A Rare Case Reveals Important Consideration of the Diagnosis of Giant Cell Arteritis in Patients with Bilateral Painful Optic Perineuritis

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

This is an interesting case report describing biopsy-proven giant cell arteritis presenting with bilateral optic perineuritis. The case is potentially valuable because GCA-associated optic perineuritis is uncommon, and early recognition has important implications for preventing irreversible visual loss. However, the manuscript requires substantial revision before publication. In its current form, there are several  insufficient ophthalmic documentation, and an incomplete discussion of differential diagnoses, especially systemic vasculitides that may present with ocular motility disturbance, diplopia, optic nerve/orbital inflammation, or retinal arterial occlusion.

The ophthalmic findings are insufficiently documented.
Given that the main presentation was acute central vision loss with MRI evidence of optic perineuritis, the manuscript should provide more detailed ophthalmic data, including best-corrected visual acuity, color vision testing, visual field findings, RAPD status, fundus photography, OCT of the optic nerve and macula, and, if performed, fluorescein angiography or OCT angiography. The current fundus description states that there was no optic disc edema or vascular abnormality, but this is not enough to exclude retinal ischemia, AION, CRAO/BRAO, or other vasculitic ocular complications.
The differential diagnosis should be broadened.
The current differential diagnosis includes GCA, idiopathic optic perineuritis, optic neuritis, retinal artery occlusion, syphilis, and sarcoidosis. However, systemic vasculitides other than GCA are not adequately discussed. In particular, polyarteritis nodosa and other medium-vessel vasculitides can present with neuro-ophthalmic manifestations, including ocular motility impairment, diplopia, and severe retinal ischemic events such as bilateral central retinal artery occlusion. The authors should discuss how PAN and other vasculitic mimickers were excluded and cite relevant recent ophthalmic case reports, including reports of PAN initially presenting with ocular motility impairment and diplopia followed by bilateral CRAO.
The claim of novelty should be more carefully framed.
The authors state that the overlap between optic perineuritis and GCA is rarely reported and compare their case mainly with prior GCA-associated OPN reports. However, the novelty would be clearer if the authors summarized previously reported cases in a small table, including laterality, visual symptoms, ocular motility findings, MRI features, biopsy status, treatment, and outcome. This would help readers understand what is truly new about the present case.
The conclusion is somewhat overstated.
The conclusion states that clinicians should consider GCA in older adults with OPN “even without systemic features”. However, this patient did have systemic and cranial symptoms suggestive of GCA, including temporal tenderness, jaw claudication, and elevated ESR/CRP . The conclusion should be revised to better match the actual presentation.
The title uses the phrase “A Novel Case,” but novelty should be demonstrated by comparison with prior reports rather than asserted in the title.
The MRI figure legend is difficult to follow. The authors should more clearly explain which panels demonstrate optic nerve sheath enhancement, which sequences were used, and how optic neuritis, orbital myositis, and other orbital inflammatory diseases were excluded.
The histopathology figures are valuable, but the legends should be improved. Specific findings such as disruption of the internal elastic lamina, intimal thickening, luminal narrowing, and giant cells should be indicated more clearly with arrows or labels.
The discussion would benefit from a broader consideration of systemic vasculitides that may present with neuro-ophthalmic manifestations. Although temporal artery biopsy supports GCA in the present case, the initial presentation with painful ocular symptoms and reported motility disturbance overlaps with other vasculitic disorders. In particular, polyarteritis nodosa, a medium-vessel vasculitis, has been reported to initially present with diplopia and ocular motility impairment, followed by severe retinal ischemic events such as bilateral central retinal artery occlusion. The authors should discuss how PAN and other systemic vasculitides were excluded and cite relevant recent ophthalmic case reports to better define the diagnostic specificity of GCA-associated optic perineuritis.

Author Response

This is an interesting case report describing biopsy-proven giant cell arteritis presenting with bilateral optic perineuritis. The case is potentially valuable because GCA-associated optic perineuritis is uncommon, and early recognition has important implications for preventing irreversible visual loss. However, the manuscript requires substantial revision before publication. In its current form, there are several  insufficient ophthalmic documentation, and an incomplete discussion of differential diagnoses, especially systemic vasculitides that may present with ocular motility disturbance, diplopia, optic nerve/orbital inflammation, or retinal arterial occlusion. – Thank you for these comments. We have addressed them below as requested.

