Uveitis is commonly associated with systemic rheumatologic conditions which require assessment and management by rheumatologists.[13, 14] In addition, the use of IMT to manage uveitis and / or the associated systemic diseases requires the expertise of rheumatologists. This often necessitates multiple separate office visits with the potential for lost communication and poor patient follow-up. A combined uveitis clinic potentially lessens the patient burden of visits to multiple providers, minimizes potential delays in therapy, and reduces poor clinical outcomes. In this study, we evaluated patient clinical outcomes of a combined uveitis clinic in which an ophthalmologist and a rheumatologists managed patients simultaneously, and to compare them to those before the establishment of the clinic. We found the combined effort led to increased utilization of IMT and more patients at target dose of IMT, with a potential improvement of ocular inflammation and reduction of systemic steroid usage.
Logistically, it is difficult to establish a combined ophthalmology-rheumatology clinic, but when established, the treatment outcomes seem favorable. The Horst-Bruinsma group in the Netherlands utilized a similar approach with multidisciplinary team meetings and a specialized ocular rheumatology outpatient clinic, to which ophthalmologists could refer patients. 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. The clinical approach described is different from our combined clinic. Practically, it may be difficult to have frequent multidisciplinary meetings for uveitis, but a combined clinic may be more feasible. To the best of our knowledge, this is the first analysis of clinical outcome data from a combined ophthalmology-rheumatology clinic in North America.
While corticosteroids remain the mainstay of treatment to control active uveitis, serious systemic and ocular side effects, such as hyperglycemia and glaucoma, respectively, render this treatment option practical for only a short period of time.[20–22] 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. 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. Our study showed that the combined uveitis clinic resulted in more frequent prescriptions of IMT and also a greater variety of immunomodulatory agents used to control uveitis and/or associated systemic autoimmune diseases. These joint efforts increased the number of patients at target dosage of IMT, demonstrating the effectiveness of the collaboration.
Although the change in visual acuity after the initial combined uveitis clinic was statistically significant, the improvement may not be clinically significant. Visual acuity may not be a meaningful marker for the benefits of the combined clinic as they can be affected by other ocular comorbidities. Interestingly, our data shows that the improvement in most of the other quantifiable markers of inflammation did not reach statistical significance. This is contrary to the expectation that offering a combined clinic would decrease the appointment burden and improve patient attendance, consequently allowing better inflammation control. However, from our experience, patients with uveitis tend to seek ophthalmological evaluation during an acute uveitis flare, i.e. when inflammation worsens, which can be controlled with local and systemic steroids. Therefore, inflammation control at predefined time points, as in our study (e.g. prior to and after the combined clinic) may not differ significantly. In our population, rheumatology appointments were more commonly missed, especially when the eye was asymptomatic, and the suboptimal dose of IMT in these patients would be a barrier to achieving long-term control. It is possible that there were more uveitis flares prior to implementing the combined clinic, but this was not easily quantifiable for our study duration.
There are several limitations in this study. Firstly, our sample size is relatively small. The small sample size, in combination with the large variation of patients who had uveitis, increases the chance of type 2 error in our study. This may partially account for the lack of significant differences in ocular inflammatory variables after the initial combined clinic visit. Secondly, the short duration of follow-up time in our study limits the potential for revealing the benefits of the combined clinic. It is possible that as follow-up duration increases, a greater proportion of patients will achieve the target dose of IMT, and the reduction of average systemic corticosteroid dose will reach statistically and clinically significance. Thirdly, the retrospective nature of the study limits the definiteness of the conclusion. However, given the likelihood of improved IMT management found in this study, it may not be appropriate to randomize patients to combined versus separate ophthalmology and rheumatology clinics. Rather, it may be preferable to compare outcomes in institutions where both combined and separate uveitis-rheumatology clinics exist.