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E W NEWS & OPINION 44 2. Be as specific as possible when referring patients to rheumatolo- g ists. Esen K. Akpek, MD, professor of ophthalmology and rheumatol- ogy, director of the Ocular Surface Disease and Dry Eye Clinic, and associate director of the Johns Hopkins Jerome L. Greene Sjogren's Syndrome Center, Johns Hopkins University School of Medicine, Baltimore, believes ophthalmologists need to be more detailed regarding a patient's signs and symptoms when referring to a rheumatologist. They should list any possible systemic diagnoses and what drugs could be appropriate. "If you don't do the proper workup, you can never get the right diagnosis," Dr. Akpek said. You may need to spend some time explaining eye diseases. "Oph- thalmologists should never assume that a rheumatologist has a full understanding of the differences among the various ocular condi- tions, such as episcleritis versus scleritis or anterior versus posterior versus pan-uveitis," Dr. Wise said. "In addition, we don't have a good understanding of the history of vari- ous ocular syndromes, particularly regarding the risk of progression or risk of recurrence once inflamma- tion is controlled." Those are areas you'll want to address as needed with rheumatologists. Dr. Akpek also encouraged physicians from both specialties to pick up the phone at least once to discuss a patient's collaborative care—something that sounds obvious but does not happen often enough, she added. 3. Encourage rheumatologists in your area to refer certain p atients for regular monitoring. "Because many of the drugs we commonly use in our practice may be associated with ocular problems, we frequently refer asymptomatic patients for regular screening," Dr. Wise said. "This applies particularly to patients on corticosteroids and hydroxychloroquine, where regular screening is a routine practice." Dr. Wise also noted that patients with juvenile inflammatory arthritis should be managed by specialists from both sides because of the higher risk for uveitis. As Dr. Wise mentioned, you'll want to keep regular tabs on any rheumatic patient using steroids. Although excessive steroid use can lead to an elevated IOP and increase the risk for cataracts, it's common for physicians outside of ophthal- mology to prescribe steroids to patients without monitoring their use, said Dr. Akpek. Two relatively newer corticos- teroid implants of interest to both ophthalmologists and rheumatolo- gists for chronic noninfectious uveitis are Retisert (fluocinolone acetonide intravitreal implant, Bausch + Lomb, Rochester, N.Y.) and Ozurdex (dexamethasone intravit- real implant, Allergan, Irvine, Calif.), which can be placed in the eye for 2.5 years and six months, respec- tively, Dr. Papaliodis said. However, even those advances require moni- toring for the avoidance of long- term steroid effects. A newer long-acting intravitreal steroid preparation from pSivida (Water- town, Mass.), Iluvien, currently under phase 3 trials for posterior noninfectious uveitis, can be inserted in the office and may last up to three years, said Dr. Sheppard. 4. Let rheumatologists know what you can do for dry eye disease. Rheumatologists often recommend the use of artificial tear supplements for patients with dry eye, said Alan B aer, MD, associate professor of medicine and director of the Johns Hopkins Jerome L. Greene Sjogren's Syndrome Center, Johns Hopkins University School of Medicine. Although the tears may be a first step, the rheumatologist may not be a ware of stronger treatments com- monly used in ophthalmology, such as cyclosporine ophthalmic emul- sion (Restasis, Allergan). You can also remind your rheumatologist colleague (or the patient) that punctal plugs, ointments, gels, and changes to the patient's environ- ment could help relieve dry eye s ymptoms. One treatment used sometimes in rheumatology for dry eye is secre- tagogues. "In some cases, secreta- gogues like pilocarpine and cevimeline can help promote tear flow and relieve dry eye symptoms," Dr. Baer said. Inform the rheumatologist that a patient with an autoimmune dis- ease can have dry eye but not feel the symptoms—and corneal ulcera- tion or scarring can occur—which is yet another reason why ophthalmol- ogists should be part of that person's care, Dr. Akpek said. 5. Ask patients about treatments they receive by injection or infusion. These may be part of a regularly scheduled treatment regi- men for certain rheumatic diseases. "Many patients forget to mention these treatments when asked to list their medications," Dr. Baer said. "However, these treatments, often biologic agents, can predispose pa- tients to opportunistic infections and other rare ophthalmologic prob- lems, such as optic neuritis with tumor necrosis factor antagonists." 6. Hold simultaneous clinics with your ophthalmic colleagues when possible. Dr. Sheppard believes that a specialized clinic involving both disciplines for the treatment of tough patients can save patients time (they come for one appoint- ment versus two separate ones) and can increase collaboration among physicians. However, he acknowledged that it can be logisti- cally difficult to get patients and staff members involved from a variety of physicians' offices in one place at the same time. If a clinic is not possible, then Dr. Sheppard is also a fan of fre- quent, regular appropriate referrals, which can offer patients better care and help increase regular collabora- tion and business between the two s pecialties. "Teaming with a rheuma- tologist for these patients is almost always beneficial," he said. 7. Expect certain rheumatic treat- ments to be part of the ophthal- mologists' armamentarium in the f uture. Ophthalmology has more of a "stepchild" image in medicine, so it has to rely on research done in other specialties that can benefit eyecare, Dr. Foster said. In that realm, there is research underway with tumor necrosis factor-alpha in- hibitors to be used as future treat- ments for ocular inflammation. U ntil now, any such use has been off-label, he said. Research in rheumatology is aiming to better target certain in- flammatory responses, which may one day lead to less frequent use of corticosteroids. That could help avoid some of the negative side effects associated with long-term steroid use, Dr. Papaliodis said. Newer biologic agents for in- flammatory arthritis, lupus, and vas- culitic syndromes will likely enable more effective treatments both for rheumatic and ophthalmologic symptoms, Dr. Wise said. There are also advances in diag- nostic testing that are of interest to rheumatology, Dr. Sheppard said. For instance, a new point of service office test from Nicox (Sophia Antipolis, France) should be able to identify novel Sjogren's disease auto- antibodies expressed at a much ear- lier stage than previously possible, he said. The test detects the disease three or more years earlier than previously possible with traditional serum analysis. Additionally, the National Insti- tutes of Health is conducting a large study to assess the value of salivary biomarkers for the diagnosis of Sjogren's syndrome. EW Editors' note: The physicians have no financial interests related to this article. Contact information Akpek: esakpek@jhmi.edu Baer: alanbaer@jhmi.edu Foster: sfoster@mersi.us Papaliodis: George_Papaliodis@meei.harvard.edu Sheppard: docshep@hotmail.com Wise: cmwise@vcu.edu March 2014 Better continued from page 43 When to refer your patients to a rheumatologist H ere are a few specific times when your local trusted rheumatologists would appreciate a referral: • When a patient has scleritis or uveitis if an underlying systemic disease has not been identified. • Any patients with significant dry eye disease, particularly "if they have prominent extraocular manifestations, such as prominent dry mouth, joint pain, or abnormal screening labs," Dr. Baer said. • Any time you suspect a systemic problem that a rheumatologist could help with and that may be outside the scope of your normal eye exam. "If the ophthalmologist is concerned about severity and f requently occurring symptoms, they should refer to a rheumatolo- gist," Dr. Papaliodis said. • When a patient requires systemic immunomodulators. "Most ophthal- mologists are not comfortable giving them," Dr. Papaliodis said. 18-47 News_EW March 2014-DL2 copy_Layout 1 3/6/14 2:47 PM Page 44