The ophthalmic findings are insufficiently documented. – Thank you for this comment, this has been addressed. The Ophthalmologic findings are included now. “During her follow up visit with Neuro-ophthalmology, the patient underwent a number of ophthalmologic testing including visual acuity testing which demonstrated normal visual acuity at 20/20 vision bilaterally. Ishihara plates were utilized for color vision with the patient getting 13/14 correct in the right eye and 11/14 correct in the left eye. Slit lamp testing and funduscopic testing were well within normal limits without evidence of structural damage or abnormalities in the corneal, lens, or the structures of the retina. Lastly, Optical Coherence Tomography of the retinal nerve fiber layer (RNFL) and macular ganglion cell layer (GCL) did not demonstrate any focal thinning bilaterally.”

Given that the main presentation was acute central vision loss with MRI evidence of optic perineuritis, the manuscript should provide more detailed ophthalmic data, including best-corrected visual acuity, color vision testing, visual field findings, RAPD status, fundus photography, OCT of the optic nerve and macula, and, if performed, fluorescein angiography or OCT angiography. The current fundus description states that there was no optic disc edema or vascular abnormality, but this is not enough to exclude retinal ischemia, AION, CRAO/BRAO, or other vasculitic ocular complications. – Thank you for this comment, this has been addressed. The Ophthalmologic findings are included now. “During her follow up visit with Neuro-ophthalmology, the patient underwent a number of ophthalmologic testing including visual acuity testing which demonstrated normal visual acuity at 20/20 vision bilaterally. Ishihara plates were utilized for color vision with the patient getting 13/14 correct in the right eye and 11/14 correct in the left eye. Slit lamp testing and funduscopic testing were well within normal limits without evidence of structural damage or abnormalities in the corneal, lens, or the structures of the retina. Lastly, Optical Coherence Tomography of the retinal nerve fiber layer (RNFL) and macular ganglion cell layer (GCL) did not demonstrate any focal thinning bilaterally.”

The differential diagnosis should be broadened. – Thank you for this specific comment, this has been done per your request. “Multiple Sclerosis, Neuromyelitis Optica Spectrum Disorder, Myelin Oligodendrocyte Glycoprotein Antibody-Associated Disease, GCA or other vasculitidies, idiopathic perineuritis, idiopathic optic neuritis, central/branched retinal artery occlusion, syphilis, sarcoidosis, or infection of the orbits.”

The current differential diagnosis includes GCA, idiopathic optic perineuritis, optic neuritis, retinal artery occlusion, syphilis, and sarcoidosis. However, systemic vasculitides other than GCA are not adequately discussed. In particular, polyarteritis nodosa and other medium-vessel vasculitides can present with neuro-ophthalmic manifestations, including ocular motility impairment, diplopia, and severe retinal ischemic events such as bilateral central retinal artery occlusion. The authors should discuss how PAN and other vasculitic mimickers were excluded and cite relevant recent ophthalmic case reports, including reports of PAN initially presenting with ocular motility impairment and diplopia followed by bilateral CRAO. – Thank you for this specific comment. We have included a new sentence per your request. “GCA was chosen as the diagnosis over other medium vessel vasculitidies due to the pathology results, the age of the patient, the lack of other systemic symptoms such as weight loss or fever, the presence of classical symptoms of GCA such as jaw claudication, and lastly, the lack of other infectious causes which might precipitate other vasculitides such as Hepatitis B or C, Tuberculosis, Syphilis, or Coccidioides.” And in the discussion, “OPN has been described secondary to Polyartiritis Nodosa¹⁹, Graves' disease, granulomatosis with polyangiitis (GAP), systemic lupus erythematosus (SLE), Immunoglobulin G4-related disease (IgG-4 RD), Rheumatoid arthritis, Sarcoidosis, Behcet's disease, scleroderma, and gout²⁰.”

The claim of novelty should be more carefully framed. – Thank you for this specific comment, This has been done per your request. In the original writing it was made clear that this is a rarer presentation including sentences such as, “Prior studies on GCA patients have revealed that while between 10% and 23% present with vision changes only 0.5%-1% present with initial onset of OPN^{9, 10}.”

