Combined Phacoemulsification and Vitrectomy for Proliferative Diabetic Retinopathy: An Increased Risk of Early Recurrence but Not Long-Term Neovascular Glaucoma

Combined Phacoemulsification and Vitrectomy for Proliferative Diabetic Retinopathy: An Increased Risk of Early Recurrence but Not Long-Term Neovascular Glaucoma | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Article Combined Phacoemulsification and Vitrectomy for Proliferative Diabetic Retinopathy: An Increased Risk of Early Recurrence but Not Long-Term Neovascular Glaucoma Qiujie Chen, Gengjia Li, Ruibin Wu, Xinyi Zhang, Mingwei Zheng This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7422427/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Purpose: To compare the long-term incidence of recurrent vitreous hemorrhage(VH) and neovascular glaucoma (NVG) in patients with proliferative diabetic retinopathy (PDR) undergoing pars plana vitrectomy (PPV) alone versus combined PPV and phacoemulsification (PPV&P). Methods: This large, single-center, retrospective cohort study analyzed 556 eyes (144 PPV&P, 412 PPV-alone) with a minimum 12-month follow-up. Kaplan-Meier survival analysis and multivariable Cox proportional hazards regression models were used to compare outcomes and identify independent predictors for complications within a 2-year follow-up period. Results: Over the entire follow-up, the overall incidence of recurrence(VH) and NVG did not differ significantly between the groups. However, multivariable Cox regression analysis for the first two years revealed that PPV-alone was a significant protective factor against recurrence (adjusted Hazard Ratio [aHR], 0.64; 95% CI, 0.43-0.96), while severe preoperative traction was a major risk factor (aHR, 2.31; 95% CI, 1.45-3.68). For NVG development within two years, the surgical approach was not a significant factor. Instead, severe preoperative traction (aHR, 5.08; 95% CI, 1.66-15.51) and older age (aHR, 1.07; 95% CI, 1.02-1.12) were the primary independent risk factors. Conclusion: Combined PPV with phacoemulsification is associated with an increased risk of recurrence(VH) within the first two postoperative years but does not increase the risk of neovascular glaucoma. The severity of baseline proliferative disease, particularly the degree of traction, is a more critical determinant of postoperative complications than the surgical strategy regarding the lens. This supports tailoring the surgical approach based on individual patient cataract status and retinal pathology. Health sciences/Diseases/Eye diseases Health sciences/Risk factors Proliferative diabetic retinopathy Pars plana vitrectomy Phacoemulsification Neovascular glaucoma Vitreous hemorrhage Surgical outcomes Figures Figure 1 Figure 2 Introduction Diabetic retinopathy (DR) is a leading cause of preventable blindness among working-age adults worldwide 1 – 4 . Its most advanced stage, proliferative diabetic retinopathy (PDR), is characterized by retinal neovascularization that can lead to vision-threatening complications, including persistent vitreous hemorrhage (VH) and tractional retinal detachment (TRD) 5 . For these severe manifestations, pars plana vitrectomy (PPV) is the definitive surgical intervention, enabling the clearance of hemorrhagic media and the release of vitreoretinal traction 6 . A frequent comorbidity in PDR patients is cataract, creating a clinical dilemma: whether to perform PPV alone or combine it with phacoemulsification (PPV&P) in a single session. The rationale for a combined procedure is strong, offering the convenience of a single surgery, faster visual rehabilitation, and avoidance of the technical challenges inherent in operating on a previously vitrectomized eye 7 , 8 . Furthermore, removing the cataract provides the surgeon an unobstructed, panoramic view of the posterior segment, which facilitates more meticulous membrane dissection and complete panretinal endophotocoagulation 7 . However, these benefits are countered by concerns that PPV&P may exacerbate postoperative complications. The extensive surgical manipulation of a combined procedure can intensify the breakdown of the blood-aqueous barrier. This physiological disruption is hypothesized to increase the risk of severe postoperative inflammation, cystoid macular edema, and, most critically, anterior segment neovascularization leading to neovascular glaucoma (NVG)—a devastating and often intractable complication 9 – 11 . Consequently, the optimal surgical strategy remains a subject of intense debate. Previous studies on this topic have yielded conflicting and inconclusive results. While some reports suggest combined surgery does not increase the risk of NVG or recurrent VH 12 – 14 , others associate it with poorer outcomes. These discrepancies may stem from variations in study design, patient populations, follow-up duration, and surgical techniques. Critically, a definitive consensus is lacking on whether the surgical approach independently influences the long-term risk of major complications after accounting for baseline patient and disease characteristics. Therefore, this large-scale, single-center retrospective study was designed to address this