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Background Retinoblastoma is the most common intraocular tumour in children. This study aimed to assess the visual outcomes and risk factors leading to visual impairment in children with retinoblastoma in the Indian population.Methods This is a single-centre retrospective analysis of all patients with unilateral or bilateral retinoblastoma presenting from the year 2014 to mid-2024.Results A total of 426 eyes in 306 patients were included in the study. 240 (78.43%) had unilateral macular tumours, while 45 (14.71%) had bilateral macular tumours. 29 (24.17%) patients were classified as visually impaired, and 22 (18.33%) patients were legally blind. The visual impairment and legal blindness observed in groups D and E (55.18% vs 68.18%) was statistically significant compared with groups A–C, with a p value of <0.05. Visual impairment and legal blindness were noted in only 27.59% and 0.05% of patients without macular tumours. Three patients had motor and speech delay. Out of 120 patients with bilateral tumour, 45 successfully underwent occlusion therapy.Conclusion Macular involvement and late-stage presentation were major predictors of poor vision. This study underscores the importance of early diagnosis and treatment, and improved access to paediatric vision screening and visual rehabilitation.