The authors state that the overlap between optic perineuritis and GCA is rarely reported and compare their case mainly with prior GCA-associated OPN reports. However, the novelty would be clearer if the authors summarized previously reported cases in a small table, including laterality, visual symptoms, ocular motility findings, MRI features, biopsy status, treatment, and outcome. This would help readers understand what is truly new about the present case. – While such a suggestion is useful, this falls outside the scope of the methodology of a case report and is better suited for a scoping review which would require a PRISMA search strategy and appropriate steps in order to not miss or to prevent mischaracterize the data that is being presented. A scoping review is a separate methodological paper and would require that every case of OPN secondary to GCA be reviewed to provide clinical context. While we are willing to do so if the editor is desirous for the team to do this, again falls out of the scope of a singular case report with general review of the literature.

The conclusion is somewhat overstated. – Thank you for this comment, this has been addressed per your request.

The conclusion states that clinicians should consider GCA in older adults with OPN “even without systemic features”. However, this patient did have systemic and cranial symptoms suggestive of GCA, including temporal tenderness, jaw claudication, and elevated ESR/CRP . The conclusion should be revised to better match the actual presentation. – Thank you for this comment, this has been addressed per your request.

The title uses the phrase “A Novel Case,” but novelty should be demonstrated by comparison with prior reports rather than asserted in the title. – Thank you for this specific comment, This has been done per your request. The title has been changed per your request

The MRI figure legend is difficult to follow. The authors should more clearly explain which panels demonstrate optic nerve sheath enhancement, which sequences were used, and how optic neuritis, orbital myositis, and other orbital inflammatory diseases were excluded. – Thank you for this specific comment. This has been done per your request. “Magnetic Resonance Imaging of the brain and orbits. (A) is an axial T1 weighted image that demonstrates normal vasculature. (B) is an axial T1 weighted image that demonstrates normal optic nerves. (C) is an axial T1 weighted image that demonstrates normal extraocular musculature sand peri-optic nerve hyperintensity with signs of inflammation. (D) is a Sagittal T2 weighted imaging of right orbit and (E) is a Sagittal T2 weighted imaging of left orbit showing the extent of optic sheath hyperintensity and peri-neuritis compared to the optic nerve itself.”

The histopathology figures are valuable, but the legends should be improved. Specific findings such as disruption of the internal elastic lamina, intimal thickening, luminal narrowing, and giant cells should be indicated more clearly with arrows or labels. – Thank you for this specific comment. This has been done per your request.

The discussion would benefit from a broader consideration of systemic vasculitides that may present with neuro-ophthalmic manifestations. Although temporal artery biopsy supports GCA in the present case, the initial presentation with painful ocular symptoms and reported motility disturbance overlaps with other vasculitic disorders. In particular, polyarteritis nodosa, a medium-vessel vasculitis, has been reported to initially present with diplopia and ocular motility impairment, followed by severe retinal ischemic events such as bilateral central retinal artery occlusion. The authors should discuss how PAN and other systemic vasculitides were excluded and cite relevant recent ophthalmic case reports to better define the diagnostic specificity of GCA-associated optic perineuritis. – Thank you for this specific comment. We have included a new sentence per your request. “GCA was chosen as the diagnosis over other medium vessel vasculitidies due to the pathology results, the age of the patient, the lack of other systemic symptoms such as weight loss or fever, the presence of classical symptoms of GCA such as jaw claudication, and lastly, the lack of other infectious causes which might precipitate other vasculitides such as Hepatitis B or C, Tuberculosis, Syphilis, or Coccidioides.” And in the discussion, “OPN has been described secondary to Polyartiritis Nodosa¹⁹, Graves' disease, granulomatosis with polyangiitis (GAP), systemic lupus erythematosus (SLE), Immunoglobulin G4-related disease (IgG-4 RD), Rheumatoid arthritis, Sarcoidosis, Behcet's disease, scleroderma, and gout²⁰.”

 

This Reviewer suggested that English Be revised for the research and for the tables and figures. This was read over by a native english speaker and revised with that individual to better address all the English language deficiencies.

