PURPOSE: This multicenter study aimed to evaluate visual outcomes and analyze the specific viral pathogens and other factors associated with severe visual impairment (SVI), and retinal detachment (RD) in patients with acute retinal necrosis (ARN). METHODS: A retrospective multicenter cohort study included ARN patients who underwent aqueous or vitreous PCR testing. Multivariable mixed-effects Poisson regression was used to identify factors associated with viral pathogens and SVI. A mixed-effects parametric survival-time model was applied to evaluate RD risk factors. RESULTS: A total of 56 patients (65 eyes) diagnosed with ARN were included. 31 patients (47.7%) had a final visual acuity of 20/200 or worse. SVI was associated with zone 1 involvement (aRR 4.2), immunocompromised status (aRR 2.8), and RD (aRR 4.8). RD occurred in 23 patients (35.4%) after an average of 4.26 months from the onset of ARN. The incidence rate of RD was 1.4 per 1,000 eye-days (95% CI: 0.9-2.1. It increased in VZV-ARN cases by 4.02 times (log-rank CONCLUSION: Zone 1 involvement, immunocompromised status, and RD were key risk factors for SVI in ARN. RD occurred in approximately one-third of cases. Early and aggressive intervention is essential in VZV-ARN cases, particularly in cases where retinitis involves 2-3 quadrants of the retina and in immunocompetent individuals, to mitigate the risk of RD.