critical knowledge gap. By analyzing a substantial cohort of PDR patients with long-term follow-up, we aimed to rigorously compare the incidence of recurrent vitreous hemorrhage and neovascular glaucoma between patients undergoing PPV alone versus combined PPV&P. Using survival analysis and multivariable Cox regression models, we sought not only to compare outcomes but also to identify independent predictors of these vision-threatening complications, thereby providing stronger evidence to guide clinical decision-making. Methods Study Design and Ethical Approval This single-center, retrospective cohort study was conducted at the Department of Ophthalmology, The First Affiliated Hospital of Shantou University Medical College, in adherence with the tenets of the Declaration of Helsinki. The study protocol was approved by the institutional review board, which waived the requirement for informed consent due to the retrospective nature of the analysis. Patient Selection and Study Groups We reviewed the medical records of patients with proliferative diabetic retinopathy (PDR) who underwent either pars plana vitrectomy (PPV) alone or combined PPV with phacoemulsification (PPV&P) between January 2019 and May 2024. Patients were included if they were aged 18 years or older, had surgical indications for PDR (Persistent vitreous hemorrhage or tractional retinal detachment), and had a minimum follow-up of 12 months. Exclusion criteria were: (1) prior vitrectomy or cataract surgery in the study eye; (2) pre-existing rubeosis iridis or neovascular glaucoma (NVG); (3) other significant confounding ocular pathologies, such as age-related macular degeneration (AMD), high myopia (axial length >26 mm or refractive error > −6.0 D), or retinal vascular occlusions; and (4) incomplete follow-up data. Based on the procedure performed, patients were stratified into two cohorts: the PPV&P group and the PPV-alone group. The surgical approach was determined by the surgeon's clinical judgment and patient preference. Surgical Procedures All surgeries were performed by experienced vitreoretinal surgeons.A standardized 23-gauge three-port PPV was executed on all cases, with scleral incisions sutured postoperatively to ensure wound integrity. The procedure involved a core vitrectomy, induction of posterior vitreous detachment if not already present, and meticulous removal of vitreous and epiretinal membranes using delamination, segmentation, and peeling techniques to relieve all traction. Comprehensive panretinal endophotocoagulation (PRP) was applied from the posterior pole to the ora serrata, with scleral depression as needed to ensure complete peripheral treatment. The choice of intravitreal tamponade—balanced salt solution, air, C3F8 gas, or silicone oil—was at the surgeon's discretion based on intraoperative findings. For patients in the PPV&P group, phacoemulsification was performed prior to vitrectomy, followed by the implantation of a foldable acrylic intraocular lens into the capsular bag. Data Collection and Outcome Measures Relevant preoperative, intraoperative, and postoperative data were extracted from patient medical records. Preoperative variables included demographics, systemic markers (serum creatinine, HbA1c), ocular history, recent anti-VEGF use, and primary surgical indications. Intraoperative variables included the grades of lens sclerosis and proliferative traction, tamponade agent, laser parameters, and any complications. The primary outcomes were the incidence of recurrent vitreous hemorrhage and the development of NVG. Recurrence was defined as any postoperative hemorrhage obscuring the retina for over three weeks or the development of a recurrent retinal detachment. NVG was defined as iris neovascularization with elevated intraocular pressure (IOP). Secondary outcomes included changes in best-corrected visual acuity (BCVA) and IOP, and rates of postoperative complications like ocular hypertension (IOP >25 mmHg). Time-to-event was calculated from the surgery date to the diagnosis date of a primary outcome. Statistical Analysis Statistical analyses were performed using SPSS software (version 25.0). Continuous variables were compared using independent samples t-tests, while categorical variables were compared using the chi-squared (χ²) or Fisher’s exact test. Time-to-event data for recurrence and NVG were analyzed using the Kaplan-Meier method with the log-rank test for curve comparison. Multivariable Cox proportional hazards regression models were constructed to identify independent predictors for outcomes within a 2-year follow-up period. For all analyses, a two-sided P value of less than 0.05 was considered statistically significant. Results Baseline Demographics and Clinical Characteristics A total of 556 eyes from 556 patients were included, with 144 in the PPV&P group and 412 in the PPV-alone group. Patients in the PPV&P group were significantly older than those in the PPV-alone group (mean [SD] age, 58.39 [10.15] vs. 50.97 [9.70] years, respectively). The two groups were well-matched at baseline, with no significant differences in systemic health markers (serum creatinine, HbA1c), history of prior laser