A Multidisciplinary Care Approach

It takes a village of health professionals to create the ideal multidisciplinary care team for people living with autoimmune eye conditions. But how close are we to this ideal?

Rosemary Ainley, from the patient advocacy group Global Health Living Foundation Australia (GHLF Australia), gathered perspectives of health professionals and patients on how well multidisciplinary teams are working now, and how they can be improved.

WRITER Rosemary Ainley

People with autoimmune conditions often see a vast range of health professionals to manage and treat their disease. In the past, different disciplines operated in silos within the health system, with patients having little control over their quality of care.

Today, effective multidisciplinary teams exist in many parts of the system, yet patients still experience fragmented care for their autoimmune conditions.

MULTIDISCIPLINARY HEALTHCARE

Globally, there has been an increased desire to build better multidisciplinary care models as best practice among governments and health organisations. The Australian National Safety and Quality Primary and Community Healthcare Standards Guide for Healthcare Services includes multidisciplinary collaboration as a key component of its Clinical Safety Standard, stating:

“A substantial proportion of potentially preventable adverse events are underpinned by failures in communication and teamwork (between members of a single healthcare service or across multiple healthcare services). Multidisciplinary collaboration… is an important element of comprehensive care.”1

In Australia, many multidisciplinary teams (MDTs) are managed by a patient’s general practitioner (GP), who can refer the patient to other healthcare professionals (HCPs) as appropriate.

There are also countless examples of MDTs working effectively across our healthcare system, including in hospitals and between networked services. However, these examples are still siloed to an extent, and we are yet to build funding frameworks at a national level that allow all members of a patient’s healthcare team to work together seamlessly, with no gaps.

CARE NEEDS OF PEOPLE WITH AUTOIMMUNE EYE CONDITIONS

People with complex autoimmune conditions often need to see many different HCPs to help manage their spectrum of symptoms. With patients at the centre of a healthcare team, other members can include primary health professionals, specialists, nurses, dentists, pharmacists, and a cross-section of allied health professionals (AHPs).

In these teams, the common primary goals are to reduce inflammation in the person’s body, reduce their symptoms, and improve their quality of life.

TAKING AN EYE HEALTH PERSPECTIVE

Autoimmune eye conditions can occur as primary or secondary conditions. Examples you may see in your practice include uveitis, Sjogren’s syndrome, scleritis, dry eye syndrome, and thyroid eye disease. Other autoimmune conditions that can have related eye symptoms include:

• Lupus,

• Graves’ disease,

• Multiple sclerosis,

• Ankylosing spondylitis,

• Rheumatoid arthritis,

• Juvenile idiopathic arthritis,

• Psoriasis,

• Giant cell arteritis, and

• Inflammatory bowel disease.

Dr Richard Symes is a Consultant Ophthalmologist at the Sydney Eye Hospital, Gordon Eye Surgery, and Lane Cove Eye Surgery, all in Sydney. Sometimes patients already have a diagnosis before they see him, but sometimes their eye symptoms are new.

“The patient’s eye inflammation may be caused by an undiagnosed systemic condition, so we must remain alert to this possibility,” said Dr Symes.

He said examples of conditions that may be first seen by an eye health professional include sarcoidosis, latent tuberculosis, and even inflammation caused by undiagnosed syphilis infection.

“We need to be guided by the clinical picture and dust off our history-taking skills to help us narrow down a likely diagnosis,” he added.

“In these situations, we need to communicate with GPs, rheumatologists, immunologists, infectious disease specialists, dermatologists, respiratory specialists, or anyone else required to help treat the patient’s systemic condition.”

As well as diagnoses, medical MDTs often need to discuss other key aspects of care, especially the use of immunosuppressive agents and potential contraindications.

“This is becoming increasingly complex with more agents now available. A few years ago, there were only a few agents used in inflammatory eye disease management. But the list is becoming ever longer, with the addition of biologics, JAK (Janus kinase enzyme) inhibitors, and more,” said Dr Symes.

“In some clinics, we can work alongside a rheumatologist or immunologist. While not essential, this can be a very helpful model to facilitate care.”

Dr Symes is a member of an MDT at Sydney Eye Hospital. It holds meetings in which registrars, fellows, and consultants discuss care plans before each weekly clinic. “In many cases, the patient discussion will be on the day of the patient’s appointment, so they are directly involved in the plan too,” he said.

