This article is more than 5 years old. Information may no longer be current.
ODs increase their role in comanaging – and even detecting – systemic diseases
Click Here to Manage Email Alerts
Comanagement with medical specialists often begins when the eye care provider first sees ocular signs indicating possible systemic disease.
Sometimes the signs and symptoms are subtle and not absolutely diagnostic by themselves, according to the four experts that we consulted for this article. But all four discussed the importance of recognizing the symptoms and developing strong relationships with the patient’s disease specialist for the benefit of those with multiple sclerosis, rheumatoid arthritis, HIV or allergy.
“I often see the patient with retrobulbar optic neuritis as the initial presenting episode of the multiple sclerosis. If I know the patient has not been diagnosed before, I will refer him or her to the neurologist for a neurological exam,” explained Robert P. Wooldridge, OD, FAAO, clinical director of the Eye Foundation of Utah, Salt Lake City.
Dr. Wooldridge recommends developing a strong relationship with a local neurologist. “We can work hand-in-hand with the neurologist, not only in the initial diagnosis of MS, but for the continued evaluation and management of these patients,” he said.
Multiple sclerosis
|
Dr. Wooldridge performs a normal comprehensive eye exam on his patients with MS, paying particular attention to the patient’s history for symptoms of MS-related problems such as optic neuritis. One additional test that may be performed on a patient with MS is a threshold visual field exam.
“Optometrists are in a position to aid the neurologist in the ongoing care of an MS patient by assessing the patient’s visual acuity, color vision, visual fields and motility, and to rule out other potential causes of a patient’s vision loss that may not be related to MS,” said Dr. Wooldridge.
If a patient who has not been diagnosed with MS is found to have the most common ocular presentation of the disease, retrobulbar optic neuritis, Dr. Wooldridge refers the patient to a neurologist and will order an MRI.
According to information found on the National Multiple Sclerosis Society Web site, studies have shown that about 50% to 60% of people — usually white, female patients in their 30s — with isolated optic neuritis go on to develop MS. A patient may not develop MS for possibly 15 years after an episode of optic neuritis.
“We can significantly reduce the recurrence of MS episodes with treatment,” said Dr. Wooldridge. See the accompanying chart for Dr. Wooldridge’s recommendations for eye care providers.
“Assessing a patient’s pupils is generally something a neurologist can do quite capably, but I believe we are in a position to dilate the eye and to perform a better evaluation of the optic nerve,” said Dr. Wooldridge.
Rheumatoid arthritis
The most common eye problem associated with rheumatoid arthritis is dry eye. About 15% to 20% of patients with rheumatoid arthritis may complain of dry eye, explained Dennis L. Smith, OD, FAAO, of Forest Grove, Ore.
If a patient who is not aware of having any systemic disorder has a certain set of eye problems such as recurrent episcleritis, Dr. Smith said he may add some tests to the regular eye exam to rule out rheumatoid arthritis. This includes a patient history including a history of joint stiffness, swelling or pain and an examination with palpation of the joints in the hands, wrists and feet, and tear function and tear break-up time tests. Dr. Smith may then refer the patient to a rheumatologist for further diagnosis.
Dr. Smith stays in close contact with a patient’s rheumatologist. “Most rheumatologists recognize that there are eye problems associated with rheumatoid arthritis, such as episcleritis, scleritis and retinal changes, so they keep in touch with me as well to make sure the patient’s vision is being monitored,” said Dr. Smith.
Interaction between the eye care provider and the rheumatologist is escalated when a patient is placed on medications that can further affect the eyes, such as Plaquenil (hydroxychloroquine sulfate, Sanofi-Synthelabo Inc.) therapy.
Ocular side effects with hydroxychloroquine use are rare compared to those with chloroquine use, but they do include corneal and retinal changes. For this reason it is important to get some baseline information before the patient begins taking Plaquenil. Dr. Smith recommends a thorough ophthalmoscopic examination to look not only at the posterior pole, but the periphery as well.
“I like to do a central threshold visual field,” he told Primary Care Optometry News. “I like to do contrast sensitivity and color vision testing. I also take the best photographs I can of the posterior pole. I’ll also do a careful slit lamp exam, because hydroxychloroquine can affect both the retina and the cornea.”
Practitioners should document the findings for the patient either before or as soon as they are placed on Plaquenil, suggested Dr. Smith. Once the patient is placed on Plaquenil, follow up with him or her every 6 months. Continue that follow-up schedule for several years after the patient stops taking Plaquenil. Retinal toxicity, in particular, can occur years after a patient has discontinued the medication, he said.
Dr. Smith’s most important recommendation when dealing with rheumatoid arthritis is to remember that it is a systemic disease with many systemic manifestations other than joint involvement.
“If I have a patient with recurring episcleritis, and I am suspecting rheumatoid arthritis, I would want to know not only about joint involvement but general health concerns as well,” Dr. Smith said. “Initially a patient may have a low-grade fever, loss of appetite, a little weight loss and aching and stiffness in the joints. The patient may tend to pass it off, and if the eye care practitioner is not paying close attention, he or she may pass it off as well.”
HIV/AIDS
When performing an eye exam on patients with HIV, practitioners should take extra precautions to ensure privacy when going over history and discussing findings, explained Kevin B. Wynne, OD, FAAO, in private practice in Pittsford, N.Y. Dr. Wynne is a consultant on HIV ocular disease for the University of Rochester, Department of Infectious Disease at Strong Memorial Hospital, as well as a consultant for Community Health Network, a community-based infectious disease clinic in Rochester.
|
Other special considerations during an eye exam with HIV patients include adding several tests, depending on the patient’s findings.
