|LETTER TO THE EDITOR
|Year : 2016 | Volume
| Issue : 7 | Page : 547-548
Vivek Pravin Dave1, Rajeev R Pappuru2
1 Department of Vitreoretina, Netra Mandir Eye Institute, Borivali, Mumbai, Maharashtra, India
2 Smt. Kanuri Santhamma Center for Vitreo Retinal Diseases, LV Prasad Eye Institute, Hyderabad, Telangana, India
|Date of Web Publication||9-Sep-2016|
Vivek Pravin Dave
Netra Mandir Eye Institute, Madona Colony Road, Borivali W, Mumbai - 400 103, Maharashtra
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Dave VP, Pappuru RR. Authors' reply. Indian J Ophthalmol 2016;64:547-8
We thank the readers for their observations about our case report. , Our explanation to the raised concerns is mentioned below.
We accept and apologize for the typographical errors pointed out. Regarding the diabetic status of the patient not being mentioned, the readers have quoted an article citing differences between the diabetic and nondiabetic nonarteritic ischemic optic neuropathic (NAION) cases. We would like to point out that the concerned paper concludes no clinical difference between the initial visual acuity presentation and the final visual outcome.  Rather all significant clinical differences are only demographic.
Fundus fluorescein angiography (FFA) findings have not been mentioned as the invasive test was not done. FFA in our case would not have changed our diagnosis or management approach. Although FFA does assist in diagnosing inflammatory pathologies, the absence of findings such as vitreous cellularity, vascular cuffing and sheathing, cystoid changes at the fovea, and hemorrhages and exudates clinically rules out inflammation. Given the advanced age of the patient, hypertensive systemic status and optic atrophy with similar complaints in the past in the other eye, the diagnosis of NAION was most suggestive without the need for further testing.
In the article that they quote, visual acuity improvement in patients similar to our presentation is mentioned to be 40%, and hence the readers say that improvement in visual acuity cannot be contributed to intravitreal bevacizumab with certainty and could be a natural history-related improvement.  We observe that statistically speaking a proportional confidence interval for 40% in the mentioned article varies from 26.17% (improvement in the worst case scenario) to 57.7% (improvement in the best case scenario). Thus, treating for the worst case scenario seems justified. Visual field on follow-up was not documented as the patient did not consent for the same. In any case, our therapy was directed toward the central subretinal fluid on optical coherence tomography, and thus toward central visual acuity and not change in visual field. The reference that the readers mention about resolution of macular edema actually describes optic disc edema and does not clearly mention about macular edema.  Although a randomized trial as the readers mention is ideal, considering an incidence of NAION of 82/100,000 persons, the logistics are clearly prohibitive. 
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Kalamkar C, Radke NV, Mukherjee A, Radk SN. An unusual presentation of non arteritic ischemic optic neuropathy with sub retinal fluid treated with intra vitreal bevacizumab. Indian J Ophthalmol 2016;64:546-7.
Dave VP, Pappuru RR. An unusual presentation of non arteritic ischemic optic neuropathy with sub retinal fluid treated with intra vitreal bevacizumab. Indian J Ophthalmol 2016;64:87-8.
Hayreh SS, Zimmerman MB. Nonarteritic anterior ischemic optic neuropathy: Clinical characteristics in diabetic patients versus nondiabetic patients. Ophthalmology 2008;115:1818-25.
Hayreh SS, Zimmerman MB. Nonarteritic anterior ischemic optic neuropathy: Natural history of visual outcome. Ophthalmology 2008;115:298-305.e2.
Lee MS, Grossman D, Arnold AC, Sloan FA. Incidence of non-arteritic ischemic optic neuropathy: Increased risk among diabetic patients. Ophthalmology 2011;118:959-63.