treatment, IOP, BCVA, surgical indications, preoperative anti-VEGF use, or the grade of proliferative traction (P > 0.05 for all). As anticipated by the surgical grouping, lens opacity was significantly more severe in the PPV&P group (P < 0.001) (Table 1). Surgical and Postoperative Outcomes Intraoperative management, including the choice of tamponade agent, application of retinal laser, and use of intravitreal triamcinolone, was comparable between groups (P > 0.05). However, the PPV&P group experienced a significantly higher rate of intraoperative complications, including posterior capsule tear, anterior chamber hemorrhage, and corneal edema (P < 0.01 for all) (Table 2). The mean follow-up duration was 29.68 [12.01] months for the PPV&P group and 30.49 [11.79] months for the PPV-alone group. Postoperative outcomes were largely similar, with no significant differences in final IOP, BCVA improvement, or the overall rates of recurrence(VH) (29.2% vs. 27.2%), neovascular glaucoma (NVG), or the need for repeat PPV (P > 0.05 for all). However, the PPV&P group had a significantly higher incidence of postoperative inflammatory reactions and silicone oil in the anterior chamber (P < 0.05) (Table 3). Time-to-Event Analysis Kaplan-Meier analysis revealed no significant difference in the overall cumulative risk of recurrence(VH) (log-rank P = 0.466) or NVG (log-rank P = 0.956) between the groups over the entire follow-up period (Figure 1). The estimated 2-year risk for recurrence(VH) was 27.1% in the PPV&P group and 23.7% in the PPV-alone group (P = 0.240). The 2-year risk for NVG was 4.1% in the PPV&P group and 5.6% in the PPV-alone group(P = 0.329). Although the survival curves for both outcomes appeared to diverge after three years, these long-term findings are limited by the small number of patients remaining at risk. Independent Predictors of Postoperative Complications Multivariable Cox regression analysis was performed for the 2-year follow-up period to identify independent predictors of major complications. For recurrence(VH) , significant predictors included undergoing PPV-alone surgery (adjusted Hazard Ratio [aHR], 0.64; 95% CI, 0.43-0.96) and older age (aHR, 0.98; 95% CI, 0.96-0.99), both of which were protective. Conversely, the presence of severe preoperative traction was a significant risk factor (aHR, 2.31; 95% CI, 1.45-3.68) (Figure 2A). For the development of NVG, the surgical approach was not a significant factor. The primary risk factors were the presence of severe preoperative traction (aHR, 5.08; 95% CI, 1.66-15.51) and older age (aHR, 1.07; 95% CI, 1.02-1.12) (Figure 2B). Discussion This study contributes nuanced evidence to the long-standing debate over the optimal surgical management for proliferative diabetic retinopathy (PDR) with coexisting cataracts. Our primary finding is that while the overall, long-term incidence of major complications did not differ between combined phacoemulsification with pars plana vitrectomy (PPV&P) and PPV-alone, a time-dependent analysis revealed a critical distinction: combined surgery was associated with a significantly higher risk of recurrence(VH) specifically within the first two postoperative years. Recurrent Vitreous Hemorrhage: An Early Risk for Combined Surgery Our multivariable Cox regression analysis identified PPV-alone as an independent protective factor against recurrence(VH) within a 2-year timeframe (aHR, 0.64). This result substantiates the hypothesis that the greater surgical trauma of a combined procedure potentiates a more significant breakdown of the blood-ocular barrier, leading to a transient, heightened inflammatory state. This early postoperative period is critical, as fragile neovascular tissue is most susceptible to bleeding 5 . The significantly higher incidence of postoperative inflammatory reactions observed in our PPV&P group lends clinical support to this pathophysiological mechanism. Interestingly, our Kaplan-Meier analysis showed this increased risk was front-loaded. Beyond three years, the recurrence curve for the PPV&P group flattened, while the risk in the PPV-alone group continued to ascend gradually. Although long-term data must be interpreted cautiously due to patient attrition, this trend suggests that once the initial inflammation from combined surgery resolves, the re-bleeding risk diminishes. Conversely, patients who undergo PPV-alone may face a delayed risk from subsequent cataract progression, which can impede fundus visualization for monitoring and supplementary laser, potentially allowing undetected neovascular activity to cause late-onset hemorrhage. Neovascular Glaucoma: Challenging Traditional Dogma A pivotal finding of our study is the lack of any significant association between combined surgery and an increased risk of neovascular glaucoma (NVG). For decades, a primary argument against PPV&P has been the fear that removing the crystalline lens 12 —a supposed barrier to the anterior diffusion of vasoproliferative factors like VEGF—would precipitate catastrophic anterior segment neovascularization 14 – 19 . Our results, consistent with several contemporary studies 12 – 14 , challenge this dogma. The 2-year NVG risks were low and