Cleared for Takeoff: Atypical Optic Neuritis in a Commercial Pilot Revealing Myelin Oligodendrocyte Glycoprotein Antibody Disease—A Case Report and Literature Review

Abstract

MOG antibody–associated disease (MOGAD) is an emerging autoimmune demyelinating disorder of the central nervous system, distinct from multiple sclerosis and neuromyelitis optica spectrum disorder (NMOSD), and most commonly presenting with optic neuritis. We report the case of a 22-year-old previously healthy pilot presenting with a two-week history of bilateral ocular pain, photophobia, and acute visual loss. Ophthalmologic examination revealed bilateral papillary hyperemia with vascular tortuosity. Papillary OCT demonstrated retinal nerve fiber layer involvement, accompanied by central and peripheral visual field deficits. Orbito-cerebral MRI showed bilateral intraconal enhancement, and visual evoked potentials confirmed severe optic neuropathy. Extensive serologic and infectious evaluation, including anti-AQP4 and anti-MOG antibodies, was negative, with low-titer positive antinuclear antibodies. High-dose intravenous corticosteroids were ineffective; however, plasma exchange resulted in complete recovery of visual acuity and progressive improvement of visual fields. At five-month follow-up, the patient remained clinically stable, with an inactive demyelinating plaque on MRI. Based on the radioclinical profile, a diagnosis of probable seronegative MOGAD was established, and rituximab maintenance therapy was initiated, achieving sustained clinical, radiological, and laboratory remission. Given the potential  implications for flight safety, aeromedical clearance was granted under strict monitoring following a formal waiver.