Spectral-domain optical coherence tomography (SD-OCT) image and Humphrey visual field (HVF) from a 50-year-old woman who had been using Plaquenil 400 mg daily for 10 years to treat systemic lupus erythematosus. Notably, she also had lupus-related nephrotic syndrome. Her Plaquenil dosage, which was based on actual body weight, was 4.4 mg/kg/d. She was completely asymptomatic. However, SD-OCT (left) showed attenuation of the ellipsoid zone and interdigitation zone in a perifoveal pattern, with early “flying saucer” sign with relative preservation of the central photoreceptors. Given the characteristic superior arcuate defect on the 10-2 HVF (right), Plaquenil was stopped. It is likely that renal disease accelerated the presentation in this patient despite the dose being within the American Academy of Ophthalmology recommendation of 5 mg/kg/d or less. Therefore, clinicians should maintain heightened vigilance in patients with renal disease, especially when no alternatives to Plaquenil can be safely used.