Plaquenil Toxicity

Receiving a diagnosis of hydroxychloroquine (Plaquenil) toxicity can be a distressing and confusing moment for patients. Many have been taking the drug for years–often without symptoms–and suddenly face the prospect of losing their vision. Unfortunately, once toxicity is confirmed, there is no medical treatment that can reverse the retinal damage.

However, the outcome depends greatly on how early the toxicity is detected and how quickly action is taken. In most cases, the only available intervention is to stop the medication immediately and monitor for further progression.

No Known Treatment for Retinal Toxicity

To date, there is no pharmacologic, surgical, or laser-based therapy that can treat Plaquenil-induced retinopathy or restore lost photoreceptors. Once structural damage has occurred–particularly in the retinal pigment epithelium (RPE) or photoreceptor layers–the changes are permanent and irreversible.

According to the 2016 American Academy of Ophthalmology guidelines, “retinopathy is not reversible, and there is no present therapy” once damage to retinal cells has occurred.

While some nutritional supplements (like lutein or zeaxanthin) are often discussed in the context of general eye health, there is no scientific evidence that they can halt or reverse Plaquenil toxicity.

Damage May Progress Even After the Drug Is Stopped

One of the more sobering aspects of Plaquenil toxicity is that retinal degeneration can continue even after the medication is discontinued. This is due to several factors:

• Hydroxychloroquine has a long half-life and remains stored in retinal tissue for months after cessation.
• Once retinal cells are metabolically injured, they may continue to decompensate over time, particularly if the RPE has already been compromised.
• The process is not immediate, but gradual worsening of visual field defects or OCT abnormalities can continue for 6–12 months or longer, even in the absence of further drug exposure.

That said, the rate and severity of progression depends on how early the condition was detected. The earlier the diagnosis–and the more intact the retinal architecture–the more likely it is that central vision will remain stable over time.

Best Outcomes Occur When Caught Before RPE Damage
Early detection is the single most important predictor of visual prognosis.
When Plaquenil toxicity is identified before the RPE and fovea are affected, discontinuing the medication can halt progression and preserve useful vision. At this early stage, imaging may show localized thinning of the photoreceptor outer segments or mild paracentral visual field loss–but visual acuity often remains near normal.

A 2014 study in JAMA Ophthalmology found that patients with early-stage toxicity (no visible RPE damage) showed only mild and stable changes after drug cessation, with preservation of central vision.

On the other hand, once the RPE is compromised and bull’s-eye maculopathy has developed, the risk of long-term vision loss becomes significantly higher. These patients may eventually experience:

• Widening of scotomas (blind spots)
• Central vision loss
• Decreased night vision and contrast sensitivity
• Legal blindness in severe cases

Because of this, timing of diagnosis is crucial–and failures in proper screening or delayed discontinuation can have devastating consequences.

Shared Decision-Making Is Essential

Discontinuing Plaquenil is not a decision to be made lightly. For many patients, especially those with systemic lupus erythematosus (SLE) or rheumatoid arthritis, hydroxychloroquine plays a central role in disease control. Stopping it too soon–or without alternative treatment plans–may trigger disease flares, joint damage, or life-threatening complications.

That’s why all medical guidance emphasizes the importance of shared decision-making between:

• The patient
• The prescribing physician (e.g., rheumatologist, dermatologist)
• The eye care provider (ophthalmologist or retinal specialist)

This collaborative approach ensures that:

• The severity of retinal damage is clearly communicated
• The risks of continued use are weighed against the risks of disease relapse
• Any decision to stop or continue Plaquenil is fully informed and medically justified

The 2020 Joint Statement from the ACR, AAO, AAD, and RDS affirms this position, stating that the drug should not be discontinued based on uncertain or borderline findings, and that continued monitoring and further testing are appropriate in such cases.