Visual outcomes in thyroid-associated ophthalmopathy with no light perception.

BACKGROUND: Thyroid-associated ophthalmopathy (TAO) presenting with no light perception (NLP) is uncommon and its visual prognosis is uncertain. We described visual outcomes after orbital decompression and explored factors associated with postoperative improvement. METHODS: This retrospective cohort study included 20 TAO patients with NLP in at least one eye treated between May 2017 and May 2025. Orbital decompression was performed when feasible, with postoperative intravenous methylprednisolone; otherwise, intravenous methylprednisolone pulse therapy (IVMP) only was given. The primary outcome was best postoperative change in visual acuity (VA). Kaplan-Meier analysis estimated the cumulative probability of VA improvement. Univariable linear regression explored factors associated with postoperative VA improvement. RESULTS: Eighteen patients underwent decompression (external, n = 13; endoscopic, n = 5) and two received IVMP only. After decompression, median VA improved by 2.1 logMAR. Among decompressed patients, 16/18 (89%) showed any VA improvement and 13/18 (72%) recovered to counting fingers or better during follow-up. No VA improvement occurred with IVMP only. By 1 week, the estimated cumulative probability of any VA improvement was 72.2% (95% CI 41.5 to 86.8). Longer fellow-eye P2 latency (per 10 ms; β - 0.24; 95% CI - 0.46 to -0.02), absent fellow-eye pupillary light reflex (vs. brisk; β - 2.05; 95% CI - 3.88 to -0.21) and higher thyroid-stimulating hormone (β - 0.08; 95% CI - 0.13 to -0.02) were associated with less postoperative VA improvement. CONCLUSION: Most TAO patients presenting with NLP recovered to counting fingers or better after orbital decompression, with recovery often occurring early. These findings suggest NLP in TAO may represent a potentially reversible functional state when decompression is feasible.