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Re: Intravenous tocilizumab in the treatment of resistant optic perineuritis: a case report

Published:December 21, 2021DOI:https://doi.org/10.1016/j.jcjo.2021.11.008
      Dear Editor,
      We read the report by Maleki et al.,
      • Maleki A
      • Ramezani K
      • Colombo A
      • Foster CS.
      Intravenous tocilizumab in the treatment of resistant optic perineuritis: a case-report.
      and while we find it interesting, we believe that it contains significant errors that call into question the diagnosis optic perineuritis (OPN) and invalidate the conclusions made by the authors. The authors have failed to demonstrate that the patient truly had OPN, which relies mostly on neuroimaging for diagnosis. In Figure 1, the authors claimed to have shown enhancement of the optic nerve sheath near the right globe based on one unenhanced axial T2-weighted magnetic resonance imaging (MRI) image of the brain. It is not possible to assess enhancement on this MRI sequence (it can only be seen after gadolinium is administered). The authors needed to show the T1 postcontrast MRI image of the orbits with fat suppression, which should demonstrate optic nerve sheath enhancement. Likewise, the authors failed to provide objective evidence that the patient actually had a recurrence of OPN when his eye pain worsened because MRI of the orbits was reported as normal at that time. The work-up presented for OPN, which should include investigations for infectious (e.g., syphilis) and inflammatory (e.g., vasculitides such as granulomatosis with polyangiitis) causes, also was incomplete.
      • Xie JS
      • Donaldson L
      • Margolin E.
      Optic perineuritis: a Canadian case series and literature review.
      From a neuro-ophthalmology perspective, we found it unusual that the patient was treated with only a single dose of intravenous methylprednisolone. The typical standard treatment for inflammatory optic neuropathies is 3–5 days of high-dose corticosteroids, which is often followed by a longer tapering dose of oral prednisone starting at 1 mg/kg of body weight.
      • Abel A
      • McClelland C
      • Lee MS.
      Critical review: typical and atypical optic neuritis.
      The authors also did not describe the timeline between the first dose of intravenous steroids and the first dose of tocilizumab. Based on our reading of the report, it is plausible that the intravenous methylprednisolone was the reason that the patient improved initially. The authors also made a statement at the end of their report documenting that the patient complained about returning pain at the visit for his second monthly tocilizumab infusion and that this “was confirmed with optic nerve head leakage on FA.” Pain is a subjective symptom and thus cannot be confirmed with fluorescein angiography. We would encourage the authors to collaborate with their neuro-ophthalmology and neuroradiology colleagues when treating patients with OPN, especially if reporting their results for publication, to avoid diagnostic and treatment errors.

      Footnotes and Disclosure

      The authors have no proprietary or commercial interest in any materials discussed in this correspondence.

      References

        • Maleki A
        • Ramezani K
        • Colombo A
        • Foster CS.
        Intravenous tocilizumab in the treatment of resistant optic perineuritis: a case-report.
        Can J Ophthalmol. 2022; 57: 284
        • Xie JS
        • Donaldson L
        • Margolin E.
        Optic perineuritis: a Canadian case series and literature review.
        J Neurol Sci. 2021; 430 (Epub 2021 Oct 24)120035
        • Abel A
        • McClelland C
        • Lee MS.
        Critical review: typical and atypical optic neuritis.
        Surv Ophthalmol. 2019; 64 (Can J Ophthalmol 2021;11:000–000): 770-779

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