The potential for permanent vision loss from a widely prescribed medication has prompted eye specialists to update their surveillance strategies after a decade of clinical experience. Hydroxychloroquine, commonly used for autoimmune conditions like lupus and rheumatoid arthritis, can cause irreversible retinal damage that develops silently over years before symptoms appear. The American Academy of Ophthalmology has issued revised screening guidelines that reflect new understanding of how this toxicity manifests across different populations and how modern imaging can detect it earlier. The updated recommendations maintain the established daily dose limit of 5 milligrams per kilogram of body weight, while emphasizing that severely obese patients should not exceed 400 milligrams daily regardless of weight. Importantly, the guidelines now recognize distinct patterns of retinal damage between ethnic groups, with European patients typically developing central vision problems while East Asian patients more commonly experience peripheral vision loss. The screening protocol prioritizes optical coherence tomography and fundus autofluorescence imaging as primary detection tools, relegating visual field testing to a confirmatory role. These imaging techniques can identify structural retinal changes before patients notice vision problems, potentially preventing irreversible damage. This revision represents a significant evolution in preventive ophthalmology, moving from reactive symptom-based detection to proactive structural monitoring. For the millions of patients taking hydroxychloroquine long-term, these guidelines offer a more sophisticated approach to preserving vision while maintaining access to an essential therapeutic agent. The emphasis on baseline examinations and population-specific screening patterns reflects how precision medicine principles are being applied to drug safety monitoring.