-risk categories.Conclusion: Routine screening using multimodal imaging and risk-based frequency can facilitate early diagnosis and prevention of HCQ-induced retinal damage. SD-OCT remains the most sensitive standalone modality. Personalized risk stratification can optimize screening in clinical practice.