Some GPs are included in these team discussions. Those who aren’t members are still updated about decisions and outcomes afterwards. However, unless AHPs are also specifically included in such teams, other medical professionals would normally defer to the GP to refer patients to relevant AHPs.

MDTs AND ALLIED HEALTH

Sarah Comensoli is an exercise physiologist at BJC Health, a combined rheumatology and allied health clinic in Sydney. She has seen firsthand the difference it can make when clinicians collaborate well.

“I believe that multidisciplinary care works best when it feels seamless to the person receiving it. There is a sense that the team is genuinely working together, not just in the same building, but with shared intent and clear communication. That kind of care can save someone time, reduce confusion, and prevent the frustration of having to repeat their story and challenges multiple times,” said Ms Comensoli.

Australian AHPs cannot refer people directly to medical health professionals. However, Ms Comensoli always asks her clients about their existing healthcare team, especially the clients with complex autoimmune conditions.

“Early on, I ask whether they currently see any specialists. I then aim to communicate regularly with all those involved in the clients’ care, including those outside our clinic.”

Ms Comonsoli explained that this feels more efficient, respectful, and aligned with the person’s needs. “Of course, it is not always easy. Coordinating care, getting alignment on goals, and respecting each other’s expertise takes time and a willingness to work as a team,” she said.

If Ms Comonsoli suspects her client has early signs of an autoimmune condition, she communicates directly with the person’s relevant specialist. If that person isn’t under specialist care, she contacts their GP to express her concerns. “My goal in these situations is to support early identification of any new issues and make sure the right professionals are looped in so that care can be coordinated effectively,” she continued.

HOW AHPs HELP PEOPLE WITH CHRONIC CONDITIONS

Ms Comensoli believes MDTs are one of the most valuable ways healthcare providers can support people with chronic conditions. “In my experience, these conditions rarely affect just one aspect of a patient’s life. A chronic condition might end up impacting sleep, energy levels, eating habits, work, relationships, mood, movement, and more. No single clinician can provide the needed support and knowledge in those areas all at once,” she said.

AHPs play a key role in helping people with autoimmune conditions manage inflammation, reduce pain, and improve overall quality of life. While not everyone needs to see multiple AHPs, some people do. It depends on the goals and priorities of each person and where they might benefit from getting some tailored support.

“At the heart of it, I think our role is not just about education. It is about walking alongside people, coaching them through the ups and downs, helping them stay motivated, and being a consistent and trusted part of their support team,” said Ms Comensoli.

MDTs FROM PATIENTS’ PERSPECTIVES

For members of the GHLF Australia community, everyday experiences of MDTs vary greatly in quality and quantity.

Paul’s Story: Sudden Vision Changes

Paul Gallagher lives with multiple sclerosis (MS), an autoimmune condition that attacks the central nervous system, causing damage to the body’s communication pathways. It can affect any area of the body, so symptoms vary widely between individuals. Early symptoms may include vision problems, including optic neuritis, double vision, and involuntary eye movement due to damage to the nerve pathways in the brain and optic nerve.2,3 Therefore, it is important for health professionals to consider MS as a possible diagnosis when these symptoms arise.

Just before Mr Gallagher’s MS diagnosis in 2016, he lost his eyesight temporarily. He had no other symptoms, and nothing prompted it. His vision in both eyes abruptly turned to tiny pinpricks. “It was, effectively, a near-complete loss of sight. It remained that way for 90 minutes, and then my sight suddenly came back, and it did not happen again,” said Mr Gallagher.

One afternoon in the following years, Mr Gallagher briefly lost the ability to see all colours. “It was as if my eyesight turned to sepia. It turned on and off a few times over that day and again a few months later.” He later learned that it is not uncommon for someone with MS to experience such vision issues.

Mr Gallagher’s loss of vision, though temporary, became rolled into an overall diagnosis of MS. “It led to rapid investigation of my brain and spine to see what might be causing it,” he said. “Once the MS was identified and diagnosed, the eyesight issue was left as a bullet point in my medical history.” Further eye problems went the same way. When they occurred, Mr Gallagher managed them on his own.

Mr Gallagher has used many medical and allied health services over the years, including counselling to help him cope with his MS diagnosis. However, he has never been referred to an eye specialist or anyone with expertise in the vision symptoms of MS. He feels what was missing was the professional input from someone trained in eye care, especially for neurological conditions.

