Prognostic Modeling for the Failure of Intravenous Methylprednisolone and the Risk of Visual Disability in AQP4-IgG Positive NMOSD-ON

Purpose: To identify factors influencing best corrected visual acuity (BCVA) prognosis in patients with AQP4-IgG+ neuromyelitis optica spectrum disorder-related optic neuritis (NMOSD-ON) after treating with high-dose intravenous methylprednisolone. Methods: A total of 161 intravenous methylprednisolone (IVMP)-treated patients were randomized into training (n = 113) and internal validation (n = 48) sets at a ratio of 7:3. Using Least Absolute Shrinkage and Selection Operator regression, 16 candidate predictors were screened to construct a logistic model to predict follow-up BCVA after six months post-ON attack. Discrimination (area under curve [AUC]), calibration, and clinical net benefit (decision curve analysis [DCA]) were assessed. Results: The final model included seven predictors: age, AQP4-IgG titer, non-ON attack history, baseline BCVA, mean deviation, macular ganglion cell inner plexiform layer thickness, and treatment window. AUCs were 0.904 (95% confidence interval [CI], 0.850-0.959) and 0.864 (95% CI, 0.761-0.967) in training and validation sets, respectively. Calibration curves indicated high consistency, and DCA demonstrated significant net benefit at 10%-90% risk thresholds. Conclusions: The validated prediction model effectively stratifies IVMP-treated patients at risk of visual disability, enabling precision management. Translational Relevance: By converting heterogeneous prognostic factors into a practical prediction tool, this work empowers clinicians to deliver precision care for a blinding complication of NMOSD, directly reducing preventable visual disability.