Journal of Neuro-Ophthalmology, March 2013, Volume 33, Issue 1

Spontaneous Resolution of Optic Perineuritis

While unproven in the nervous system, there is substantial evidence that pentoxifylline is efficacious in treating delayed-onset radionecrosis of various soft tissues (3-5). Pentoxifylline improves blood viscosity and flow, decreases fibroblast pro-liferation and wound healing, and mitigates the production of inflammatory mediators, such as tumor necrosis factor (6-8). Pentoxifylline in combination with vitamin E, a powerful antioxidant, has been proposed as an even more potent, tar-geted approach. Using this combination, in vivo studies of irradiated cells have demonstrated reduced generation of re-active oxygen species and impaired fibrosis (3,9) and histo-logic normalization of irradiated tissues in animal models (10,11). Promising results of using pentoxifylline and vitamin E in humans have been reported anecdotally (12,13) and in one randomized placebo-controlled trial (14). Both our patient and the patient reported by Farooq et al (1) demonstrated potential reversibility of radiation-induced injury to the anterior visual pathways by targeting underlying etiologic mechanisms. Pentoxifylline is gaining credibility in the treatment of radiation-induced injury to nonneural tissues, is less expensive than bevacizumab, and is established as safe based on decades of systemic administration. Further study is war-ranted for its potential role in managing patients with RON. Harinder S. Chahal, MD Department of Ophthalmology, University of California, Davis, Sacramento, California. [e-mail] Alexander Lam, BS School of Medicine, University of California, Davis, Sacramento, California S. Khizer Khaderi, MD, MPH Department of Ophthalmology, University of California, Davis, Sacramento, California REFERENCES 1. Farooq O, Lincoff NS, Saikali N, Prasad D, Miletich RS, Mechtler LL, Novel treatment for radiation optic neuropathy with intravenous bevacizumab. J Neuroophthalmol. [published ahead of print August 3, 2012] doi:10.1097/WNO.0b013e3182607381. 2. Nieder C, Zimmermann FB, Adam M, Molls M. The role of pentoxifylline as a modifier of radiation therapy. Cancer Treat Rev. 2005;31:448-455. 3. Futran ND, Trotti A, Gwede C. Pentoxifylline in the treatment of radiation-related soft tissue injury: preliminary observations. Laryngoscope. 1997;107:391-395. 4. Delanian S, Lefaix JL. Current management for late normal tissue injury: radiation-induced fibrosis and necrosis. Semin Radiat Oncol. 2007;17:99-107. 5. Chiao TB, Lee AJ. Role of pentoxifylline and vitamin E in attenuation of radiation-induced fibrosis. Ann Pharmacother. 2005;39:516-522. 6. Adams JG Jr, Dhar A, Shukla SD, Silver D. Effect of pentoxifylline on tissue injury and platelet-activating factor production during ischemia-reperfusion injury. J Vasc Surg. 1995;21:742-748; discussion 8-9. 7. Needham D, Armstrong M, Hatchell DL, Nunn RS. Rapid deformation of "passive" polymorphonuclear leukocytes: the effects of pentoxifylline. J Cell Physiol. 1989;140:549-557. 8. Sonkin PL, Sinclair SH, Hatchell DL. The effect of pentoxifylline on retinal capillary blood flow velocity and whole blood viscosity. Am J Ophthalmol. 1993;115:775-780. 9. Berman B, Wietzerbin J, Sanceau J, Merlin G, Duncan MR. Pentoxifylline inhibits certain constitutive and tumor necrosis factor-alpha-induced activities of human normal dermal fibroblasts. J Invest Dermatol. 1992;98:706-712. 10. Lefaix JL, Delanian S, Vozenin MC, Leplat JJ, Tricaud Y, Martin M. Striking regression of subcutaneous fibrosis induced by high doses of gamma rays using a combination of pentoxifylline and alpha-tocopherol: an experimental study. Int J Radiat Oncol Biol Phys. 1999;43:839-847. 11. Dion MW, Hussey DH, Osborne JW. The effect of pentoxifylline on early and late radiation injury following fractionated irradiation in C3H mice. Int J Radiat Oncol Biol Phys. 1989;17:101-107. 12. Delanian S, Balla-Mekias S, Lefaix JL. Striking regression of chronic radiotherapy damage in a clinical trial of combined pentoxifylline and tocopherol. J Clin Oncol. 1999;17:3283-3290. 13. Fischer M, Wohlrab J, Marsch W. Crux medicorum ulcerated radiation-induced fibrosis - successful therapy with pentoxifylline and vitamin E. Eur J Dermatol. 2001;11:38-40. 14. Delanian S, Porcher R, Balla-Mekias S, Lefaix JL. Randomized, placebo-controlled trial of combined pentoxifylline and tocopherol for regression of superficial radiation-induced fibrosis. J Clin Oncol. 