Multimodal Imaging in Idiopathic Neuroretinitis with Localized Choroidal Insufficiency: A Case Report
Round 1
Reviewer 1 Report
The authors response to reviewer comments are acceptable but both the introduction and discussion present this affirmation:
'the first description ' ' the first case'
please remove both of them and state the importance of multimodal imaging modalities.
Author Response
Dear Reviewer,
Thank you very much for giving me a wonderful opportunity. It is great honor for me for academic advancement.
Point 1: The authors response to reviewer comments are acceptable but both the introduction and discussion present this affirmation:'the first description ' ' the first case'
please remove both of them and state the importance of multimodal imaging modalities.
Response 1: Thank you for your comment. I removed both of ‘the first description’ and ‘the first case’ and then, I describe usefulness of swept-source OCTA, to detect focal choroidal flow deficit. It would explicate possible pathogenesis of neuroretinitis. Also, it could be a useful, noninvasive tool to look at the course of the neuroretinitis. We described the importance of multimodal imaging modalities, as follows:
[Line38-40] “The present case shows multimodal imaging features of idiopathic neuroretinitis with SS-OCTA, which may therefore contribute to better understand the underlying pathophysiology of the disease.”
[Line 126-128] “Here, we detect focal choroidal circulation insufficiency in idiopathic neuroretinitis, using multimodal imaging. SS-OCTA can offer additional valuable insight into the current multimodal imaging techniques used for characterisation of neuroretinitis”.
Author Response File: 
Author Response.docx
Reviewer 2 Report
- line 126, "this is the first case of neuroretinitis that evaluated 126 choroidal circulation insufficiency using multi-modal imaging.
There has been a report about multimodal choroidal imaging in idiopathic neuroretinitis. (Esaki Y et al. Multimodal Imaging in a Case of Idiopathic Neuroretinitis. Case Rep Opththalmol 2018:0;487-492.
Authors need to consider this paper in their discussion.
Author Response
First of all, thank you for your professional and detailed comments. It is a great honor for me to reply to your comments.
Point 2: line 126, "this is the first case of neuroretinitis that evaluated 126 choroidal circulation insufficiency using multi-modal imaging.
There has been a report about multimodal choroidal imaging in idiopathic neuroretinitis. (Esaki Y et al. Multimodal Imaging in a Case of Idiopathic Neuroretinitis. Case Rep Opththalmol 2018:9;487-492.
Authors need to consider this paper in their discussion.
Response 2: Thank you for your suggestion. Esaki Y et al. also reported choroidal involvement in idiopathic neuroretinitis using OCT and ICGA, which supports our findings as neurochorioretinitis. We added this paper as a reference and briefly describe in the discussion part, as follows:
[Line 151-154] “Esaki Y et al 9 previously reported that choroidal involvement in both posterior pole and mid-peripheral retina by OCT and ICGA imaging in idiopathic neuroretinitis which supports the current findings as neurochorioretinitis”.
Author Response File: Author Response.docx
This manuscript is a resubmission of an earlier submission. The following is a list of the peer review reports and author responses from that submission.
Round 1
Reviewer 1 Report
The case presented is interesting and in my opinion could add some informations regardinf papillophlebitis.
Page 1 Line 39 Authors wrote Here medical hystorybut I believe they mean Her .
Clinical case description is correct and images represent clearly what is described along the manuscript.
In the discussion paragraph please eliminate the sentence line 118-119, is not proper in my opinion to state that this is the first case that evaluated...
Line 141 I believe that authors finding as they wrote also in the introduction may relate with pathophysiology but not with phatogenesis. In my opinion impairment of choroidal circulation is a consequence of papillophlebitis not a cause. Please address this point and clarify what is the meaning of the sentence.
Author Response
Dear Reviewer,
First of all, Thank you very much. It is great honor for me to have mentioned from you.
[Comment #1]
Page 1 Line 39 Authors wrote Here medical history but I believe they mean Her .
[Response #1]
I agreed to your comment, I corrected the typo ‘Here’ to ‘Her’.
“Her medical history and ocular history were otherwise unremarkable.”
[Comment #2]
In the discussion paragraph please eliminate the sentence line 118-119, is not proper in my opinion to state that this is the first case that evaluated...
