We appreciate the correspondence and feedback from Badakere and associates, who raise several important issues about this study.
In terms of race, the ethnic background of each patient was recorded during the initial data collection. The race breakdown of the 46 patients in the study was as follows: White 70% (n = 32), Black 15% (n = 7), Asian 2% (n = 1), Other 7% (n = 3), and Declined to answer 7% (n = 3). Of the 4 patients with a poor visual outcome at 1 year (visual acuity <20/40 in the worse eye at presentation), there were 3 white patients and 1 Asian patient. Given the preponderance of white patients in the study and the incomplete data on ethnicity, it was decided to exclude race from the analysis in order to avoid the potential harm of making false conclusions about the effect (or lack of effect) of race on visual outcomes. However, we certainly recognize that race may play a key role in the presentation and prognosis of optic neuritis and we appreciate the useful data from Badakere and associates about the clinical features of their cohort of pediatric patients with optic neuritis in India.
At our institution, treatment with systemic steroids is generally considered to be the standard of care for optic neuritis in children. However, given the lack of prospective evidence supporting treatment efficacy, the neurology and ophthalmology services collaborate to assess each case and make individual treatment recommendations. In the study, the 4 untreated patients were all older, between the ages of 15 and 17 years old, with unilateral optic neuritis and visual acuity between 20/25 and 20/80 at presentation. The patients did not have any systemic demyelinating conditions at presentation, but 3 of the 4 were eventually diagnosed with relapsing-remitting multiple sclerosis. In 1 case, the patient had several white matter lesions on magnetic resonance imaging and treatment was strongly recommended, but the family declined. In the other cases, the patients had unilateral isolated optic neuritis with vision of 20/40 or better. In these cases, a decision was made, in conjunction with the family and patient, to follow closely without treatment. All of the untreated patients in the study did recover normal (20/20 or better) visual acuity, but treatment would have been initiated promptly if the vision had worsened or not fully recovered. This discussion continues to highlight the need for a prospective study evaluating the efficacy of steroids and multimodal therapy for optic neuritis in children.