Uveitis, A multidisciplinary approach
Uveítis, un abordaje multidisciplinar
Uveitis comprises a number of diseases characterized by some unique traits that attribute to uveitis a very special nature. To start with, its pathogeny is mainly in alterations focused in extracellular organs, mainly related with the immunological system.1 In fact, uveitis are considered to be the paradigm of ocular diseases with extracellular pathogeny. Secondly, and remaining in the systemic domain, its association with general self-immune/self-inflammatory diseases has been demonstrated, including sarcoidosis or Behçet's disease, and infectious diseases such as toxoplasmosis or syphilis. The results of the majority of etiological studies, some with very large cohorts, revealed that in almost 60% of patients a systemic cause is recognized as the substrate of the uveitis.2, 3 Lastly, the surgical indication is very infrequent as a treatment and, when indicated, is circumscribed to problems derived from uveitis complications. In addition, in most cases the treatments indicated for uveitis are administered systemically and could rarely give rise to severe secondary effects. Drugs such as cyclosporine, the latest alpha tumoral necrosis factor antagonists and valganciclovir, in the domain of infectious uveitis, are clear examples of this.
Accordingly, all the above can be summarized in the title of this note: uveitis require a multidisciplinary approach. However, this concept is not new. In countries like the United States or Germany, the diagnosis and treatment of uveitis is not addressed without the direct involvement of an internist or a rheumatologist. In Spain, generally and even though it is obvious that this multidisciplinary approach is crucial for adequate diagnostic and treatment, the fact is that quite a few health centers restrict multidisciplinary approaches to request internal consultation to the medical services. On the other hand, we should also analyze the reasons why uveitis have failed to arouse the interest of internists and rheumatologists. One explanation could be that on many occasions, the role they are asked to play is merely to monitor pharmacological toxicity secondary to the therapy being administered. The reverse situation could be imagined, raising the following question: who is passionate about monitoring the retinal toxicity of anti-malaria drugs? At this point, arguments in favor of multidisciplinary approaches should involve a reciprocal pedagogical aspect which should not be underestimated. This can be underscored by the following examples: ocular tuberculosis without active systemic infection also exists4 or anterior uveitis due to citomegalovirus manifests in immunocompetent patients and valganciclovir substantially improves this condition.5
Likewise, communication and the use of the same terminological language should be the cornerstone for the relationships between interdisciplinary groups. On this basis, it is easy to devise a classification of uveitis in clinical patterns, which would constitute a simple and enormously useful method for unifying criteria.6 It also seems advisable to take advantage of the opportunity and inform internists or rheumatologists about the effects of treatment on the resolution of macular edema which is visible in optic coherence tomography.
The logistical organization of assisting uveitis patients should be based on a close relationship between the ophthalmologist and the internist/rheumatologist. Joint medical attention can reach unusually high efficiency rates as it brings together a desirable matching in diagnostic–and sometimes therapeutic−procedures, mutual scientific learning which is of great value, and in addition the management of resources seems very adequate and economical. A multidisciplinary team in which the ophthalmologist and the internist/rheumatologist are the main figures in the organization chart, should be completed with the cooperation of other specialists in the clinical area as well as from basic research. The contribution of specialists in infections, oncohematologists, microbiologists, pathologists and immunologists, ideally from the same hospital, could be relevant in many cases. A multidisciplinary team gives rise to assistance as well as research activities including academic and training activities involving all the group members.
Uveitis, as an ocular disease, must be seen in the first place by the ophthalmologist who must establish the guidelines for the involvement of the other multidisciplinary team members whose contribution will be more decisive in cases where systemic involvement is suspected. By way of example and when a systemic involvement is suspected, the guidelines to be followed must consist in an ophthalmological exploration and preparation of a differential diagnostic related to specific diseases. Subsequently, the suspected diagnosis must be reported to the internist/rheumatologist, who must then verify the presence or absence or systemic semiology or alterations in supplementary explorations to confirm or discard the ophthalmologist's suspicion. During the treatment, the ophthalmologist's decision is crucial and must be in agreement with the conclusions reached by the internist/rheumatologist or other specialists who participate in the team after a full assessment of the patient.
It is clear that, in comparison with other areas of ophthalmology, uveitis is a range of diseases with particular traits. The ophthalmologist who decides to focus on this ocular disease must receive specific training. In some countries like the United States there have been for a number of years specialization programs for uveitis. Unfortunately, to date in Spain it is not possible to receive official training in this specialty.
By way of conclusion, the particular characteristics of uveitis require multidisciplinary participation for an adequate diagnostic and therapeutic approach. In the majority of cases, this approach enables appropriate diagnosis and treatment as all the clinical and analytical expressions that can be associated to this peculiar ocular disease can be adequately assessed.
☆ Please cite this article as: Fonollosa A, Adán A. Uveítis: un abordaje multidisciplinar. Arch Soc Esp Oftalmol. 2011;86:393–4.
Corresponding author. firstname.lastname@example.org
Bibliography1.Luger D, Caspi RR. New perspectives on effector mechanisms in uveitis. Semin Immunopathol. 2008;30:135-43.
2.Jakob E, Reuland MS, Mackensen F, Harsch N, Fleckenstein M, Lorenz HM, et al. Uveitis subtypes in a German interdisciplinary uveitis center—analysis of 1916 patients. J Rheumatol. 2009;36:127-36.
3.Llorenç Bellés V, Adán Civera A, Espinosa Garriga G, Cervera Segura R, González Martínez J, Pelegrín Colás L, et al. Uveitis diagnosis characterization at a referral centre in the area of Barcelona. Med Clin (Barc). 2011 Oct 11.
4.Wroblewski KJ, Hidayat AA, Neafie RC, Rao NA, Zapor M. Ocular tuberculosis: a clinicopathological and molecular study. Ophthalmology. 2011;118:772-7.
5.Van Boxtel LA, Van der Lelij A, Van der Meer J, Los LI. Cytomegalovirus as a cause of anterior uveítis in immunocompetent patients. Ophthalmology. 2007;114:1358-62.
6.Bañares A, Jover JA, Fernández-Gutierrez B, Benítez del Castillo JM, Garcia J, Vargas E, et al. Patterns of uveítis as a guide in making rheumatologic and immunologic diagnoses. Arthritis Rheum. 1997;40:358-70.