Reply to Letter to the Editor: Atypical Optic Neuritis After COVID-19 Vaccination: Response

We thank Dr. Sookaromdee and Dr. Wiwanitkit for their interest and comments about our case series (1)

Letters to the Editor Pathum Sookaromdee, PhD Private Academic Consultant, Bangkok, Thailand Atypical Optic Neuritis After COVID-19 Vaccination W e would like to share ideas on “Case Series: Atypical Optic Neuritis After COVID-19 Vaccination (1).” We agree that the optic neuritis might occur after COVID-19 vaccination. The pathological mechanism is still unknown. For a complication after immunization, “1) molecular mimicry, 2) epitope spreading, or 3) polyclonal stimulation of B lymphocytes” was 3 proposed pathomechanisms (2). Other possibilities should be addressed in addition to those outlined mechanisms. First, the vaccine recipient may or may not have a pre-existing immunological disease that could be activated by immunization. Considering reported cases, it is totally not known on background immune status and optic condition of the patient. Second, there is a chance vaccine recipients have a medical problem at the same time. Concurrent infection in a vaccination recipient has been documented in the literature. Dengue fever is a probable side effect of the COVID-19 vaccination (3), and concomitant dengue is a likely cause of atypical optic neuritis (4). Reply to Letter to the Editor: Atypical Optic Neuritis After COVID-19 Vaccination: Response W e thank Dr. Sookaromdee and Dr. Wiwanitkit for their interest and comments about our case series (1). Indeed, multiple potential pathophysiologic mechanisms have been proposed in the literature to explain optic neuritis that occurs postvaccination (2), and it is possible for a patient with a pre-existing autoimmune disease to develop optic neuritis after COVID-19 vaccination. In our article, we referenced the previously published case of the patient with multiple sclerosis who developed chiasmal optic neuritis after vaccination with the AstraZeneca COVID-19 vaccine (3). Our patients did not have underlying autoimmune disease or concurrent infection at the time of diagnosis of optic neuritis. Both patients had negative COVID-19 polymerase chain reaction testing. We also appreciate the global perspective that these authors provide in discussing dengue as a possible etiology for atypical optic neuritis in endemic regions. Dengue cases are infrequent in the United States, and there were no dengue outbreaks in our region when our patients developed optic neuritis (4). Madina Tugizova, MD Department of Neurology and Neurological Sciences, Stanford University, Stanford, California Letters to the Editor: J Neuro-Ophthalmol 2023; 43: e37-39 Viroj Wiwanitkit, MD Department of Community Medicine, Dr DY Patil University, Pune, India The authors report no conflicts of interest. REFERENCES 1. Tugizova M, Siegel DT, Huang S, Su E, Subramanian PS, Beres S, Vora N. Case Series: atypical optic neuritis after COVID-19 vaccination. J Neuroophthalmol. 2022. Online ahead of print. doi:10.1097/WNO.0000000000001519 2. Cabral G, Gonçalves C, Serrazina F, Sá F. MRI negative myelitis induced by Pfizer-BioNTech COVID-19 vaccine. J Clin Neurol. 2022;18:120–122. 3. Kebayoon A, Wiwanitkit V. Dengue after COVID-19 vaccination: Possible and might be missed. Clin Appl Thromb Hemost. 2021;27:10760296211047229. 4. Kulkarni R, Pujari S, Gupta D. Neurological manifestations of dengue fever. Ann Indian Acad Neurol. 2021;24:693–702. Diane T. Siegel, MD Sue Anschutz-Rodgers University of Colorado Eye Institute and Department of Ophthalmology, University of Colorado School of Medicine, Aurora, Colorado Sally Huang, MD Department of Psychiatry, Stanford University, Stanford, California Elaine Su, MD Department of Neurology and Neurological Sciences, Stanford University, Stanford, California Prem S. Subramanian, MD, PhD Departments of Neurology and Neurosurgery, University of Colorado School of Medicine, Aurora, Colorado Division of Ophthalmology, Uniformed Services University of the Health Sciences, Bethesda, Maryland Shannon Beres, MD Department of Neurology and Neurological Sciences, Stanford University, Stanford, California e37 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. Letters to the Editor Nirali Vora, MD Department of Neurology and Neurological Sciences, Stanford University, Stanford, California The authors report no conflicts of interest. REFERENCES 1. Tugizova M, Siegel DT, Huang S, Su E, Subramanian PS, Beres S, Vora N. Case series: atypical optic neuritis after COVID-19 Unilateral Carotid-Cavernous Fistula Associated With Primitive Persistent Trigeminal Artery Leading to Bilateral Ophthalmic Presentations I n our previous accepted article (1), we described a case with contralateral ocular manifestations of a left primitive persistent trigeminal artery (PPTA)-induced carotidcavernous fistula (CCF). Interestingly, 3 months after the previous intervention, she experienced the same problems of her left eye, so she revisited our hospital. On examination, we found conjunctival injection with corkscrew vessel pattern, no ocular vaccination. J Neuroophthalmol. 2022;1–3. (doi: 10.1097/ WNO.0000000000001519). 2. Stubgen J. A literature review of optic neuritis following vaccination against virus infections. Autoimmun Rev. 2013;12:990–997. 3. Helmchen C, Buttler GM, Markewitz R, Hummel K, Wiendl H, Boppel T. Acute bilateral optic/chiasm neuritis with longitudinal extensive transverse myelitis in longstanding stable multiple sclerosis following vector-based vaccination against the SARSCoV-2. J Neurol. 2022;269:49–54. 4. Centers for Disease Control and Prevention. Dengue in the US states and territories. 2020. Available at: https:// www.cdc.gov/dengue/areaswithrisk/in-the-us.html. Accessed January 22, 2022. hypertension, and no motility restriction in the left side (Fig. 1A). Her visual acuities were normal. Digital subtraction angiography demonstrated a new fistula from the basal arterial side of PPTA in the left side (Fig. 2A–C). We performed another coil embolization to repair this (Fig. 2D). Three days later, her left proptosis and conjunctival injection improved (Fig. 1B). Thus, this case turned out to be a unilateral PPTA causing bilateral ophthalmic findings with late onset of the ipsilateral abnormality. Chen et al described a case with bilateral PPTA, but only one fistula was identified (2). In addition, Demartini reported a patient suffering from traumatic unilateral CCF with contralateral ophthalmic manifestations (3). However, this clinical scenario seems to be extremely unique to the best of our knowledge. FIG. 1. Left proptosis and conjunctival injection before (A) and after (B) intervention. e38 Letters to the Editor: J Neuro-Ophthalmol 2023; 43: e37-39 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited.