In the 1700s, Scottish physician George Cleghorn discovered quinine (from cinchona bark) could fight malaria. British soldiers in India began drinking quinine water (“tonic water”), but the bitter taste led them to add gin, lime, and lemon — the birth of Gin & Tonic.
Fast forward: quinine derivatives gave us hydroxychloroquine (Plaquenil) — still one of the safest and most effective drugs for rheumatic disease like SLE and RA.
And yet in practice, I’ve found something puzzling...
Rheumatologists are always very concerned about Plaquenil-induced maculopathy. For years, patients come to me convinced they could lose vision. But after carefully managing many many of these individuals, and now with OCT imaging, I have yet to see a single case of clinically significant maculopathy.
A JAMA study (4,677 patients, 5–15 years of follow-up) found only 2.7% developed retinopathy. The absolute risk is very low.
And here’s the irony: while Plaquenil worry dominates, oral steroids — used long-term by many rheumatology patients — induce ocular hypertension and cataracts in nearly 33% of individuals. Yet I have not once received a referral or concern from rheumatology about steroid risk.
So why the obsession with Plaquenil — and the silence on steroids?
This reveals a bigger truth: the real world is not about p-values and statistics, it’s about patterns, vigilance, and continuity of care. People deserve physicians who can contextualize risk and bring balance to the conversation, not instill unnecessary fear.
That’s the kind of holistic medically grounded philosophy which will define The Ophthalmic Physician.
👉 Curious? Read my new book "A Foundation for The Ophthalmic Physician" and help support a new specialty in medicine.
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With appreciation,
"John"
John R. Martinelli, MD, OD, FAAO
Founder, The Ophthalmic Physician
Pioneering Ophthalmic Medicine & the OD -> OMD Residency
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