How should the ophthalmologists treat the methanol-induced toxic optic neuropathy?

I enjoyed reading the manuscript titled “Hooch blindness: a community study report on a few indoor patients of toxic optic neuropathy following consumption of adulterated alcohol in West Bengal” that has been published in your journal (Samanta et al, 2012). The authors reported ten cases of blindness due to methanol intoxication in West Bengal, India. After presentation of their patients’ histories, ophthalmologic examinations, fundus photographs, and assessment of the functional condition of the optic nerve, they have described the treatment performed for their patients. Their treatment included intramuscular injection of hydoxycobalamine (a bolus of 1000 mg repeated after one week), administration of anti-oxidant tablet once daily with local neuroprotective agents for 3 weeks. Since they believed that this treatment resulted in partial recovery of visual disturbances (VD) in all but one of their patients, they recommended the physicians to treat all such patients using this protocol irrespective of their severity of visual disturbances and/or the time elapsed between methanol ingestion and hospital presentation. However, there are some major points worth mentioning about the general management of these methanol-intoxicated patients and the management performed for their VD, in particular. It is not clear why the physicians of the local hospital (District Hospital) have not properly managed the patients in acute stage of methanol intoxication. They have only administered intravenous (IV) infusion of sodium bicarbonate and absolute alcohol. As you know, in methanol intoxication, hemodialysis is absolutely indicated in any patient with VD of any degree accompanied by metabolic acidosis or a detectable methanol level in addition to the antidotal therapy (ethanol or fomepizole), administration of folic or folinic acid, and sodium bicarbonate if indicated (Hovda et al, 2004; Hovda et al, 2008; Sanaei-Zadeh et al, 2011; Shah et al, 2012). Also, interestingly, the authors have not mentioned anything about the type and dose of the administered anti-oxidant tablet and local neuroprotective agents that have suggested. To my knowledge, to date, no other published study has reported managing methanol-induced optic neuropathy in such a way. Instead, in addition to the successful management of a case of methanol-induced VD with prednisone and vitamin B1 (Rotenstreich et al, 1997), IV prednisolone for methanol-induced VD has been used in 6 other studies (36 cases), so far. This treatment has resulted in complete or incomplete recovery of VD in all but three of the patients (Fujihara et al, 2006; Abrishami et al, 2011; Bang et al, 2007; Sodhi et al, 2001; Shukla et al, 2006; Sharma et al, 2011). ). Moreover, it has been recently suggested that retrobulbar injection of triamcinolone may improve visual outcome in methanol-induced toxic optic neuropathy (Shah et al, 2012). In contrast, it has been Sanaei-Zadeh H Methanol induced toxic optic neuropathy Nepal J Ophthalmol 2012; 4 (8):348-350