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Neuromyelitis optica is characterised by severe visual impairment and neurologic dysfunction, and aggressive plasmapheresis treatment is often recommended. Medication and therapeutic interventions for acute and chronic treatment have been the subject of retrospective studies and case reports; however, the clinical improvement that follows plasmapheresis cannot be explained merely by the removal of the pathogenic antibodies. The guidelines regarding plasma volume in plasmapheresis are often not adhered to; however, treatment of lesser volume reduces complications and the cost incurred, without affecting clinical outcome. The goal of this review is to understand the biologic and clinical data supporting plasmapheresis, examine the possible role of low-volume plasma treatment, and highlight advanced apheresis techniques that may be applied as therapeutic modalities.