Letter to the editor: comment on "primary visual cortex impairment due to trans-synaptic degeneration after optic neuritis: a systematic review of neuroimaging studies".

This letter addresses the systematic review by Hsiao et al. on trans-synaptic degeneration (TSD) in optic neuritis (ON), highlighting several areas for further exploration to optimize clinical management. A significant gap identified is the lack of individualized brain anatomical analysis in evaluating TSD. Future studies should incorporate personalized brain models using techniques like surface-based morphometry and volumetric analysis to better assess TSD and guide personalized treatment strategies. Additionally, the review primarily relies on cross-sectional data, which limits the understanding of TSD progression over time. Longitudinal studies with multiple imaging time points are necessary to track TSD from the acute to chronic phases of ON and determine the optimal timing for intervention. Furthermore, the integration of functional imaging techniques such as functional MRI (fMRI) and visual evoked potentials (VEPs) with structural imaging can provide valuable insights into the functional impairments of the visual cortex and inform treatment decisions. Finally, integrating immune activity with neuroimaging can significantly improve patient management, particularly for those with autoimmune diseases like multiple sclerosis and neuromyelitis optica spectrum disorder. By combining immune marker monitoring with neuroimaging, clinicians can adjust immunosuppressive therapies based on realtime changes in immune activity and visual function. This comprehensive approach will provide a better understanding of TSD and improve clinical outcomes for ON patients.