Standardization of red flags for referral to rheumatologists and ophthalmologists in patients with rheumatic diseases and ocular involvement: a consensus statement

Abstract

Ocular involvement is a common manifestation of inflammatory rheumatic diseases, often requiring a multidisciplinary collaboration between rheumatologists and ophthalmologists. The aim of this study was to standardize "red flags" for referral for rheumatologists and ophthalmologists using a Delphi consensus for the management of rheumatic diseases with ocular involvement. The scientific board comprised 11 Italian hospital-based rheumatologists (N = 6) and ophthalmologists (N = 5). A systematic review identified potential red flags for referral. The panel developed 19 statements consisting of (a) referral from ophthalmologist to rheumatologist (b) referral from rheumatologist to ophthalmologist and (c) overarching principles relating to multidisciplinary roles/goals and management. Voting was performed anonymously using an online Delphi method. Each participant expressed a level of agreement on each statement using a 5-point scale (1="strongly disagree"; 5="strongly agree"). Total cumulative agreement was defined as the sum of the percentage of response to items 4 ("agree") and 5 ("absolutely agree"), consensus defined as ≥ 80% cumulative agreement for each statement. Positive consensus among 11 participants was reached for 15/19 (78.9%) statements. Statements not reaching consensus were discussed in a face-to-face meeting prior to the second vote (10 participants). Positive consensus was reached for all 19 statements, with final total cumulative agreement of 90-100%. This is the first Delphi consensus undertaken to standardize red flags for referral to rheumatologists and ophthalmologists for patients with rheumatic diseases and ocular involvement.

Psoriatic Syndrome or Psoriatic Disease?

“…Further valuable liaisons have been generated between these specialists and workers in related disciplines of imaging, molecular biology, and therapeutics, among others, to throw further light on this fascinating and ever challenging disease complex." 4 As president of the Italian Society of Rheumatology, Olivieri organized a series of scientific meetings with dermatologists, gastroenterologists, and ophthalmologists with the aim of developing recommendations for a shared clinical approach to spondyloarthritic patients with psoriasis 5 , inflammatory bowel diseases 6 , and uveitis 7 .…”

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“…Furthermore, another study standardized red flags for referral to rheumatologists from ophthalmologists for patients suffering from acute anterior non-granulomatous non-infectious uveitis or patients suffering from intermediate, posterior, non-infectious uveitis, or panuveitis. One or more of the following statements should determine the ophthalmologist to refer the patient in a rheumatological unit: chronic low back pain ≥ 3 months (only for patients suffering from acute anterior non-granulomatous non-infectious uveitis); family or personal history of psoriasis involving the skin and/or nails, and/ or of SpA and/or IBD and/or Behçet's disease; genital and/or oralaphthae; children (any diagnosis) with suspect joint involvement; erythema nodosum; retinal vasculitis (only patients suffering from intermediate, posterior noninfectious uveitis, or panuveitis); disorders of the central nervous system (only patients suffering from intermediate,posterior non-infectious uveitis, or panuveitis); child with suspect joint involvement, in whom Fuchs' uveitis has been excluded (patients suffering from chronic anterior non-infectious uveitis) [15].…”

“…The CORE study managed to identify a series of "red flags" for patients with established rheumatic disease and suspected ocular disease to be referred from rheumatologist to ophthalmologist. One or more of the following statements should determine the referral for patients suffering from SpA, JIA or Behçet's disease: red eye; ocular pain; photophobia; blurred vision and/or reduction in visual acuity; his-tory of ocular inflammation; children diagnosed with JIA; patients diagnosed with Behçet's disease [15].…”

Early Spondyloarthritis Clinic: Organizational Improvements in the Patient Journey

“…A factor contributing to late identification of these diseases is the lack of specific biomarkers, which could help in early diagnosis. In addition, referral is more complex in SpA than in other rheumatic diseases such as Rheumatoid Arthritis as it requires a multichannel approach (i.e., the involvement of several specialists) ( 7 – 9 ). The above issues reflect some of the main unmet needs of SpA diseases, which the Early SpA Clinic, a project providing an organizational model, useful for improving the performance of the healthcare facility tried to face and solve.…”