Reviewer 2 Report

Comments and Suggestions for Authors

1. Novelty should be more accurately framed
   The case is clinically relevant and reinforces an important diagnostic message. However, the manuscript currently presents the case as “novel,” which may overstate its originality. Several prior reports have already described bilateral optic perineuritis as an initial or presenting manifestation of GCA, including biopsy-proven cases. Therefore, the authors should revise the title, abstract, and discussion to more cautiously frame this as a rare presentation rather than a unique or previously undescribed entity. Another citation suggested : Morotti A, Liberini P, Padovani A. Bilateral optic perineuritis as the presenting feature of giant cell arteritis. BMJ Case Rep. 2013 Jan 29;2013:bcr2011007959. doi: 10.1136/bcr-2012-007959. PMID: 23365154; PMCID: PMC3603633.
2. Literature review requires better organization and precision
   The discussion would benefit from a more structured comparison with previously published cases of GCA-associated OPN. At present, the manuscript cites some relevant reports, but it does not clearly explain how the present case differs from prior bilateral cases. The authors should specify whether the distinctive features are the patient’s age, bilateral biopsy positivity, central rather than peripheral visual loss, extraocular motility restriction, cranial nerve involvement, treatment course, or another element. Without this clarification, the claim of novelty remains insufficiently supported.
3. Clinical ophthalmic characterization is incomplete
   The case description lacks several ophthalmic details that would strengthen the report. In particular, visual acuity is described qualitatively as “central vision loss,” but exact baseline and follow-up visual acuity values for each eye are not clearly provided. Formal visual field testing, color vision testing, OCT retinal nerve fiber layer/ganglion cell analysis, and fundus/OCT documentation would be helpful IF available. Given that the key manifestation is visual loss, more precise ophthalmic data are needed to support the clinical course and recovery.
4. Diagnosis of optic perineuritis should be described more rigorously
   The MRI findings are central to the diagnosis, but the radiological description could be improved. The authors should explicitly describe the classic OPN imaging pattern, including optic nerve sheath enhancement with relative sparing of the optic nerve itself, and clarify whether the enhancement pattern was bilateral and circumferential on post-contrast fat-suppressed orbital sequences. Figure 1 is useful, but the legend is difficult to follow and should be rewritten in clearer radiological terminology.
5. Treatment section needs clarification
   The treatment course is somewhat confusing. The abstract states that the patient was treated with corticosteroids and tocilizumab, whereas the case description states that she received IV methylprednisolone, prednisone taper, and later upadacitinib. This discrepancy should be corrected. The authors should clearly state which steroid regimen was used, whether tocilizumab was actually administered, why upadacitinib was chosen, and whether this treatment is standard or off-label in this context.
6. Some citations appear to be used imprecisely
   The statement that prior case series showed “30–40% with initial onset of OPN” seems questionable and should be verified carefully, because OPN is generally considered a rare manifestation of GCA. The authors should ensure that this percentage refers to the correct denominator and clinical entity and is supported by the cited references.

Minor comments

1. In the abstract, OPN should be defined before the abbreviation is used: “optic perineuritis (OPN).”
2. The sentence “A recent case series published by Eldaya et al. focused on the optic nerve involvement (optic neuritis) and most of these patients did also have OPN” should be rewritten for clarity and accuracy.
3. Several typographical and grammatical errors require correction, for example: “57 years-old female,” “central vision loss esrextended,” “branched retinal artery occlusion,” “spine fluid culture,” and “magnetic resonance image (MRI)”
4. The term “Disease Modifying Agents” in the keywords is vague and probably unnecessary.
5. The authors should avoid stating that GCA should be considered “even without systemic features” unless this is directly supported by the case, since this patient had temporal tenderness and jaw claudication.

