Editor’s Column February 2026
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A couple of months ago, the American Academy of Ophthalmology released an update to its recommendations on how to screen for hydroxychloroquine retinal toxicity. It took me by surprise because I thought they had just recently made an update… how much could have changed? Then I started to read the article and realized it had been nearly a decade since their last update to the screening procedures. And plenty has changed. It was a very well-written and informative article, and I encourage everyone to read it. Then I realized this was the fourth article put out about hydroxychloroquine recommendations by this same group at the AAO since 2002 – and I remember reading about each one. Each time a paper came out, it changed the way we managed these patients in our eye clinic – overnight. The first recommendation in 2002 focused on 10-2 visual fields and ERGs. Then, nine years later, in 2011, it introduced the concepts of: a cumulative dose of 1000g, using “ideal weight” in the 5mg/kg calculation, and the novel concept of using SD-OCT to check the retina for damage. Five years later, in 2016, the AAO advised to move away from ideal weight, to focus more on SD-OCT and to start taking Fundus Autofluorescence (FAF) images and introduced the findings that patients with Asian ethnicity had a much larger diameter bullseye of maculopathy.
Nine more years later, in 2025, the screening recommendations have changed again. The revision focuses on several parts. First, it directs the doctor’s attention in the OCT scans to the Interdigitation Zone as the area to first show damage, followed by the Ellipsoid Zone and then the External Limiting Membrane. Second, it again draws our attention to the fact that the diameter of the bullseye can vary depending on the ethnicity of the patient. But the revision is careful to mention that “a moderate percentage of patients from each group will show a contrary, or mixed pattern.” I think, rather than trying to only look for toxicity in a certain area for a certain ethnicity, the best way to approach this is simply to know that toxicity can happen anywhere in the posterior pole; don’t presume you know what diameter the bullseye will look like. Third, the revision focuses on the maximum of 5mg/kg dosing recommendations and the danger of exceeding this dosing. Keep in mind that this means if a patient is taking a dose of 200mg BID, and if that patient is under 176lbs, then they are taking a higher dose than recommended.
The revision ends by focusing on clinical tests, and this is where I think the biggest change in practice will come. It identifies SD-OCT and wide-angle FAF as primary tests, and visual fields and mf-ERGs as secondary, or confirmatory tests. It encourages the doctor to run the primary tests for every screening and to run a secondary test if the primary test shows any concern. Furthermore, the revision recommended 24-2C visual fields over the 10-2 visual fields, as a 10-2 is not wide enough to capture a larger-diameter bullseye.
For years in my clinic, once a patient is on hydroxychloroquine for over five years, we recommended follow up visits twice a year. On one visit, we did a DFE with OCT and FAF, and on the next visit, we ran a 10-2 visual field. It’ll be easy enough to switch to doing FAF using the 55o lens instead of the standard 30o lens. And switching from 10-2 to 24-2C is easy enough too. But I wonder if we need to be doing visual field testing at all? If the SD-OCT and widefield FAF are clear, will we skip the visual field in six months and just see the patient again in one year? What will you do in your practice?
It’s the sign of a powerful article – and the sign of a trusted institution – to be able to change the way doctors practice overnight. What are some articles that have changed practice overnight during your career? The DREAM study? A myopia or amblyopia study? I remember the rush to purchase pachymeters when the Ocular Hypertension Study came out. If your practice hasn’t changed in several years, maybe it’s because you aren’t paying as close attention to the literature as you used to. Look to the articles in this issue as a potential source to change the way you practice. Kaitlyn Rooney presents an impressively deep review of the ocular complications of illicit drugs. Annmarie Craig and team show us that xerophthalmia doesn’t just happen in underdeveloped countries, and describe what a clinician should check for in patients with the autistic spectrum disorder. Tyler Kitzman et al. write about an interesting case of MEWDS, which was found to be an epiphenomenon or secondary MEWDS. This was my first exposure to secondary MEWDS – be sure to check it out.
Finally, this issue’s featured article is a great case of Best disease by Zach Turple. It’s a tour de force that explores inherited retinal disease with multimodal retinal imaging, electrodiagnostic testing and genetic sequencing. Read these articles and see if you don’t find something that might revise the way you manage your next patient. After all, change is good. The opposite is stagnation.
Dr. Rett is the Editor-in-Chief of the Journal of Medical Optometry and the secretary for the American Board of Certification in Medical Optometry. He is the Chief of Optometry at VA Boston and sits on the national Field Advisory Board for Tele Eyecare at the VA. He is adjunct clinical faculty at several optometry schools, lectures nationally and enjoys writing about eyecare whenever and wherever.
