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A 68 year old woman with a longstanding history of non-specific inflammatory arthritis (which had been extensively investigated) was referred to the ophthalmologist with a three month history of flashing lights and blurred vision. Her regular drugs included meloxicam, omeprazole, amitriptyline, and 400 mg hydroxychloroquine, which she had been taking daily for 15 years. She was of normal body weight. Ophthalmological assessment showed a reduced visual acuity at 6/18 in the right eye and 6/12 in the left eye, with mild depression in colour vision on Ishihara plate testing. Early cataracts were present, and fundal examination identified bilateral changes in epithelial retinal pigment at both posterior poles.Visual field testing showed bilateral annular scotomas. She was referred for further investigations, including colour fundus photography, which show bilateral disturbance of retinal pigments at both maculas giving a “bull’s eye” appearance (fig 1⇓) Fig 1 Colour fundal photography of both eyes at presentation ### 1 What is the likely underlying diagnosis? #### Short answer The central visual field loss suggests macular disease, and fundus photography shows characteristic “bull’s eye” retinopathy. Because this patient is being treated with hydroxychloroquine, this finding is strongly suggestive of a toxic retinopathy secondary to this drug. #### Long answer Hydroxychloroquine is commonly used to treat inflammatory and …