Comments on the Quality of English Language

see point 3 minor comments above

Author Response

1. Novelty should be more accurately framed
   The case is clinically relevant and reinforces an important diagnostic message. However, the manuscript currently presents the case as “novel,” which may overstate its originality. Several prior reports have already described bilateral optic perineuritis as an initial or presenting manifestation of GCA, including biopsy-proven cases. Therefore, the authors should revise the title, abstract, and discussion to more cautiously frame this as a rare presentation rather than a unique or previously undescribed entity. Another citation suggested : Morotti A, Liberini P, Padovani A. Bilateral optic perineuritis as the presenting feature of giant cell arteritis. BMJ Case Rep. 2013 Jan 29;2013:bcr2011007959. doi: 10.1136/bcr-2012-007959. PMID: 23365154; PMCID: PMC3603633. – Thank you for this specific comment, This has been done per your request and the citation was added to the section where this was mentioned in the original writing.
2. Literature review requires better organization and precision
   The discussion would benefit from a more structured comparison with previously published cases of GCA-associated OPN. At present, the manuscript cites some relevant reports, but it does not clearly explain how the present case differs from prior bilateral cases. The authors should specify whether the distinctive features are the patient’s age, bilateral biopsy positivity, central rather than peripheral visual loss, extraocular motility restriction, cranial nerve involvement, treatment course, or another element. Without this clarification, the claim of novelty remains insufficiently supported. – Thank you for this specific comment, we have made the change and added the sentence to the discussion. “The difference between the prior cases and our case is that the patient had both the painful extraocular motions and the central vision loss simultaneously on presentation indicating that it was rapidly progressing to also include ischemia of the nerve and retina similar to the way that Madkhali et al describes how OPN preceded anterior ischemic optic neuropathy¹⁴.”
3. Clinical ophthalmic characterization is incomplete
   The case description lacks several ophthalmic details that would strengthen the report. In particular, visual acuity is described qualitatively as “central vision loss,” but exact baseline and follow-up visual acuity values for each eye are not clearly provided. Formal visual field testing, color vision testing, OCT retinal nerve fiber layer/ganglion cell analysis, and fundus/OCT documentation would be helpful IF available. Given that the key manifestation is visual loss, more precise ophthalmic data are needed to support the clinical course and recovery. – Thank you for this comment, this has been addressed. The Ophthalmologic findings are included now. “During her follow up visit with Neuro-ophthalmology, the patient underwent a number of ophthalmologic testing including visual acuity testing which demonstrated normal visual acuity at 20/20 vision bilaterally. Ishihara plates were utilized for color vision with the patient getting 13/14 correct in the right eye and 11/14 correct in the left eye. Slit lamp testing and funduscopic testing were well within normal limits without evidence of structural damage or abnormalities in the corneal, lens, or the structures of the retina. Lastly, Optical Coherence Tomography of the retinal nerve fiber layer (RNFL) and macular ganglion cell layer (GCL) did not demonstrate any focal thinning bilaterally.”
4. Diagnosis of optic perineuritis should be described more rigorously
   The MRI findings are central to the diagnosis, but the radiological description could be improved. The authors should explicitly describe the classic OPN imaging pattern, including optic nerve sheath enhancement with relative sparing of the optic nerve itself, and clarify whether the enhancement pattern was bilateral and circumferential on post-contrast fat-suppressed orbital sequences. Figure 1 is useful, but the legend is difficult to follow and should be rewritten in clearer radiological terminology. – Thank you for this specific comment. This has been done per your request. “Magnetic Resonance Imaging of the brain and orbits. (A) is an axial T1 weighted image that demonstrates normal vasculature. (B) is an axial T1 weighted image that demonstrates normal optic nerves. (C) is an axial T1 weighted image that demonstrates normal extraocular musculature sand peri-optic nerve hyperintensity with signs of inflammation. (D) is a Sagittal T2 weighted imaging of right orbit and (E) is a Sagittal T2 weighted imaging of left orbit showing the extent of optic sheath hyperintensity and peri-neuritis compared to the optic nerve itself.”
5. Treatment section needs clarification
   The treatment course is somewhat confusing. The abstract states that the patient was treated with corticosteroids and tocilizumab, whereas the case description states that she received IV methylprednisolone, prednisone taper, and later upadacitinib. This discrepancy should be corrected. The authors should clearly state which steroid regimen was used, whether tocilizumab was actually administered, why upadacitinib was chosen, and whether this treatment is standard or off-label in this context. – Thank you for this comment, the abstract has been corrected and a new sentence to address your comments has been inserted. “This medication was chosen as it is a once a day, oral medication that is FDA approved for the treatment of Giant Cell Arteritis and is considered to be one of the standard of care medications for this disorder.”
6. Some citations appear to be used imprecisely
   The statement that prior case series showed “30–40% with initial onset of OPN” seems questionable and should be verified carefully, because OPN is generally considered a rare manifestation of GCA. The authors should ensure that this percentage refers to the correct denominator and clinical entity and is supported by the cited references. – Thank you for this comment. An inadvertent error occurred in the writing of this case report and this has been corrected. Per see the new sentence with two relevant citations. “Prior studies on GCA patients have revealed that while between 10% and 23% present with vision changes only 0.5%-1% present with initial onset of OPN^{9, 10}.”

