Since 2016, the UCHealth Ocular Inflammation Multidisciplinary Clinic at the Sue Anschutz-Rodgers Eye Center has been a place where patients and students alike get a chance to see the complexities of medicine and the benefits of collaborating across specialties to provide individualized treatment.
“We started this clinic because rheumatologists deal with inflammation in the body and ophthalmologists deal with inflammation in the eye, but you can’t always deal with the eye alone or the body alone,” explains Alan Palestine, MD, professor of ophthalmology at the University of Colorado School of Medicine and chief of the uveitis and ocular immunology section.
Normally, that would mean a patient spends a lot of time visiting different doctors who have different skillsets in different offices, but the multidisciplinary clinic puts ophthalmology and rheumatology specialists and the patient all together in one room, allowing for a more holistic approach to assess the patient’s conditions, symptoms, and discuss treatment options, which can be complex.
“When both doctors are in the same place at the same time seeing the patient simultaneously, we can make decisions right then and there instead of going back and forth over the course of several days or weeks,” Palestine says. “It's better for the patient and it's better for the doctors. We can initiate a change, and the patients only have to make one trip to our medical campus.”
Deeper understandings of inflammation
The patients that Palestine and rheumatologist Jason Kolfenbach, MD, professor of medicine, see in the clinic typically have a systemic autoimmune disease with concurrent eye inflammation, but not always.
“We see patients with an established systemic autoimmune disease and secondary eye inflammation, but we also see patients with primary ocular inflammatory syndromes where management of medications to suppress their immune system may be challenging,” Kolfenbach says.
Medications used to treat these conditions often require expertise in ophthalmology and rheumatology because they can have an array of side effects, symptoms, or affect other organ systems.
A recent study authored by physicians in the clinic found that most patients seen in the multidisciplinary clinic had both ocular and systemic inflammatory disease, and were treated with immunomodulatory therapies such as methotrexate, adalimumab, or rituximab.
More than 40% of clinic patients underwent a change in medication management as a result of their first evaluation with the physicians. Kolfenbach believes this is because of the specific expertise that rheumatologists and ophthalmologists bring to the multidisciplinary clinic, and the close working relationships formed between himself and the uveitis specialists.
“Based upon on our joint evaluation, we commonly arrived at a new diagnosis and changed medical management for a substantial number of patients” he says. “A new systemic diagnosis often provides new avenues for drug therapy, given the more limited treatment options for idiopathic uveitis. Our evaluation also allows us to identify concurrent health conditions that may increase the risk of certain therapies, so medication can be tailored to the specific patient.”
An added bonus of the clinic, Palestine and Kolfenbach say, is that it saves time, which can be critical in treating an autoimmune disease.
“We often say ‘time is organ function’. Low-grade inflammation in a joint, kidney, or eye that goes unrecognized or is undertreated can unfortunately lead to irreversible damage. Identifying problems early is a huge benefit to our patients,” he says.
These combined benefits are the result of functioning as a unit, Palestine adds.
“We’ve developed a common understanding that has been really helpful to both of us in knowing our options, how we can discuss those options, and what’s an urgent matter and what isn’t,” Palestine says.
Extending educational opportunities
Working together has also garnered research and educational opportunities for the doctors and trainees, who benefit from a deeper understanding of how rheumatology and ophthalmology intersect and affect one another.
The two programs exchange trainees both ways so that rheumatology fellows spend time in the eye clinic learning more about uveitis, and ophthalmology trainees spend time working with rheumatologists.
“Our rheumatology fellows get to see how to diagnose eye inflammation in our patients with rheumatic illness, and then, similarly, ophthalmology residents work with us in their first year of training to learn about management of immunosuppressive medications and how we think about risk-benefit discussions,” says Kolfenbach, who serves as the program director of the rheumatology fellowship program.
Palestine echoes the benefits, saying the partnership broadens trainees’ knowledge base and reminds them to consider the rest of the body, not just the eye. Working closely together means the two physicians are constantly updating each other, sharing the newest information in their respective specialties, and broadening their overall knowledge base.
“Our trainees like seeing something a little bit different, and they like learning about a field that feels a little bit unknown to them,” Kolfenbach says. “In rheumatology, diseases can affect multiple organs, so there’s always a feeling of wanting to know more about other systems throughout the body, and here you get that.”
