A 21 year old female presented to us with sudden drop in vision in her left eye since

5days and gradual reduction in vision in right eye since 6months. She also had left
sided headache with periocular pain since 5days.She had consulted an ophthalmologist
previously and diagnosed as optic neuritis for which she had been prescribed some
oral medications.She gave a history of slight weakness and tingling sensation in her
limbs.There was neither any history of ocular or head trauma nor a history of fever
,vomiting or seizure disorder in the past. CT-Scan brain (done 6months back) were
absolutely normal.Her BCVA was 20/600,<N36 in right eye and NPL in left eye.Colour
vision assessment showed no demo plates in both eyes.Pupil was round ,regular but
sluggishly reacting in right eye whereas in left eye she had grade1 RAPD.Rest anterior
segment was within normal limits.IOP was within normal limits in both eyes.EOM were
grossly full and free .Dilated fundus examination revealed a pale optic disc with CDR of
0.2:1 in right eye and 0.2:1 CDR with superior and inferior disc edema in left eye.Thus a
provisional diagnosis of atypical optic neuritis with optic atrophy in right eye and
unilateral disc edema in left eye was made.Fundus photo was documented and the
patient was sent for MRI brain and Spine.MRI brain depicted B/L Optic nerve
hyperintensities with involvement of right optic chiasma suggestive of B/L Optic
neuritis.There was no evidence of obvious demyelineating plaques.MRI of cervical
spine was normal. HVF of both eyes showed presence of central scotoma. While
awaiting serum anti-aquaporin 4IgG antibody testing reports( in view of suspicion of
Neuromyelitis optica),a trial of IVMP 500 mg BD was given under GVP after taking
fitness clearance from the consulting physician.After completion of 6doses of
IVMP,patient showed only symptomatic relief ,but no improvement in BCVA was
noted.Then she was put on tapering doses of oral corticosteroids for 2 weeks. After 2
weeks her serum aquaporin 4 antibody(anti AQP4-IgG) test reports came out to be
positive(2+).This gave us a final diagnosis of neuromyelitis optica(Devic's disease).We
stopped oral steroids and referred the patient for neurology consultation.While
undergoing treatment by a neurologist we called her for of follow up at 2months when
we found her BCVA to be improved to 20/400,N18 in right eye and 20/60 ,N8 in left
eye .Colour vision assessment showed no demo plates in right eye but 23/23 in left
eye.Pupil showed grade1 RAPD in right eye ,but left eye was RRR.Resolution of disc
edema in left eye had been noteworthy,which led to marked improvement in BCVA ,but
in right eye visual prognosis was quite poor.She is under regular follow up at 3monthly
interval and simultaneously treated by her consulting neurologist.
Neuromyelitis optica (NMO) is an autoimmune disorder of the CNS, previously thought
to be a variant of multiple sclerosis (MS).  Spinal cord and optic nerve are the major
target tissues.It is often relapsing and shows a female preponderance. The discovery of
a novel biomarker anti aquoporin 4 immunoglobulin G (anti AQP4-IgG) has largely
improved the specificity of diagnosi( In nearly 70-80% of cases) . Absence of Dawson's
finger,and “U” fiber lesions on MRI are strongly suggestive of NMO.