Kathryn Mayer was sitting outside with friends one evening when she experienced a strange sensation that caused her right eye to feel very blurry. She went to bed that night thinking it must be an issue with her contact lenses and carried on normally the next day.
“I had to go to the pharmacy and pick up a prescription, so I was driving,” Mayer says. “All of a sudden, I couldn’t see anything out of my right eye. It was all of these floaters and squiggly lines – I truly could not see. I pulled over, and [my husband] had to get me and drive me home.”
Unexpected diagnosis leads to multidisciplinary care
During her visit to the eye center, Mayer met with Alan Palestine, MD, professor of ophthalmology and chief of the Uveitis and Ocular Immunology Section at the University of Colorado School of Medicine.
That’s where she received an unexpected diagnosis: punctate inner choroidopathy (PIC), a rare form of uveitis that is believed to be an autoimmune condition. Uveitis is a broad term for conditions causing inflammation inside the eye, particularly the middle layer called the uvea. There are more than 50 types of uveitis that present with ocular inflammation. PIC causes inflammation in the back of the eye and is considered a severe form.
While the diagnosis felt daunting, Mayer had heard something similar before.
She was diagnosed in 2017 with another rare autoimmune disease called relapsing polychondritis, which causes cartilage inflammation particularly in the ears, nose, throat, and joints. In 2018, she had become a patient of Jason Kolfenbach, MD, associate professor of rheumatology.
“It’s like a punch to the gut,” Mayer recalls. “I was hoping or assuming that it was the original diagnosis, but to have two autoimmune conditions that you’re actively trying to figure out, it was unfortunate.”
Although Mayer faced a new challenge of managing two chronic conditions, it was common to see associations between ocular inflammation and rheumatic diseases.
Because of this common occurrence, Kolfenbach and Palestine teamed up in 2016 to create the Ocular Inflammation Multidisciplinary Clinic at the UCHealth Sue Anschutz-Rodgers Eye Center. The two specialists not only see patients, like Mayer, with some of the most severe inflammatory eye disease in the Rocky Mountain region, but their joint approach to care is one of a kind.
Ocular inflammation is typically classified according to the section of eye involved:
Uveitis may appear in acute, painful episodes, or during which patients may experience eye redness, light sensitivity, or blurred vision. The other form is chronic and progressive but may not cause pain or redness.
"Many ophthalmologists collaborate with rheumatologists, but almost nobody I know of actually sees the patient together simultaneously,” Palestine says. “We sit in the same room with the same patient, looking at the images. We can look at the laboratory results together. What we've learned is that by reviewing the data and evaluating the patient together and discussing things, the complexity of what we're dealing with becomes clearer.”
Five to six rheumatic conditions can commonly be associated with ocular inflammation, but virtually any patient with a rheumatic illness may have an elevated risk for ocular inflammation, according to Kolfenbach. In addition, around 25 to 30 percent of patients presenting with uveitis have a systemic rheumatic disease associated with it.
Their collaboration is critical when a patient is experiencing an isolated eye condition, as many times ocular inflammation can precede the symptoms and diagnosis of systemic disease.
A unified plan leads to improved patient outcome
The dual approach to diagnosis and management for Mayer’s rheumatic and ocular autoimmune conditions was important.
“Kathryn is a good example of someone whose extraocular disease was well controlled enough that we would not have made any medication changes if it wasn't for findings that [Palestine] identified on his ocular exam,” Kolfenbach says. “It was the collaboration and the testing that was helpful.”
Prior to her joint uveitis evaluation with Kolfenbach and Palestine, Mayer was taking methotrexate to manage her polychondritis. The two specialists came to an integrated solution and shifted her treatment to combine the methotrexate with a biologic drug, adalimumab (Humira).
“The key is to understand the eye disease, understand the systemic disease, and understand the implications of how to diagnose and treat the two together,” Palestine says.
From a patient perspective, Mayer found this to be one of the best medical experiences she’s ever had.
“I love it because so much of healthcare is siloed, especially when you deal with a chronic condition,” she says. “I’m at different doctors a lot. I see my primary doctor, I see a rheumatologist, I see Dr. Palestine, I see nephrologists, and there’s a lot of things that get lost in communication. This is the first time that I’ve had them both sit together, and I wish that healthcare could always be like that. It really makes you feel cared for at a different level. It took off some of that edge, confusion and anxiety when I realized I had a second, rare diagnosis to have them come together and tackle it as one team.”
Through this multidisciplinary approach, Kolfenbach and Palestine are providing efficient care, coming to a clear solution together, and helping patients return to their lives.
“Time is organ function. The longer you wait, you might have, unfortunately, eye damage that may not be reversible, or you may see irreversible kidney or joint damage accumulate,” Kolfenbach says. “If we want to improve patients’ quality of life, being more timely arriving at a diagnosis is probably the biggest benefit of our multidisciplinary approach.”