Multidisciplinary management of auto‐immune ocular diseases in adult patients by ophthalmologists and rheumatologists

Abstract

Purpose Management of chronic vision threatening auto‐immune ocular diseases (AIOD, e.g. uveitis, scleritis) can be challenging. Guidelines recommend a multidisciplinary approach (MDA) with ophthalmologists and rheumatologists, to enhance the recognition of systemic diseases and guide the use of immunosuppressives. However, the indications and results of such an approach have not yet been studied. Methods A monocentre, retrospective chart review of all patients treated in a MDA between ophthalmologists and rheumatologists, in a Dutch tertiary center. The collaboration was twofold: a combined multidisciplinary team meeting every 2 weeks, and an ophthalmology‐dedicated rheumatology outpatient clinic. Primary endpoints of this descriptive study were as follows: indications for MDA, new diagnoses of systemic auto‐immune diseases and changes in systemic immunosuppression and prednisone dosages. Results In total, 157 adults (mean age 46 years, 57% female, median disease duration 19 months) were included, mainly with uveitis (74%) and scleritis (12%). Multidisciplinary approach (MDA)‐indications included diagnostic workup (32%), treatment support (44%), diagnostic‐and‐treatment support (10%) and side effects (8%). A systemic disease was newly diagnosed in eight and already present in 34 patients. At baseline, 54 patients used oral prednisone at >7.5 mg/day. Non‐corticoid immunosuppressives, mostly methotrexate, were started in 41% of the patients. During follow‐up, systemic prednisone was lowered to ≤7.5 mg/day in 68% of the patients. Conclusion This evaluation of an MDA‐programme in the management of AIOD demonstrated its added value. Mainly, it addressed the high demand for support in managing systemic immunosuppression, resulting in significant corticosteroid tapering. In addition, it resulted in the recognition of underlying systemic diseases.

Patient Clinical Outcomes in Standalone Versus a Combined Ophthalmology-Rheumatology Uveitis Clinic

“…[19] They reported that these forms of multidisciplinary team collaboration generates favorable clinical outcomes: supporting the usage of IMT, tapering corticosteroid dosage, and leading to new diagnoses of underlying systemic diseases. [19] The clinical approach described is different from our combined clinic. Practically, it may be di cult to have frequent multidisciplinary meetings for uveitis, but a combined clinic may be more feasible.…”

“…[20][21][22] The need for long-term therapy for chronic uveitis and possible associated systemic autoimmune diseases, therefore, necessitates the prescription of immunomodulatory agents which requires co-management with rheumatologists for careful monitoring of disease activities and medication side effects. [18,19,23] Previous studies have demonstrated that one of the most important reasons for ophthalmologists to consult rheumatology is the need for therapeutic advice regarding systemic IMT. [19] A recent report concerns that the majority of ophthalmologists are not familiar with the usage of IMT in managing uveitis, leading to delays in corticosteroid tapering.…”

A Non-Infectious Uveitis Multidisciplinary Clinic in a Tertiary Referral Center: Clinical Impact and Added Value

“…Specifically, in our sample we think that the way this NIU clinic is organized enhances a corticoid-sparing approach in our patients, decreasing morbidity and optimizing prognosis. 8 Active discussion of medical history and investigations, reviewing imaging exams in the team, can be an authentic game-changer when it comes to decision-making in entangled cases. 35 Not only patients but also clinicians benefit from multidisciplinary work.…”

“…5,6 Hence, there is a significant burden for the healthcare systems and the working-age population associated with NIU. 7,8 In particular, NIU is associated with late and often incorrect diagnosis, adverse outcomes, irreversible structural complications, limited clinical expertise and low-grade evidence for best practice. 3,7 Multidisciplinary teams (MDT) have been recognized in the literature as the core model for managing complex chronic conditions.…”

“…11 In 2017, the Fundamentals Of Care for Uveitis (FOCUS) study group suggested that patients with NIU may benefit from the input from more than one medical specialty 3 and the added value of this collaboration has been demonstrated elsewhere. 8 Moreover, this initiative underlined the lack of guidelines to make the dialog between Rheumatology and Ophthalmology clinicians effective. 3 The usefulness of these clinics and close collaboration between Rheumatologists and Ophthalmologists in NIU has been shown in literature elsewhere.…”