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

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.