Ocular inflammatory disease services form a major component of a medical ophthalmology unit due to the complexity of the conditions managed and the range of treatments offered.
A uveitis or ocular inflammation service is usually regional within a tertiary service. However, depending on their specialist interest, a medical ophthalmologist within a district general hospital is likely to have a uveitis service. The prevalence of uveitis is approximately 115.3 per 100,000 population and the incidence is approximately 52.4 per 100,000 population.
The infrastructure required to support a uveitis service includes:
- clinical nurse specialist
- outpatient nurse
- allied health professional eg specifically trained to manage an imaging facility*
- other investigations*: Humphrey visual field machine and operator, electrophysiology, Goldman visual field and operator*
- biologics infusion service and trained infusion delivery nurses*
- departmental secretary.
*shared with other ophthalmology services
A large number of people with ocular inflammatory disease are treated with immunosuppression. The service should ideally be organised with a clinical nurse specialist who is:
- trained in counselling for immunosuppression
- able to screen blood results
- able to train patients in administration of self-injected subcutaneous medication
- able to provide support for patient queries outside of clinic (as for rheumatology services) to meet the need for monitoring and immunotherapy treatment, and shared care pathways with GPs.
Special treatments offered within a uveitis service
The provision of biologic therapies is currently regulated by NHS England. They are expensive and only 2% of patients attending a tertiary referral centre for uveitis are likely to require them.
Biologic therapies should come under a dedicated infusion service with dedicated nursing support. This infusion service is ideally shared with other services that heavily rely on immunotherapy, such as rheumatology.
Ozurdex (a long-term steroid) implants are delivered intravitreally. Access to this drug is regulated by local commissioning processes (CCGs).
Small numbers of patients also receive other forms of intravitreal injections such anti-VEGF or triamcinolone.
Interdisciplinary care of patients
Surgical ophthalmology teams, oculoplastics and cornea services require the support of medical ophthalmologists who have uveitis subspecialty expertise for the management of uncommon conditions such as corneal graft rejection or thyroid eye disease.
Uveitis is frequently part of a multi-system disease, requiring collaboration with other physician teams. Multidisciplinary team meetings may be required depending on the patient cohort. If a medical ophthalmologist is not available, a uveitis service may be supported by another physician, usually a rheumatologist.
Specialty clinics for patients with juvenile idiopathic arthritis require a paediatric rheumatologist and a medical ophthalmologist working together in close liaison or within a multidisciplinary clinic. This is because both the joints and eyes are affected by this condition. A one-stop shop clinic model minimises patient appointments if other needs such as physiotherapy and occupational therapy are included. They are also associated with high patient satisfaction.