“So much attention went to the brain and spine that individual signs of MS were viewed as the consequence of a bigger problem and brushed aside. I remember telling one specialist about a range of symptoms I was experiencing, but he responded as though they were check boxes in a list of MS identifiers, not problems to manage,” said Mr Gallagher.

“I think eye health professionals might have had something to say about my symptoms. They might have given me a deeper understanding of how MS was affecting my eyes and what might happen to my vision in the future.

“The best information I got about eyesight problems in MS was from googling other people’s experiences. Knowing others had dealt with similar issues helped me deal with mine as they came up,” he concluded.

Danielle’s Story: Personal and Professional Perspectives

Associate Professor Danielle Hitch lives with ankylosing spondylitis (AS) and recently experienced her first bout of uveitis. AS is a form of axial spondyloarthritis, a painful and progressive type of inflammatory arthritis. It mainly affects the spine and pelvic joints but can also affect other parts of the body.

When Assoc Prof Hitch first experienced symptoms of uveitis, she was worried about the possibility of vision loss. She was referred to an eye health clinic and received excellent treatment, but felt her care could have been more holistic.

“I would have appreciated some reassurance (about her vision risks) and information I could have referred to later about prevention and management of uveitis,” said Assoc Prof Hitch. “I felt my treatment was only reactive, but I haven’t had a follow-up appointment yet,” she added.

“Also, in my case, there was no coordination between my rheumatologist and ophthalmologist. I just told my rheumatologist about it when I saw them next.”

Assoc Prof Hitch is a clinician and researcher in occupational therapy at the School of Health and Social Development at Deakin University and Western Health, Victoria. So her views on the role of allied health professionals in MDTs are formed by both lived and professional experience. She believes there is a definite role for occupational therapists in such teams.

“In the short term, our role could be about helping the person modify what they are doing to be safe or to manage their treatments,” said Assoc Prof Hitch. “If they have permanent vision impairments, we have a lot of expertise working with them to make sure they are still participating in the activities and roles that make life meaningful.”

Veronica’s Story: Self-Coordinating Care

Veronica Miller lives with thyroid eye disease (TED), Graves’ disease, and vitiligo. TED is an autoimmune disease that causes inflammation and damage to the fatty tissues, connective tissues, and muscles around the eyes.

Symptoms include eye pain, dryness, redness, proptosis, strabismus, vision issues, and more.

Ms Miller first developed TED in 2004 during her first pregnancy, and she was diagnosed with Graves’ disease several months later. At that time, she received medical care from an ophthalmologist, an endocrinologist, and her GP.

No medical treatment options were available then, so the ophthalmologist monitored her symptoms, and Ms Miller did her best to manage them with non-medical treatments. She was aware that if her disease got worse, her vision could be affected, and she might need surgery. She found the visibility of her symptoms, alongside the changes in her body during her pregnancy, quite distressing, so she was referred to a psychologist by her GP.

“I just relied on my specialists to guide me, and I concentrated on getting through my pregnancy,” she said.

When Ms Miller developed active TED again in 2024, she saw a similar group of medical professionals with the addition of an immunologist. However, she found the coordination of her care challenging. “It appeared to me that my specialists were working separately, and the case manager in me wanted everyone around the table to form a cohesive plan,” said Ms Miller.

“I don’t know how much communication occurred between my specialists, as I wasn’t privy to their communication. But from my perspective, it felt that it was up to me to organise and coordinate my care,” she added.

“I would have preferred to speak with my ophthalmologist and endocrinologist together to manage my treatment and side effects, but this doesn’t appear to be common practice.”

Ms Miller worked hard to learn from each specialist, and she appreciated the care she received from each of them.

“My endocrinologist sent me written summaries, which were useful when I received weekly outpatient treatments as they gave my nursing staff an official record of my plan,” she said. “She also phoned me each week to check in and review my pathology results. This extra level of care from her was deeply reassuring, as I knew she was paying close attention to my recovery and any adverse results would be quickly addressed,” Ms Miller added.

Ms Miller’s disease was severely impacting her vision, making it difficult for her to drive, work, and concentrate on visual tasks.