Minor comments

1. In the abstract, OPN should be defined before the abbreviation is used: “optic perineuritis (OPN).” – Thank you for this suggestion, this has been done per your request
2. The sentence “A recent case series published by Eldaya et al. focused on the optic nerve involvement (optic neuritis) and most of these patients did also have OPN” should be rewritten for clarity and accuracy. – Thank you this has been done per your request. “A recent case series of 13 patients with GCA and 8 patients with non-arteritic anterior ischemic optic neuropathy published by Eldaya et al. in Frontiers of Ophthalmology focused on the optic nerve pathology¹. In those patients with pathology confirmed Giant Cell Arteritis, 7 of those patients (over half) also had optic nerve perineuritis, which may indicate possible under-diagnosis of OPN.¹”
3. Several typographical and grammatical errors require correction, for example: “57 years-old female,” “central vision loss esrextended,” “branched retinal artery occlusion,” “spine fluid culture,” and “magnetic resonance image (MRI)” – Thank you for this suggestion, this has been done per your request
4. The term “Disease Modifying Agents” in the keywords is vague and probably unnecessary. – Thank you for this suggestion, this has been done per your request
5. The authors should avoid stating that GCA should be considered “even without systemic features” unless this is directly supported by the case, since this patient had temporal tenderness and jaw claudication. – Thank you for this suggestion, this has been done per your request

This reviewer requested that the English be revised. This was done with a native English Speaker to ensure that the language and syntax better flowed throughout the document

Round 2

Reviewer 1 Report

Comments and Suggestions for Authors

The revised manuscript has improved; however, two minor issues remain.

First, the legends for Figures 2 and 3 state that blue circles/circles indicate key histopathological findings, including giant cells and disruption of the internal elastic lamina. However, the corresponding circles are not clearly visible in the figure panels. The authors should add clearly visible circles or arrows directly to the relevant panels, or revise the legends accordingly.

Second, the authors have added polyarteritis nodosa (PAN) to the discussion of systemic vasculitic mimickers. Because the manuscript also includes central/branch retinal artery occlusion in the differential diagnosis and discusses PAN as a vasculitic mimicker, it may be useful to briefly mention that PAN can also present with ocular motility disturbance, diplopia, and retinal arterial ischemic events, supported by relevant ophthalmic case reports. This should be clearly distinguished from optic perineuritis itself.

Author Response

The revised manuscript has improved; however, two minor issues remain.

First, the legends for Figures 2 and 3 state that blue circles/circles indicate key histopathological findings, including giant cells and disruption of the internal elastic lamina. However, the corresponding circles are not clearly visible in the figure panels. The authors should add clearly visible circles or arrows directly to the relevant panels, or revise the legends accordingly. – Thank you for this specific comment. This has been done per your request.

Second, the authors have added polyarteritis nodosa (PAN) to the discussion of systemic vasculitic mimickers. Because the manuscript also includes central/branch retinal artery occlusion in the differential diagnosis and discusses PAN as a vasculitic mimicker, it may be useful to briefly mention that PAN can also present with ocular motility disturbance, diplopia, and retinal arterial ischemic events, supported by relevant ophthalmic case reports. This should be clearly distinguished from optic perineuritis itself. – Thank you for this specific comment. This has been done per your request. “In cases of Polyarteritis Nodosa there are reports of retinal vasculitis and central retimal artery occlusion²⁴, diplopia²⁵, and ocular motility disturbances²⁶ which can mimic classical symptoms of optic perineuritis but these clinical findings are distinctly different than OPN.”

24. Emad, Y., Basaffar, S., Ragab, Y., Zeinhom, F., & Gheita, T. (2007). A case of polyarteritis nodosa complicated by left central retinal artery occlusion, ischemic optic neuropathy, and retinal vasculitis. Clinical rheumatology, 26(5), 814-816.
25. Miteva, M., Norgauer, J., & Ziemer, M. (2007). Diplopia and myalgia: potential heralding symptoms of polyarteritis nodosa. American journal of clinical dermatology, 8(3), 175-178.
26. Martins, A., Pinheiro, F. O., Vedor, S., Oliveira, D., Seabra Rato, M., Fonseca, D., Madureira, P., Braz, L., Pimenta, S., & Costa, L. (2023). Oculomotor nerve palsy, an unusual onset of polyarteritis nodosa. Reumatologia, 61(1), 71–77. https://doi.org/10.5114/reum/161085

In addition, the figure legends and the actual english have been re-reviewed by a third native english speaker with a significant writing and editing background to address all syntax and grammar errors.

Reviewer 2 Report

Comments and Suggestions for Authors

Although the manuscript has improved after revision, several sections would still benefit from further language and stylistic editing.

