Table 3.

Protocol for Assessment of Hydroxychloroquine (Plaquenil®) Toxicity.

Date of examination:	________________________________________________
Date of initiation of therapy:	________________________________________________
Total cumulative dose:	________________________________________________
Diagnosis:	________________________________________________
	________________________________________________
	________________________________________________
Investigations:	Right eye	Left eye
1. Visual acuity (corrected)	_____________	____________
2. Funduscopy	_____________	____________
3. Visual fields 10-2 (Fovea, OU)	_____________	____________
4. Multifocal electroretinogram (ERG)	_____________	____________
5. OCT (Macula)	_____________	____________
6. Fundus photograph	_____________	____________
7. Fundus autofluorescence	_____________	____________
Risk factors:
1. Duration > 5 years	Yes _________	No _________
2. Daily dose >6.5 mg/kg/day of ideal weight	Yes _________	No _________
3. Renal or Hepatic disease	Yes _________	No _________
4. Age >60 years	Yes _________	No _________
5. Pre-existing macular disease	Yes _________	No _________