“Color vision testing becomes important in patients with HIV, since patients are often taking medications such as interferon Alfa 2b (Intron-A, Schering; Rebetron Combination Therapy, Schering), a medication used to treat hepatitis C. This agent may also cause optic neuropathy,” said Dr. Wynne.
Dr. Wynne said he would also add a Schirmer’s test to the regular eye exam because dry eye conditions are common in patients with HIV. Dry eye in these patients is thought to be related to the HIV rather than the medications.
Digital photography may be used to monitor high-risk patients that may have HIV retinopathy. “We want to make sure HIV retinopathy is not actually an early presentation of cytomegalovirus (CMV) retinitis,” Dr. Wynne explained.
Also, when neurologic complications exist, cranial nerve testing or visual field testing may be necessary.
“If there is a high degree of suspicion of CMV retinitis, another test that an OD can suggest to the infectious disease specialist is a PP65 antegenemia test. It is a new test that has a fairly high predictability for development of CMV retinitis,” Dr. Wynne said.
The results of the test, which involves blood work, will then be reported back to the optometrist, and the optometrist can adjust the follow-up based on the results. “If the PP65 antegenemia test comes back positive, we may accelerate the patient’s follow-up schedule,” said Dr. Wynne.
Because of the complexity of the disease and the various medications an HIV patient takes for the treatment of HIV itself as well as secondary infections, communication with the infectious disease specialist along with more frequent follow-up visits become important in the ongoing care and management of HIV patients.
“Since I work in the infectious disease clinics, my communication with the specialist is usually through the chart notes, or in face-to-face meetings with the doctor,” said Dr. Wynne. “But when the patient is in my private practice, the communication with the physician is essential, especially when the patient is at high risk.” Usually the communication would be accomplished through phone calls or letters.
High-risk patients have CD4 T-cell counts of less than 50 mm3, explained Dr. Wynne. They may also have evidence of CMV viremia or other infections such as Cryptococcus or herpes zoster. See the accompanying chart for Dr. Wynne’s recommendations on follow-up schedules depending on CD4 T-cell counts.
Some medications that HIV patients take for secondary infections may cause eye problems. Rifabutin (Mycobutin, Pharmacia & Upjohn), which is used to treat Mycobacterium avium complex, can sometimes cause an iritis. Ethambutol HCl (Myambutol, Dura), which is used to treat tuberculosis, can sometimes cause optic neuropathies. Pegylated alpha interferon therapy, a relatively new medication used in conjunction with ribavirin (Rebetron combination therapy, Schering; Virazole, ICN), has been associated with changes in color vision.
Allergy
|
Because of the prevalence of allergy, practitioners should pay close attention to history during the routine eye exam, said Art Epstein, OD, of Roslyn, N.Y. “In treating patients with allergies, I’m obviously going to focus on the ocular condition, but I’m going to look at it in the context of the systemic disease,” said Dr. Epstein.
Typically, if a patient has significant allergy and he or she requires medications other than a topical allergy medication, the patient is often already under the care of another physician. In these cases, Dr. Epstein said he coordinates with the other physician to lend his specific expertise in ocular allergy. Communicating by letters is often efficient for patients with routine allergy problems.
“It is very important to establish yourself within the medical community and build relationships with the allergist and primary care physician for continuity in terms of the patient’s care,” said Dr. Epstein.
Research shows that patients with limited allergic reactions such as conjunctivitis, rhinoconjunctivitis or allergic conjunctivitis with mild sinusitis have better results with topical treatments than with systemic treatments, Dr. Epstein told Primary Care Optometry News.
“One reason for this is that many systemic medications dry the eye and add to the surface disease being caused by the allergy,” he said. “All the modern antihistamines are wonderful medications for patients who have significant systemic allergy, but they have consequences in terms of ocular dryness and surface disease.”
Therefore, a much more direct way to treat many patients, according to Dr. Epstein, is locally, with a topical combination product. Patanol (olopatadine HCl ophthalmic solution 0.1%, Alcon Laboratories) is his first choice, followed by Zaditor (ketotifen fumarate ophthalmic solution 0.025%, Novartis Ophthalmics).
“Medications for treating allergy systemically will get better, and that will facilitate the need for communication between the optometrist and the primary physicians and allergists, especially if the allergist feels that the optometrist is up to date with the latest research on allergy. I’ve had some very good relationships with allergists who will refer patients to me for the ocular perspective. Concentrating on allergy has been a great practice building strategy.”
For Your Information:
- Robert P. Wooldridge, OD, FAAO, can be reached at 201 E. 5900 South, Suite 201, Salt Lake City, UT 84107; (801) 268-6408; fax: (801) 262-9216; e-mail: rpwod@aol.com. Dr. Wooldridge has no direct financial interest in the products he mentions in this article, nor is he a paid consultant for any of the companies he mentions.
- Dennis L. Smith, OD, FAAO, can be reached at Pacific University, 2043 College Way, Forest Grove, OR 97116; (503) 352-2791; fax: (503) 352-2929; e-mail: dsmith@pacificu.edu. Dr. Smith has no direct financial interest in the products he mentions, nor is he a paid consultant for any of the companies he mentions.
- Kevin B. Wynne, OD, FAAO, can be reached at 56 State Street, Pittsford, NY 14534; (585) 381-4640; fax: (585) 381-3322. Dr. Wynne has no direct financial interest in the products he mentions, nor is he a paid consultant for any of the companies he mentions.
- Art Epstein, OD, can be reached at 1025 Northern Blvd., Roslyn, NY 11576; (516) 627-4090; fax: (516) 627-4169; e-mail: artepstein@artepstein.com. Dr. Epstein has no direct financial interest in the products he mentions. He serves on an allergy advisory panel and speaker’s alliance for Alcon and serves on a speaker’s bureau for CIBA Vision/Novartis.