PurposeTo evaluate the optical coherence tomography (OCT) images of eyes with fovea-involved complete retinal pigment epithelial and outer retinal atrophy (cRORA) as well as best-corrected visual acuity (BCVA) to explore the pathogenesis of visual impairment and atrophy. DesignRetrospective observational study. SubjectsData of eyes with cRORA associated with age-related macular degeneration with foveal center involvement were collected from 10 hospitals in Japan. MethodsOphthalmic examination data, BCVA, and extents of RORA, represented by choroidal hyper-transmission, and outer plexiform layer (OPL) deterioration, central retinal thickness (CRT), and central choroidal thickness (CCT) measured using built-in software on the sectional OCT images were evaluated. Main Outcome MeasuresRelationship between BCVA and extents of RORA and OPL deterioration. ResultsOf the 64 eyes of 64 patients (mean age; 76.8 ± 9.5 years old), 38 eyes (59.4%) belonged to men. Mean BCVA was 0.602 ± 0.475 (median: 0.523; range, -0.079 to 1.523) in logMAR. Mean extent of RORA was 2,921 ± 1,291 (median: 3172; range: 479-5,985) μm. BCVA in logMAR positively correlated with extents of RORA (P=0.004) and OPL deterioration (P=0.004) and negatively correlated with CRT (P=0.022). BCVA ≥ 0.5 was associated with extents of RORA ≥ 3,000μm (Odds Ratio [OR], 4.227; 95% Confidence Interval [95% CI], 1.440-12.408; P=0.009) and OPL deterioration ≥ 1,700μm (OR, 2.984; 95% CI, 1.034-8.609; P=0.043), and presence of complete central OPL defect (cCOD) (OR, 12.700; 95% CI, 2.439-66.132; P=0.003), after adjusting for age and sex. The extent of RORA ≥ 3000μm was associated with BCVA ≥ 0.5 (OR, 4.213; 95% CI, 1.437–12.356; P=0.009), extent of OPL deterioration ≥ 1,700μm (OR, 58.682; 95% CI, 6.865-501.592; P<0.001), and presence of cCOD (OR, 4.107; 95% CI, 1.339-12.604; P=0.014), after adjusting for age and sex. The extent of RORA positively correlated with that of OPL deterioration (P<0.001), CRT (P=0.001), and CCT (P=0.041). ConclusionsA longer extent of cRORA in the OCT images with foveal center involvement was associated with a longer extent of OPL deterioration and the presence of cCOD, and worse BCVA. Further studies focusing on OPL changes are warranted for understanding the pathogenesis of RORA and vision loss.