A female, 34, has episodes of vision loss. How to prevent it?

Question

Hello doctor,

A 34-year-old female presents with recurrent episodes of visual loss in the right eye, associated with eye pain, numbness, and weakness in both lower limbs for the past three years. She reports difficulty walking and frequent falls during relapses. MRI of the brain and spinal cord shows longitudinally extensive transverse myelitis and optic nerve involvement. Serum testing is positive for aquaporin-4 (AQP4) antibodies. She has experienced partial recovery after high-dose corticosteroid therapy during attacks. Her past medical history is unremarkable, and there is no family history of demyelinating disorders. Laboratory tests, including routine blood work, thyroid profile, and autoimmune panel, are within normal limits except for an elevated ESR of 30 mm/hr.

She is concerned about recurrent relapses, long-term disability, and potential side effects of immunosuppressive therapy. She seeks guidance on preventive treatments, including rituximab or mycophenolate mofetil, along with monitoring strategies and rehabilitation measures to maintain mobility and quality of life.

Kindly advise.

Answer 1

Hello,

Welcome to icliniq.com.

I understand your concern.

Based on the presentation of recurrent optic neuritis, longitudinally extensive transverse myelitis, and positive aquaporin-4 (AQP4) antibody, the findings confirm a diagnosis of neuromyelitis optica spectrum disorder (NMOSD).

NMOSD is an autoimmune demyelinating disease of the central nervous system that primarily affects the optic nerves and spinal cord, often leading to recurrent relapses and accumulating disability if not properly controlled. Partial recovery after corticosteroid treatment during attacks is typical, but prevention of future relapses is crucial to preserving neurological function.

Long-term immunosuppressive therapy is recommended to reduce relapse frequency and severity. Rituximab (monoclonal antibody targeting CD20-positive B cells) is one of the most effective options and is generally well tolerated, with periodic infusions every 6–12 months under close monitoring of blood counts and infection risk.

Alternatively, Mycophenolate Mofetil (immunosuppressive antimetabolite) or Azathioprine (purine synthesis inhibitor) can be used for maintenance therapy, though they may take longer to achieve full effect and require regular monitoring of complete blood counts and liver function tests.

Preventive measures include timely management of relapses with high-dose intravenous Methylprednisolone (corticosteroid) followed by a slow taper, updating vaccinations before starting immunosuppressive drugs, and considering infection prophylaxis if prolonged therapy is required.

Regular MRI (Magnetic resonance imaging) follow-up (every 6 to 12 months or when symptoms change) helps assess disease activity and treatment response. Rehabilitation therapy, including physiotherapy and occupational therapy, is essential to improve strength, balance, and walking ability, while assistive devices help maintain mobility and independence.

Psychological support and patient education about relapse recognition, medication adherence, and avoiding triggers such as infections or heat are also important. With consistent immunotherapy and comprehensive care, the long-term prognosis can be significantly improved, and further disability can often be minimized.

I hope you are satisfied with my answer. For further queries, you can consult me at iCliniq.

Thank you.