[Response #2]
I definitely agree with your opinion, thank you for your comment. As I reviewed clinical presentation again, I thought this case was better matched with neuroretinitis. Previous reports often used multimodal imaging, but this is the first to reveal focal choroidal deficit using SS-OCTA. Thus, I cited the ‘best of our knowledge’ again.
“To the best of our knowledge, this is the first case of neuroretinitis that evaluated choroidal circulation insufficiency using multi-modal imaging.”
[Comment #3]
Line 141 I believe that authors finding as they wrote also in the introduction may relate with pathophysiology but not with phatogenesis. In my opinion impairment of choroidal circulation is a consequence of papillophlebitis not a cause. Please address this point and clarify what is the meaning of the sentence.
[Response #3]
Thank you for your comment. I absolutely agree with your comment. We hypothesized that intraretinal thickening and hyperreflective spots are signs of peripapillary retinal venous inflammation, which causes focal choroidal flow deficit.
“The current case may be involved in the possible pathophysiology of neuroretinitis.”
Author Response File: Author Response.docx
Reviewer 2 Report
Authors presents a case of papillophlebitis in which the retina was examined with multimodal imaging. The speculation is interesting. However, authors need to explain about inconsistencies in the findings and their interpretation.
- Line 134, The authors state that there is inflammation in the peripapillary veins. However, fluorescein angiography does not show leakage from retinal vessels.
- Line 116, "hyperreflective intraretinal spots, which are well-known OCT imaging biomarker of retinal inflammation." Fluorescein angiography showed no leakage on the site of the intraretinal spots. Weren't the intraretinal spots result of the leakage from the optic disc?
- What was the critical factor in authors' diagnosis of papillophlebitis? In this case, there was no venous tortuosity, so retinal veins appears not to be obstructed. With these findings, can authors explain why it is papillophlebitis and not papillitis or papilledema?
Author Response
Dear Reviewer,
Thank you very much for your professional and detail comment, it will academically improving my case report.
[Comment #1]
Line 134, The authors state that there is inflammation in the peripapillary veins. However, fluorescein angiography does not show leakage from retinal vessels.
[Response #1]
Thank you for your comment. I agree with your comment. Considering hyperemic disc, disc swelling, and hard exudate of macular star shape, we thought that peripapillary retinal edema are caused by inflammation of the optic disc. In this case, absence of severe visual loss, vessel tortuosity, vascular leakage and altitudi-nal visual fields defect assist in excluding similar disease entities such as papillitis, papilledema, papillophlebitis and AION. We concluded that idiopathic neuroretinitis is better diagnosis to describe this case better than papillophlebitis.
“The fluid exudate and edema of the optic nerve fibers due to infectious process or inflammation is known as pathogenesis.”
[Comment #2]
Line 116, "hyperreflective intraretinal spots, which are well-known OCT imaging biomarker of retinal inflammation." Fluorescein angiography showed no leakage on the site of the intraretinal spots. Weren't the intraretinal spots result of the leakage from the optic disc?
[Response #2]
Fluorescein angiography shows leakage mainly at the optic disc. So, I notice the disc swelling and macular fluid following hard exudate. Changing her diagnosis to idiopathic neuroretinitis, I talk carefully hyperreflective intraretinal spots are derived from inflammation or damage of the optic disc vasculature.
“In this case, both ICGA and SS-OCTA imaging showed focal choroidal insufficiency in the temporal peripapillary areas corresponding to hyperreflective intraretinal spots, which are well-known OCT imaging biomarker of inflammation or damage of the optic disc vasculature.”
[Comment #3]
What was the critical factor in authors' diagnosis of papillophlebitis? In this case, there was no venous tortuosity, so retinal veins appears not to be obstructed. With these findings, can authors explain why it is papillophlebitis and not papillitis or papilledema?
[Response #3]
At first, the patient was young, healthy woman without any medical history. my impression was based on clinical features such as inflammatory changes in the optic disc. In addition, absence of severe visual loss, vessel tortuosity, vascular leakage and altitudinal visual fields defect assist in excluding similar disease entities such as papillitis, papilledema, papillophlebitis and AION. We concluded that early idiopathic neuroretinitis is better diagnosis to describe this case better than papillophlebitis.
