Ophthalmology

Diagnostic Testing: Making Sense of Your Eye Exams

At a Glance

Antimalarial retinal toxicity can begin before you notice vision changes, so scheduled screening matters. OCT and wide-field FAF look for structural damage, while visual fields and mfERG assess function and help confirm uncertain results.

Because retinal damage from antimalarial medications is irreversible, the goal of medical screening is to catch “pre-clinical” changes—microscopic signs of toxicity that appear before you notice any change in your vision ^[1]^[2].

Screening is not a single test, but a specialized process involving advanced imaging and functional checks. Understanding the timeline and the different types of tests can help you participate more actively in your care.

The Screening Timeline

Current guidelines from bodies like the American Academy of Ophthalmology (AAO) recommend a clear schedule for monitoring your eye health:

Baseline Exam: You should have a complete eye exam within the first year of starting hydroxychloroquine or chloroquine ^[3]. This “starting point” scan is critical because it allows your doctor to see the natural shape of your retina before the drug has had time to cause any changes ^[4].
Routine Annual Screening: If you have no major risk factors, annual screening typically begins after 5 years of continuous use ^[3].
High-Risk Screening: If you have major risk factors—such as a high daily dose, kidney disease, or taking tamoxifen—your doctor will likely recommend starting annual surveillance from the outset, or much earlier than the five-year mark ^[5]^[4].

Primary Screening Tests

Modern screening protocols emphasize a multimodal approach, combining both structural and functional assessments.

1. SD-OCT (The Structural Scan)

Spectral Domain Optical Coherence Tomography (SD-OCT) is a non-invasive, quick imaging test that uses light waves to take cross-section pictures of your retina ^[6]. Toxicity often shows up as a “thinning” or loss of the photoreceptor layer, which can be seen on these scans long before you feel any vision loss ^[7]^[8].

2. Wide-Field FAF (The Structural Map)

Fundus Autofluorescence (FAF) uses a special blue light to map out the health of the retinal pigment epithelium (RPE). Recent guidance places an increasing emphasis on combining OCT with wide-pattern FAF as primary structural tests ^[7]^[9].

3. Automated Visual Fields (The Functional Test)

This test measures your peripheral vision and sensitivity to light. You look at a central target and click a button whenever you see a small flash of light. It tests one eye at a time and can be fatiguing. (Tip: bring your reading glasses if you use them!)

10-2 Pattern: The standard test focusing on the central 10 degrees of vision ^[3].
30-2 or 24-2C Pattern: Wider patterns used to assess pericentral regions, highly recommended for patients of Asian descent or if wider damage is suspected ^[10]^[11].

4. mfERG (Multifocal Electroretinography)

mfERG objectively measures the electrical response of your retinal cells to light. It is often used as a secondary confirmatory test when other results are uncertain ^[12]^[4].

Confirming the Diagnosis

An isolated abnormal finding on a test—such as a single missed spot on a visual field test—does not automatically mean you have toxicity. Things like dry eyes, fatigue, or a misunderstanding of the test can cause unreliable results ^[13]^[14].

Because stopping your rheumatology medication is a major medical decision, questionable results should be repeated or corroborated with additional tests ^[3]. However, this is not an absolute “two-test rule”—if your doctor sees unequivocal, clearly diagnostic objective evidence of toxicity on your scans, they will not delay making a diagnosis ^[15]. The key is that your ophthalmologist uses their clinical judgment alongside multimodal imaging to confirm the toxicity before advising you to change your treatment ^[16].

Common questions in this guide

When should I have a baseline eye exam after starting hydroxychloroquine or chloroquine?

A complete baseline eye exam is generally recommended within the first year after starting hydroxychloroquine or chloroquine. It gives your eye doctor a reference point for comparing future retinal scans.

How often should I be screened for antimalarial retinal toxicity?

If you have no major risk factors, annual screening usually begins after five years of continuous use. People with a high dose, kidney disease, or tamoxifen use may need annual monitoring from the start or much earlier.

What tests are used to find hydroxychloroquine eye damage?

Screening combines structural tests, such as SD-OCT and wide-field fundus autofluorescence, with a functional visual field test. Multifocal electroretinography, or mfERG, may be used as a secondary test when results are unclear.

Does one abnormal visual field prove I have retinal toxicity?

No. Dry eyes, tiredness, or misunderstanding the test can produce an unreliable result, so your doctor may repeat it or compare it with another test. Clearly diagnostic objective findings on retinal scans may be enough to make the diagnosis without waiting for two abnormal tests.

Why might my doctor order a 30-2 or 24-2C visual field test?

These wider visual field patterns assess areas outside the central 10 degrees and can help detect pericentral damage. They may be especially useful for people of Asian descent or when wider retinal involvement is suspected.

Get notified when new evidence is published on Toxic maculopathy due to antimalarial drugs.

We monitor PubMed for new peer-reviewed studies on this topic and email a short summary when something meaningful changes.

Key takeaways

Retinal damage from hydroxychloroquine or chloroquine can be irreversible, so screening aims to detect early changes before vision symptoms appear.
A baseline complete eye exam is generally recommended within the first year, while annual screening usually starts after five years for people without major risk factors and earlier for those at high risk.
SD-OCT and wide-field FAF look for structural retinal changes, while visual fields assess function and mfERG can help clarify uncertain findings.
One abnormal test does not automatically prove retinal toxicity because fatigue, dry eyes, or misunderstanding the test can affect results.
Wider 30-2 or 24-2C visual field patterns may help assess pericentral damage, especially in people of Asian descent or when wider damage is suspected.

References (16)

1
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Yusuf IH, Han RC, Downes SM, Sharma SM
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PMID: 39085597
2
Unmet needs and future perspectives in hydroxychloroquine retinopathy.
Yusuf IH, Charbel Issa P, Ahn SJ
Frontiers in medicine 2023; (10()):1196815 doi:10.3389/fmed.2023.1196815.
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Ophthalmology 2016; (123(6)):1386-94.
PMID: 26992838
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Target in Sight: A Comprehensive Review of Hydroxychloroquine-Induced Bull's Eye Maculopathy.
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Cost-effectiveness of hydroxychloroquine retinopathy screening: the current guideline versus no screening and reduced regimens.
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6
Prevention and detection of hydroxychloroquine-induced retinopathy in patients with systemic autoimmune diseases.
Kim KE, Ahn SJ
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PMID: 40762522
7
Clock-hour topography and extent of outer retinal damage in hydroxychloroquine retinopathy.
Kim KE, Kim JH, Kim YH, Ahn SJ
Scientific reports 2022; (12(1)):11809 doi:10.1038/s41598-022-15217-3.
PMID: 35821509
8
New proposal for a multimodal imaging approach for the subclinical detection of hydroxychloroquine-induced retinal toxicity in patients with systemic lupus erythematosus.
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9
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10
Visual field examinations using different strategies in Asian patients taking hydroxychloroquine.
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Scientific reports 2022; (12(1)):14778 doi:10.1038/s41598-022-19048-0.
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11
Diagnostic Accuracy of a Humphrey 24-2C Protocol for Simultaneous Parafoveal and Pericentral Hydroxychloroquine Retinopathy Screening.
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12
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13
Scotoma analysis of 10-2 visual field testing with a white target in screening for hydroxychloroquine retinopathy.
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14
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15
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16
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This page explains screening tests for antimalarial-related retinal toxicity for informational purposes and does not replace medical advice. Your ophthalmologist and prescribing clinician should interpret your results and decide whether medication changes are needed.