The ‘invaluable adjunct’ of ophthalmology in rheumatology

Consultant Medical Ophthalmologist Dr Duncan Rogers provided an overview of how rheumatologists can use ophthalmology to make rheumatological diagnoses and monitor the outcome of treatment in inf lammatory patients at the recent ISR Autumn Meeting. 

According to Dr Rogers, who is based in the the Mater Misericordiae University Hospital, Dublin, ophthalmology is an “invaluable adjunct in the investigation and diagnosis of the rheumatological disease”. 

In his presentation, he guided delegates through the process of patients presenting with optical symptoms, who were also later diagnosed with rheumatological conditions, which affected their vision and optical health. 

He also told the Medical Independent: “I think it just underlines the importance of different sub-specialties working together and realising that we can give really useful information to each other. And the patient benefits because they have one consultation rather than two.” 

For example, reading fundus photos, an image of the interior surface at the back of the eye, can identify inflammation and irregularities in the eye and thus help to diagnose conditions such as lupus retinitis, according to Dr Rogers. 

Optical coherence tomography (OCT) is another ophthalmological technique that can aid in diagnosing rheumatological diseases. 

“You can tell on the OCT whether the inner or outer circulation [supply to the retina] is involved,” according to Dr Rogers. “And that can give you an idea that considering the vasculature process, whether there is a small-, medium- or large-size artery involved. So, it can give you some quite useful information.” 

Using an example of a patient with vision loss and hypertension, Dr Rogers acknowledged it would be “very reasonable to be considering a stroke as the first cause”. 

However, the OCT results pushed the diagnosis in a different direction. After corresponding with serology and dermatology colleagues, the patient was diagnosed as having polyarteritis nodosa.

Fluorescein angiography, where dye binds to a blood protein, allows ophthalmologists to see blood vessels in the eye, which may detect leakages or inflammation. It can aid in diagnosing conditions depending on how long it takes for the dye to fill the blood vessels. 

This “delayed choroidal and retinal fill” is associated with reduced arterial blood flow to the eye and, in one patient example, can aid in diagnosing giant cell arteritis (GCS), where blood vessels are narrowed or blocked due to inflammation. 

Dr Rogers also noted that with his rheumatology colleagues in the Mater Hospital that fluorescein angiography with delayed retinal fill can be used to detect flaring in patients on rheumatological treatments. 

When using fluorescein angiography to detect leakages in the blood vessels in the eye, a 100 per cent certain diagnosis cannot always be given, but it can point in the right direction. 

Dr Rogers gave the example of one case where the fluorescein angiography of a patient displayed vein leakage. 

The patient also had elevated inflammatory markers, night sweats and weight loss. 

“I can’t diagnose sarcoidosis… from a fluorescein. But I can say, ‘from an ocular perspective, this speaks to me as sarcoidosis. And I think you should be potentially focusing more towards that’.” 

“It’s just a case to show you that I’m not going to be able to say it’s definitely this. But in ophthalmology, we do have the capability with our multimodal imaging to build a picture of what might be happening,” Dr Rogers added. 

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