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E W NEWS & OPINION 4 3 The two specialties have a good deal of crossover O phthalmologists and rheumatologists have a good deal of patient crossover. "Most of the inflammatory diseases we treat as rheumatologists can have ophthalmologic manifestations," said Christopher M. Wise, MD, said John D. Sheppard, MD, president, Virginia Eye Consultants, professor of ophthalmology, microbiology and molecular biology, Eastern Virginia Medical School, Norfolk, Va. Or a rheumatologist may refer a p atient to an ophthalmologist be- cause of troublesome eye symptoms or to monitor the patient when he or she uses medications that increase certain ocular risks. Although ophthalmologists and rheumatologists have a natural con- nection due to these overlapping issues, there are still some ways to i mprove care and collaboration. Here are a few suggestions from both specialties. Pearls for better patient care 1. Caution rheumatologists to not ignore ocular symptoms. "When the eye is involved, it's very clear that's a signal of bad things to come. It's like the canary in the coal mine," said C. Stephen Foster, MD, founder and president, Massachu- setts Eye Research and Surgery Insti- tution, Cambridge, Mass. Dr. Foster is active in both ophthalmological and rheumatic care. He has seen, for instance, patients with lupus on a variety of systemic treatments who suddenly experience a change in vision. Although ophthalmologists may recommend more aggressive treatment, some rheumatologists will not heed this advice. Conse- quently, he has seen patients lose their vision or experience another serious effect, such as kidney impair- ment. Encourage rheumatologists to contact you when one of their pa- tients experiences sudden ocular symptoms. At the same time, consider when the expertise of a rheumatolo- gist may aid a patient's care, said George Nick Papaliodis, MD, director of the ocular immunology and uveitis service, Massachusetts Eye and Ear Infirmary, Boston. Dr. Papaliodis is board certified in both internal medicine and ophthal- mology. "Ophthalmologists may not examine any organ aside from the eye, so the underlying diagnosis may elude them," he said. by Vanessa Caceres EyeWorld Contributing Writer Better collaboration between ophthalmologists and rheumatologists crucial for patient care References 1. Koenig, DE, Nguyen, LC, Parker, KE, Applegate, RA. Factors accounting for the four year change in acuity in patients between 50 and 80 years. Optometry and Vision Science 2013. 90:620–7. PMCID: PMC3691349. 2. Klein R, Klein BEK, Lee KE. Changes in visual acuity in a population: The Beaver Dam Eye Study. Ophthalmol 1996; 103:1169–1178. 3. Foran S, Mitchell P, Wang JJ. Five-year change in visual acuity and incidence of visual impairment: The Blue Mountains Eye Study. Ophthalmol 2003; 110:41–50. 4. Schneck ME, Haegerstrom-Portnoy G, Lott LA, Brabyn JA, Gildengorin G. Low contrast vision function predicts subsequent acuity loss in an aged population: the SKI study. Vis Res 2004; 44: 2317–2325. Contact information Applegate: rapplegate@optometry.uh.edu Koenig: darren.koenig@mcphs.edu Ophthalmic continued from page 42 continued on page 44 professor of internal medicine, rheumatology, allergy and immunology, Virginia Common- wealth University School of Medicine, Richmond, Va. "In inflammatory arthritis, pa- tients with rheumatoid arthritis may have dry eyes or specific inflamma- tory processes involving the eye, such as scleritis and uveitis," Dr. Wise said. "Patients with ankylosing spondylitis, reactive arthritis, and other spondyloarthropathies frequently get uveitis. Plus, a wide range of inflammatory processes involving the eye, ocular muscles or vessels, and orbit can be seen in lupus, primary Sjogren's syndrome, and most of the vasculitic syn- dromes—granulomatosis with polyangiitis and temporal arteritis in particular." Yet that's not all. Ocular mani- festations also can occur in sarcoido- sis, herpes zoster, Behcet's disease, Crohn's disease and ulcerative coli- tis, and juvenile idiopathic arthritis. Posterior subcapsular cataracts may occur from prolonged systemic corticosteroid use. Ocular symptoms may lead a patient into your practice. You may suspect an undiagnosed systemic disease and refer the patient to a rheumatologist for further testing. "For example, a lot of Sjogren's patients show up first in the oph- thalmologist's or dentist's office," March 2014 18-47 News_EW March 2014-DL2 copy_Layout 1 3/7/14 11:27 AM Page 43