“My eyes fatigued easily, I had very dry eyes, and I was extremely sensitive to light, even indoor lighting. It seemed that my whole life relied on my vision, and the possibility of losing my vision was overwhelming,” she said.

Speaking with a psychologist every couple of weeks helped Ms Miller cope during massive uncertainty. “I was very grateful to have someone who could take that journey and help me manage my emotional and psychological self-care while my body was responding to very demanding and draining weekly treatment,” she explained.

TIPS FOR IMPROVING MULTIDISCIPLINARY CARE

While you can only refer your patients to certain types of health professionals, you can help by informing them of other forms of care they might consider.

“I would say that as a specialist, patients often place a lot of trust in your advice. When you suggest something, it carries weight, and many people will act on your recommendations,” Ms Comensoli said.

“Listening to your patient and understanding what they might be struggling with – whether it is fatigue, pain, daily function, or mental health – can open the door to suggesting support from an allied health professional. Conversations like these can go a long way in helping someone feel more supported in their overall care.”

Ms Comonsoli believes it is important to establish connections with health professionals from other disciplines and get to know them. She appreciates that such networks take time to build, but starting locally is a great first step.

“Reach out to providers in your area, ask about their approach and get a sense of the services they offer,” she suggested. “Being able to recommend someone (or a practice) with confidence can make a big difference for your patients.”

While acknowledging the role of an eye health professional is to maintain a patient’s vision and, where appropriate, provide emergency surgical interventions, eye health professionals could offer patients a list of referral suggestions to discuss with their GP to support their treatment.

ADVOCATING FOR CHANGE

Under the current structure of the Australian healthcare system, many people with autoimmune conditions find that managing their own care is almost a full-time job. When they are also dealing with flares, pain, fatigue, and stress, self-advocacy can seem impossible.

“I would love to see Medicare fund qualified case managers who specialise in complex conditions to coordinate care for patients,” said Ms Miller. “They could run case conferences between the patient, their GP, and all relevant health professionals they see. This would ensure everyone agrees on roles, creating a clear treatment plan, and addressing all questions before starting care.

“I managed to coordinate the plan for myself, but I despair for people who don’t have my skill set. They wouldn’t necessarily know how to do this. It shouldn’t come down to luck of the draw,” Ms Miller added.

Mr Gallagher believes his ignorance of all the healthcare options available to him contributed to his fragmented care. And he thinks there is a place for a more nuanced and individualised form of MS treatment management. “The health system funds treatment to manage the overall neurological system, rather than the experiences that help define what we face. It could, and should, do better,” he stressed.

As health professionals, you can advocate for systemic changes that would allow better coordination of care for people with complex conditions. Our community calls on you to look for opportunities to participate in healthcare reform via your peak bodies, government bodies, local networks, and other pathways. You can help make a difference for us and all the people in your care.

Rosemary Ainley is the Senior Editor and Advocacy Manager for Global Health Living Foundation Australia. Further information about the organisation is available at: ghlf.org.au.

References

1. Australian Commission on Safety and Quality in Health Care. National Safety and Quality Primary and Community Healthcare Standards Guide for Healthcare Services, Clinical Safety Standard, Comprehensive care, Multidisciplinary collaboration, available at: safetyandquality.gov.au/publications-and-resources/resource-library/nsqpch-standards-guide-healthcare-services/clinical-safety-standard/comprehensive-care/multidisciplinary-collaboration [accessed Sept 2025].
2. MS Society. About MS, signs and symptoms, early signs of MS (webpage) available at: mssociety.org.uk/about-ms/signs-and-symptoms/early-signs-of-ms [accessed Sept 2025].
3. MS Plus. Your neuro condition, common symptoms, symptoms of MS vision impairment (webpage) available at: msplus.org.au/your-neuro-condition/common-symptoms/symptoms-of-ms-vision-impairment [accessed Sept 2025].

GHLF Australia is committed to elevating the voices of people living with all types of chronic diseases, including those that cause visible eye symptoms. It helps patients access information and advice that can help them in daily life. GHLF Australia is also building programs and resources to support those with chronic health conditions. To help patients with TED find reliable resources and support for their conditions, eye health professionals can share the link to the GHLF Australia TED Education and Advocacy Hub available at: ghlf.org.au/thyroideyedisease. Posters and flyers advertising the TED Hub are also available to display in your practice. Contact: info@ghlf.org.au.