1.  Risk for toxicity due to plaquenil use is  more frequent than previously thought.

2.  Early indicators of toxicity occur outside the "traditional pattern" for Asian patients.

3.  Early retinal thinning indicating toxicity occurs in a fairly specific area.

I can reference these to anyone interested, but didn't want to "footnote" a post.

Our "traditional" protocol with the Spectralis copied the first Marmor white paper and 

consisted of a horizonal and vertical 13 line box at 25 to 50 ART.  We scroll the scans and

look for changes at the level of the photoreceptor complex and then put a high resolution

(100 ART) through that area.  If there is nothing suspicious (usually the case) we put

a high res single scan through the fovea.  The protocol also includes FAF at 30 degrees.

The "Asian" article demonstrated changes outside the Marmor 10deg by 10 deg box, usually

temporal.  We went to a 30 degree box at 12 ART.  Once again, scroll and place a high

res scan through any suspicious areas.  The article used a ultra wide angle FAF and 

demonstrated perifoveal autofluorescence.  Don't have that expensive lens, so I use

a 50 degree and make sure to paint into the temporal area.  The pictures in the journal were

quite striking.  The final article indicated that thinning of the parafoveal inferior subfield correlates

to early signs of toxicity.  I didn't add any scans but now use retinal thickness analysis.  We

look at the inferior subfield and if it is near or below 300  high res scan that zone looking for changes.

Yes, a lot of point of contact effort, kinda like B-Scan. 

I really haven't seen any discussion of this recent information and was wondering if others

were evolving their protocols for plaquenil.  When I asked a couple of local non retina clinics

about this, they looked at me the same way my dachsund looks at me when I show him a

card trick.  They do a "Mac Scan".  Standardization seems a long way off.  Appreciate

 comments.