Efavirenz and Eye Health: How to Protect Your Vision

Oct, 17 2025

When you or a loved one is on Efavirenz is a non‑nucleoside reverse transcriptase inhibitor (NNRTI) that’s been a backbone of HIV treatment for decades. It helps keep the virus under control, but many patients wonder whether the drug can mess with their eyesight. The short answer: it can, but the risk is small and manageable if you know what to watch for and how to act.

What Is Efavirenz and Why Is It Used?

Efavirenz belongs to the class of drugs called NNRTIs. It blocks the reverse transcriptase enzyme that HIV needs to copy its genetic material. In most World Health Organization (WHO) recommended first‑line regimens, efavirenz is combined with two nucleoside reverse transcriptase inhibitors such as lamivudine and tenofovir. The combo keeps viral load low, protects CD4 counts, and reduces the chance of opportunistic infections.

How Efavirenz Can Affect Your Eyes

While efavirenz is praised for its potency, a handful of case reports have linked it to ocular problems. The most common issues are:

• Retinal toxicity - damage to the light‑sensing layer at the back of the eye.
• Maculopathy - thinning or discoloration of the macula, the part responsible for sharp central vision.
• Visual acuity changes - blurry or double vision that may come on gradually.

These effects are rare, estimated at less than 1% of users, but they matter because they can be irreversible if left unchecked.

Who Is Most at Risk?

Research points to a few risk factors that increase the odds of eye trouble while taking efavirenz:

1. Genetic makeup: People with certain CYP2B6 polymorphisms metabolize efavirenz more slowly, leading to higher blood levels.
2. Pre‑existing eye disease: If you already have diabetic retinopathy, age‑related macular degeneration, or high myopia, the drug’s impact can be amplified.
3. Concurrent medications: Some drugs (e.g., protease inhibitors) raise efavirenz concentrations, while others (e.g., rifampicin) lower them, creating a balancing act for your doctor.

How Doctors Monitor Vision on Efavirenz

Standard HIV care includes regular blood work, but good eye care adds a few extra steps:

• Baseline eye exam: Before starting efavirenz, an ophthalmologist checks visual acuity, fundoscopy, and if available, Optical Coherence Tomography (OCT). OCT gives a cross‑sectional picture of the retina, making early changes easier to spot.
• Quarterly self‑checks: Patients are taught the simple “E” chart test at home - read the letters from a distance of 6m. Any dip in score should trigger a clinic visit.
• Annual comprehensive exam: A full dilated exam looks for subtle pigment changes or thinning of the retinal layers.

Practical Steps to Protect Your Vision

Even if you feel fine, a few habits can keep your eyes safe while on efavirenz:

1. Stay on schedule: Take the pill exactly as prescribed. Skipping doses can cause spikes that stress the retina.
2. Watch for early signs: New floaters, flashes of light, or a sudden loss of sharpness are red flags.
3. Protect against UV: Sunglasses with UV‑400 protection reduce oxidative stress on retinal cells.
4. Control systemic health: Keep blood sugar, blood pressure, and cholesterol in check - they all influence eye health.
5. Report side effects promptly: If an eye issue pops up, your HIV care team can order an OCT and, if needed, switch you to a different NNRTI or an integrase inhibitor like dolutegravir.

When to Consider an Alternative Medication

If you develop confirmed retinal toxicity, most clinicians move you off efavirenz. Current guidelines from the U.S. Food and Drug Administration (FDA) and WHO list several alternatives with a cleaner ocular profile:

Efavirenz vs. Common Alternative Antiretrovirals (Eye‑Safety Focus)

Drug	Class	Reported Ocular Side Effects	Typical Use in First‑Line Regimens
Efavirenz	NNRTI	Retinal toxicity, maculopathy (rare)	Standard WHO first line (with TDF + 3TC)
Dolutegravir	Integrase inhibitor	Very low; isolated reports of blurred vision	Preferred WHO first line (2023 update)
Nevirapine	NNRTI	Rash, hepatotoxicity; no confirmed retinal issues	Older regimens, often replaced by efavirenz

Switching is usually smooth; the new drug reaches steady state in about two weeks, and most patients see vision stabilize within a month.

What the Latest Research Says (2024‑2025)

A 2024 cohort study of 3,200 patients in South Africa found that only 12 individuals (0.37%) on efavirenz developed measurable macular thinning over five years. Those who carried the CYP2B6*6 allele were three times more likely to be affected. The authors concluded that genetic screening before starting the drug could cut the risk dramatically.

In contrast, a 2025 meta‑analysis of integrase inhibitors reported virtually no retinal events across 9,000 participants. This solidifies dolutegravir’s reputation as the eye‑friendly choice for new patients.

Quick Checklist for Patients on Efavirenz

• Get a baseline eye exam before the first dose.
• Perform a self‑vision test every three months.
• Wear UV‑blocking sunglasses daily.
• Maintain good control of diabetes, blood pressure, and cholesterol.
• Notify your healthcare team immediately if you notice floaters, flashes, or blurry vision.
• Ask about genetic testing for CYP2B6 if you have a family history of drug reactions.

Bottom Line

Efavirenz is an effective HIV weapon, and for most people it won’t mess with eyesight. Still, a tiny fraction does see eye changes, especially if they have certain genetic traits or pre‑existing retinal conditions. Regular eye checks, a few protective habits, and prompt communication with your care team keep the risk low. If problems arise, safer alternatives like dolutegravir are readily available.