Abstract
A patient with morbid obesity, untreated obstructive sleep apnea, chronic atrial fibrillation on apixaban, uncontrolled hypertension, and anemia (hemoglobin 10.0 g/dL) presented with acute painful profound vision loss in the right eye. Examination demonstrated severe optic neuropathy with papillitis and ipsilateral Roth spots. MRI revealed long-segment enlargement and enhancement of the right optic nerve with T2 hyperintensity and associated diffusion restriction. Serum myelin oligodendrocyte glycoprotein antibody was positive (titer 1:80). Autoimmune evaluation was notable for antinuclear antibody titers (1:640, speckled pattern), while infectious, hematologic, rheumatologic, and endocarditis workup was otherwise unrevealing. The patient was treated with intravenous methylprednisolone 1 g daily for 5 days with minimal visual improvement (hand motion to counting fingers). Given limited response, plasma exchange was recommended; however, the patient declined escalation of care against medical advice and elected to continue an oral corticosteroid taper. This case highlights an atypical and potentially novel manifestation of MOGAD optic neuritis associated with ipsilateral Roth spots, severe optic neuropathy, and poor corticosteroid responsiveness. The coexistence of retinal hemorrhagic lesions and significant vascular comorbidities raises the possibility of inflammatory–ischemic overlap contributing to disease severity. This report expands the phenotypic spectrum of MOGAD and suggests Roth spots may represent an underrecognized or associative retinal finding warranting further investigation.
Presentation Date: 04/30/2026
Issue Date: 05/01/2026