1. The statement in the Introduction that “The unique OPN presentation involves bilateral painful extraocular movements (EOMs) and bilateral vision loss” should be revised. Given the heterogeneity of OPN presentations and the literature cited later in the manuscript, this wording appears overly definitive. A more cautious description of the clinical features reported in GCA-associated OPN would be preferable.
2. In the Discussion, the sentence “The difference between the prior cases and our case is that the patient had both the painful extraocular motions and the central vision loss simultaneously on presentation…” is difficult to follow and does not clearly establish how the present case differs from previously published reports. This section should be rewritten more precisely and supported by direct comparison with the cited literature.
3. Several passages adopt a narrative style rather than a scientific one. For example, the statement “She was deeply appreciative of the care of the Neurology, Rheumatology, Vascular surgery, and Pathology services” does not add scientific value and could be removed.
4. The MRI figure legend remains difficult to interpret. Expressions such as “demonstrates normal vasculature,” “demonstrates normal optic nerves,” and “demonstrates normal extraocular musculature” are not particularly informative in the context of a figure intended to highlight pathology. The legend should focus on the abnormal radiologic findings relevant to the diagnosis of optic perineuritis.
5. Several statements throughout the manuscript remain repetitive. The concepts of rarity, bilateral painful eye movements, and vision loss are reiterated multiple times in the Introduction and Discussion. Streamlining these sections would improve readability and strengthen the overall presentation.
6. literature citations are presented in a narrative style (e.g., “published by Eldaya et al. in Frontiers of Ophthalmology”). The journal name is not necessary in the main text and should be removed. The discussion would read more professionally if it focused on the findings of prior studies rather than where they were published.

Overall, the scientific message is clear, but further revision of these sections would improve precision, readability, and scientific style.

Author Response

Although the manuscript has improved after revision, several sections would still benefit from further language and stylistic editing.

1. The statement in the Introduction that “The unique OPN presentation involves bilateral painful extraocular movements (EOMs) and bilateral vision loss” should be revised. Given the heterogeneity of OPN presentations and the literature cited later in the manuscript, this wording appears overly definitive. A more cautious description of the clinical features reported in GCA-associated OPN would be preferable. – Thank you for this specific comment, this has been done per your request.
2. In the Discussion, the sentence “The difference between the prior cases and our case is that the patient had both the painful extraocular motions and the central vision loss simultaneously on presentation…” is difficult to follow and does not clearly establish how the present case differs from previously published reports. This section should be rewritten more precisely and supported by direct comparison with the cited literature. – Thank you for this specific comment, this has been done per your request.
3. Several passages adopt a narrative style rather than a scientific one. For example, the statement “She was deeply appreciative of the care of the Neurology, Rheumatology, Vascular surgery, and Pathology services” does not add scientific value and could be removed. – Thank you for this specific comment. This was added as follow up statements and the patient’s experience is REQUIRED by the CARES guidelines. We will leave this up to the Editors discretion.
4. The MRI figure legend remains difficult to interpret. Expressions such as “demonstrates normal vasculature,” “demonstrates normal optic nerves,” and “demonstrates normal extraocular musculature” are not particularly informative in the context of a figure intended to highlight pathology. The legend should focus on the abnormal radiologic findings relevant to the diagnosis of optic perineuritis. – Thank you for this comment. OPN as a distinct clinical entity is defined as perineurium enhancement and the LACK of involvement of the vasculature, the LACK of involvement of the optic nerve, and the LACK of involvement of the extraocular musculature. This is why these normal findings are highlighted so as to demonstrate that this does in-fact meet this radiographic definition. We believe therefore, that the figure legend should remain the same. We are willing to make changes, but we will leave this to the discretion of the editors.
5. Several statements throughout the manuscript remain repetitive. The concepts of rarity, bilateral painful eye movements, and vision loss are reiterated multiple times in the Introduction and Discussion. Streamlining these sections would improve readability and strengthen the overall presentation. – Thank you for this specific comment, this has been done per your request.
6. literature citations are presented in a narrative style (e.g., “published by Eldaya et al. in Frontiers of Ophthalmology”). The journal name is not necessary in the main text and should be removed. The discussion would read more professionally if it focused on the findings of prior studies rather than where they were published. – Thank you for this specific comment, this has been done per your request.

Overall, the scientific message is clear, but further revision of these sections would improve precision, readability, and scientific style.

In addition a third native english speaker with a strong history of English Writing and Editing has read the manuscript to address Grammar and Syntax.