Abstract Objective To evaluate the efficacy and safety of low-dose rituximab (RTX) strategy in patients with neuromyelitis optica spectrum disorder (NMOSD) over a period exceeding 5 years and to investigate the impact of treatment compliance on clinical outcomes. Methods We conducted a retrospective analysis of 81 NMOSD patients who received low-dose RTX at Tangdu Hospital from January 2014 to December 2019. The treatment protocol involved an induction phase of 100 mg weekly for three weeks, followed by maintenance doses of 100 mg every six months. Demographic characteristics, the expanded disability status scale (EDSS) scores, annualized relapse rates (ARR), number and date of attacks, and adverse events were collected. The influence of compliance on treatment efficacy was assessed using multivariable Cox regression and propensity score-weighted analysis. Results Over the follow-up period, 32.1% of patients experienced relapses, with the ARR significantly reduced from a median of 1.5 before treatment to 0 after RTX therapy (p