2003;21:2545-2550. Spontaneous Resolution of Optic Perineuritis Optic perineuritis (OPN) is a clinical entity characterized by painful visual loss and a distinctive neuroimaging sign of optic nerve sheath enhancement (1). It may be a manifesta-tion of a systemic disease as recently reported by McClelland et al (2). OPN may be severe and recurrent and typically requires treatment with systemic corticosteroids. While steroids are thought to be essential in the management of OPN, we recently evaluated a patient with OPN, which resolved com-pletely without treatment. A 60-year-old African American woman reported a 2-week history of visual loss, severe pain around both eyes, and headache worsened when lying down. She denied nausea, vomiting, photophobia, sonophobia, pulsatile tinnitus, or diplopia. Medical history was significant for well-controlled hypertension and glucose intolerance. Surgical history included cholecystectomy, appendectomy, and hysterectomy. She took only multivitamins, calcium, and omega-3. She denied use of tobacco, alcohol, or recreational drugs. Tung et al: J Neuro-Ophthalmol 2012; 33: 90-95 93 Letters to the Editor Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. Visual acuity was 20/25 in both eyes. Examination of the pupils, extraocular movements, and anterior segments was normal. Automated perimetry showed a superior arcuate defect in the right eye, while the left visual field showed generalized depression. Ophthalmoscopy revealed swelling of the right optic disc and a normal left optic disc (Fig. 1). Orbital magnetic resonance imaging (MRI) demonstrated thin uniform concentric enhancement along the sheath of both optic nerves (Fig. 2). Serum angiotensin-converting enzyme, syphilis serology, and lysozyme measurements were within normal limits as was a chest x-ray. The patient declined a lumbar puncture and a course of systemic corticosteroids. Six weeks later, without any treatment, her eye pain resolved. Subsequently, her visual fields became normal and she developed mild, bilateral optic disc pallor. Follow-up MRI showed near complete resolution of the bilateral peripheral optic nerve enhancement. Evaluation of patients with OPN may lead to a specific etiology, but, at times, the cause of the optic neuropathy remains unknown. Documented causes include Wegener granulomatosis (3), sarcoidosis (4), syphilis (5,6), and inflam-matory bowel disease (2). Short of comprehensive ophthalmic and systemic evaluations, there is no way to distinguish cases of OPN due to a systemic disorder from those that are idiopathic. It has been proposed that failure to treat OPN patients with corticosteroids will result in a poor visual outcome (1). Yet, our case suggests that there is a spectrum of severity in OPN, and some patients may experience spontaneous reso-lution of their optic neuropathy and retain good visual acuity. Cynthia Tung, MD Department of Ophthalmology, The University of Texas Medical Branch, Galveston, Texas Department of Ophthalmology, The Methodist Hospital, Houston, Texas Nafiseh Hashemi, MD Department of Ophthalmology, The Methodist Hospital, Houston, Texas Andrew G. Lee, MD Department of Ophthalmology, The University of Texas Medical Branch, Galveston, Texas, Department of Ophthalmology, The Methodist Hospital, Houston, Texas, Baylor College of Medicine, Houston, Texas, Departments of Ophthalmology, Neurology, and Neurosurgery, Weill Cornell Medical College, New York, New York, Department of Ophthalmology, The University of Iowa Hospitals and Clinics, Iowa City, Iowa, [e-mail] Supported in part by an unrestricted grant from Research to Prevent Blindness (RPB) to the University of Texas Medical Branch, Galveston, Texas. The authors report no conflicts of interest. FIG. 2. Contrasted, fat suppressed T1 axial (A) and coronal (B) magnetic resonance imaging shows bilateral perineural optic nerve enhancement. FIG. 1. At initial examination, there is right optic disc edema. 94 Tung et al: J Neuro-Ophthalmol 2012; 33: 90-95 Letters to the Editor Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. REFERENCES 1. Purvin V, Kawasaki A, Jacobson DM. Optic perineuritis: clinical and radiographic features. Arch Ophthalmol. 2001;119:1299-1306. 2. McClelland C, Zaveri M, Walsh R, Fleisher J, Galetta S. Optic perineuritis as the presenting feature of Crohn disease. J Neuroophthalmol. 2012;32:345-347. 3. Purvin V, Kawasaki A. Optic perineuritis secondary to Wegener's granulomatosis. Clin Exp Ophthalmol. 2009;37: 712-717. 4. Yu-Wai-Man P, Crompton DE, Graham JY, Black FM, Dayan MR. Optic perineuritis as a rare initial presentation of sarcoidosis. Clin Exp Ophthalmol. 2007;35:682-684. 5. Basta MST, Sankar KN, Dayan M. Unilateral syphilitic perioptic neuritis in a patient coinfected with human immunodeficiency virus type 1. Sex Transm Infect. 2007; 83:183-184. 6. Meehan K, Rodman J. Ocular perineuritis secondary to neurosyphilis. Optom Vis Sci. 2010;87:E790-E796. Tung et al: J Neuro-Ophthalmol 2012; 33: 90-95 95 Letters to the Editor Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited.