Neuromyelitis optica presenting with bitemporal hemianopia


  • Irina Effendi Tenang
  • Nurliza Binti Khaliddin
  • Norlisah Ramli
  • Mimiwati Zahari



neuromyelitis optica, neuromyelitis optica spectrum disorder, nmo, nmosd, bitemporal, inferior, quadrantinopia, quadrantinopsia, hemianopia, hemianopsia, cerebral lesion, optic neuritis, chiasmal neuritis, multiple sclerosis, intravenous steroids


Neuromyelitis optica (NMO) is an idiopathic immune-mediated inflammatory disease of the central nervous system (CNS) characterized by severe demyelination and axonal damage with a predilection for the optic nerves and spinal cord.  In this case report, a 60-year-old woman presented with decreased vision.  Visual field testing initially demonstrated a bitemporal inferior quadrantinopia which progressed to a bitemporal hemianopia.  The patient did not have any focal neurologic deficits.  Indirect immunofluorescence testing was performed and positive for serum anti-aquaporin 4 (AQP4) antibodies indicating a diagnosis of NMO.  The bitemporal hemianopia largely resolved following intravenous steroids.  However, she developed a relapse of her NMO requiring restarting of the intravenous steroids.  The patient was diagnosed with chiasmal neuritis.  A variety of visual field defects may be seen in optic neuropathies, but typically in NMO, a central scotoma or altitudinal hemianopia is the most frequent visual field defect in patients with optic neuritis; bitemporal hemianopia is exceedingly rare.


Wingerchuk DM, Lennon VA, Lucchinetti CF, et al. The spectrum of neuromyelitis optica. Lancet Neurology 2007; 6: 805-815.

Nakajima H, Hosokawa T, Sugino M, et al. Visual field defects of optic neuritis in neuromyelitis optica compared with multiple sclerosis. BMC Neurology 2010; 10: 45-50.

Ruiz-Gaviria R, Baracaldo I, Castaneda C, et al. Specificity and sensitivity of aquaporin 4 antibody detection tests in patients with neuromyetis optica: A meta-analysis. Multiple Sclerosis and Related Disorders 2015; 4(4): 345-9.

Gerling J, Meyer JH, Kommerell G. Visual field defects in optic neuritis and anterior ischemic optic neuropathy: distinctive features. Graefe’s Archive for Clinical and Experimental Ophthalmology 1998; 236: 188-192.

Green AJ, Cree BAC. Distinctive retinal nerve fibre layer and vascular changes in neuromyelitis optica following optic neuritis. Journal of Neurology Neurosurgery and Psychiatry 2009; 80: 1002-1005.

Roemer SF, Parisi JE, Lennon VA, et al. Pattern-specific loss of aquaporin-4 immunoreactivity distinguishes neuromyelitis optica from multiple sclerosis. Brain 2007; 130: 1194-1205.

Burde RM, Savino PJ, Trobe JD. Clinical decisions in neuro-ophthalmology, 3rd ed. St. Louis: Mosby 2002.

Keltner JL, Johnson CA, Spurr JO, et al. Visual field profile of optic neuritis. One-year follow-up in the Optic Neuritis Treatment Trial. Archives of Ophthalmolology. 1994; 112(7): 946-53.

Lee SY, Wang AG, Yen MY. Chiasmal optic neuritis: a report of three cases. Taiwan Journal of Ophthalmology 2012; 2: 68-72.

S. Abdullah, W. F. Wong, C. T. Tan. The prevalence of anti-aquaporin 4 antibody in patients with idiopathic inflammatory demyelinating diseases presented to a tertiary hospital in Malaysia: presentation and prognosis. Multiple Sclerosis International 2017; 2017: 1-6.

Fernandes DB, Ramos Rde I, Falcochio C, et al. Comparison of visual acuity and automated perimetry findings in patients with neuromyelitis optica or multiple sclerosis after single or multiple attacks of optic neuritis. Journal of Neuroophthalmology 2012; 32(2): 102–106.

Papeix C, Vidal JS, de Seze J, et al. Immunosuppressive therapy is more effective than interferon in neuromyelitis optica. Multiple Sclerosis 2007; 13: 256-259.

Watanabe S, Misu T, Miyazawa I, et al. Low-dose corticosteroids reduce relapses in neuromyelitis optica: aretrospective analysis. Multiple Sclerosis 2007; 13: 968-974.

Pittock SJ, Lennon VA, Bakshi N, et al. Seroprevalence of aquaporin-4-IgG in a northern California population representative cohort of multiple sclerosis. JAMA Neurology 2014; 71: 1433-1436.

Wingerchuk DM, Banwell B, Bennett JL, et al. International consensus diagnostic criteria for neuromyelitis optica spectrum disorders. Neurology 2015; 85(2): 177-89.





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