Aims/Purpose: The clinical progression of Leber hereditary optic neuropathy (LHON) is influenced by the causative mitochondrial DNA (mtDNA) mutation. The Case Record Survey‐2 (CRS‐2; NCT02796274) aimed to establish the natural history of LHON in idebenone‐naïve patients. Here, we report the 12‐ and 24‐month clinical outcomes by mutation.Methods: Data were extracted from case records (20 sites, 7 European countries) meeting the criteria: aged ≥12 y, m.11778G > A, m.3460G > A or m.14484T > C mtDNA mutation, onset of symptoms (OoS) after 1999, ≥2 visual acuity assessments (VAA) within 5y of OoS. Baseline (BL) was the first VAA after OoS; subacute/dynamic (S/D) and chronic eyes were ≤1 or > 1 y from OoS at BL, respectively. Spontaneous clinically relevant recovery, stabilisation and worsening (sCRR, sCRS and sCRW, respectively) were calculated as previously described.1 Eyes eligible for analysis had a VAA 12±3 or 24±3 months from BL.Results: Eligible eyes included 96 S/D and 11 chronic eyes for the 12‐month analysis and 44 S/D and 2 chronic eyes for the 24‐month analysis.At 12 months, rates of sCRR, sCRS and sCRW in overall S/D eyes were: 13% (12/96), 26% (11/42) and 66% (50/76), respectively. By mutation, these rates were: m.11778G > A: 9% (6/68), 23% (7/30), 70% (37/53); m.3460G > A: 0% (0/16), 29% (2/7), 82% (9/11); and m.14484T > C: 50% (6/12), 40% (2/5), 33% (4/12), respectively. There were few chronic eyes, with overall rates of 18% (2/11), 100% (2/2) and 67% (4/6), respectively.At 24 months, rates of sCRR, sCRS and sCRW in overall S/D eyes were: 27% (12/44), 46% (10/22) and 46% (16/35), respectively. By mutation, these rates were: m.11778G > A: 11% (3/27), 33% (5/15), 57% (13/23); m.3460G > A: 50% (7/14), 67% (4/6), 33% (3/9); and m.14484T > C: 67% (2/3), 100% (1/1), 0% (0/3), respectively.Conclusions: The CRS‐2 study offers important insights into the impact of causative mutation on the natural history of LHON.ReferencesYu‐Wai‐Man P et al. Cell Rep Med. 2024;5:101437.