Background: Optic neuritis (ON) is an acute inflammatory demyelinating optic neuropathy that typically presents with subacute, painful vision loss, and an afferent pupillary defect. Although most cases occur in younger adults and are associated with multiple sclerosis (MS), ON can present atypically—by age, field pattern, or severity—and overlap with ischemic and inflammatory mimickers in patient’s ≥50 years old. Altitudinal visual field defects are classically linked to non‑arteritic anterior ischemic optic neuropathy (NAION), yet they may occur in ON and can misdirect early management. Rapid, high‑dose corticosteroid therapy accelerates visual recovery in typical ON, while urgent exclusion of giant cell arteritis (GCA) and other non‑demyelinating etiologies remains essential in older adults. 

Case report: A 52-year-old Caucasian male presented with sudden blurry and jumping vision in the upper half of his left eye. Visual acuity was mildly impaired OS, but his visual field (VF) showed deep superior altitudinal defects. MRI orbits and brain with and without contrast showed an increased T2 signal and enhancement of the intra-orbital segment of the left optic nerve, compatible with optic neuritis. Several periventricular and subcortical white matter FLAIR/T2 hyperintensity. Cerebral spinal fluid chemistry confirmed the presence of oligoclonal band (IgG) with a high synthesis rate. The patient was referred to neurology for further management and put on 80 mg/d prednisone with taper schedule. Altitudinal VF defects were resolved almost completely after a month. Further workup by neurologist confirmed MS diagnosis and he is being managed by neurologist and rheumatologist. 

Conclusion: This case highlights an atypical presentation of ON in a mid‑life patient with a deep, but transient, superior altitudinal defects. After extensive neurological and laboratory work ups, MS was the definitive diagnosis. Sudden vision loss and optic neuropathy require a interprofessional team including internist, optometrist, radiologist, neurologist and rheumatologist for timely and effective management.