statistically indistinguishable between groups. This suggests that with modern surgical techniques—including thorough removal of the vitreous scaffold, complete relief of traction, and extensive panretinal endophotocoagulation—the theoretical risk conferred by phacoemulsification is effectively negated. Instead of surgical strategy, our analysis identified severe preoperative traction and older age as the most potent independent predictors for NVG. This underscores a crucial paradigm shift: the primary driver of NVG is not the absence of the lens but the severity of the underlying retinal ischemia. Incomplete traction removal or insufficient photocoagulation leaves a powerful ischemic stimulus intact, which is the true engine of neovascularization. The association with older age is a novel finding that may reflect a reduced vasoregenerative capacity or increased endothelial susceptibility to ischemic insults in elderly patients. Clinical Implications and Surgical Decision-Making Our findings have direct implications for clinical practice, supporting a move away from a rigid, risk-averse stance on PPV&P toward a more individualized approach 6 , 7 , 20 . For patients with visually significant cataracts, the benefits of a combined procedure—superior intraoperative visualization facilitating more complete surgery and faster visual rehabilitation—likely outweigh the transiently increased risk of early postoperative recurrence(VH), especially since our data show the long-term risk of NVG is not elevated. For patients with a clear or only mildly opaque lens, performing PPV-alone may be the more prudent approach to minimize the risk of early recurrent hemorrhage, with a staged phacoemulsification performed later if needed. Regardless of the approach, the surgical focus must remain on addressing the fundamental pathology. Meticulous removal of all vitreoretinal traction 7 , 13 , 21 , 22 and comprehensive panretinal photocoagulation are paramount in preventing both recurrent VH and NVG 23 – 26 . The severity of preoperative traction, as identified in our study, should be a primary factor in guiding surgical strategy and patient counseling. Limitation This study has several limitations. First, its retrospective, single-center design is susceptible to inherent selection and ascertainment bias. The non-randomized allocation of surgical approach, based on surgeon and patient preference, is a key potential confounder. Second, while the follow-up was substantial, it may be insufficient to capture very late-onset complications, and patient attrition limits the reliability of findings beyond two to three years. Therefore, a large-scale, multicenter randomized controlled trial is still necessary to definitively confirm these findings and provide the highest level of evidence. Conclusion In conclusion, this study demonstrates that while combined PPV and phacoemulsification is associated with an increased risk of recurrent vitreous hemorrhage within the first two postoperative years, it does not increase the long-term risk of neovascular glaucoma. The most critical determinant of postoperative outcomes is not the surgical strategy for the lens, but rather the severity of the baseline proliferative disease and the thoroughness of the vitrectomy and endophotocoagulation. This evidence should empower surgeons to tailor their approach based on the individual patient's cataract status and retinal pathology, rather than an unsubstantiated fear of devastating complications from a combined procedure. Declarations Acknowledgments None. Conflicts of Interest The authors declare no conflicts of interest. Data Availability Statement The data supporting the findings of this study are available from the corresponding author upon reasonable request. Due to their size, the raw datasets cannot be deposited in a public repository but can be accessed following a justified inquiry. Financial support: None. Financial Disclosure: The sponsor or funding entity played no part in the conception or execution of this research. All authors declare no financial or conflicting interests. Contributors: Genjia Li: Data curation,Original draft, Methodology, Formal analysis. Qiujie Chen: Writing – review & editing,Supervision, Project administration. References Yau JW, Rogers SL, Kawasaki R, Lamoureux EL, Kowalski JW, Bek T et al. Global prevalence and major risk factors of diabetic retinopathy. Diabetes Care 2012; 35 (3) : 556-564. Lee R, Wong TY, Sabanayagam C. Epidemiology of diabetic retinopathy, diabetic macular edema and related vision loss. Eye Vis (Lond) 2015; 2: 17. Chong DD, Das N, Singh RP. 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Tables Table 1.Baseline Characteristics and Surgery Indications Parameter PPV&P（n=144） PPV（n=412） P Value Age, mean (SD), y 58.39（10.15） 50.97（9.70） ＜ 0.001 Sex, No. (%) Male 82（56.9） 270（65.5） 0.066 Female 62（43.1） 142（34.5） HbA1c, mean (SD),% 7.46（1.67） 7.50（1.76） 0.803 Creatinine , mean (SD), umol/L 125.51（118.36） 121.04（111.57） 0.684 Preoperative IOP, mean (SD), mmHg 13.19（1.66） 13.21（1.65） 0.929 Preoperative BCVA,Snellen(logMAR) , mean (SD) 1.67（0.62） 1.58（0.57） 0.115 Preoperative lens nuclear sclerosis , No. (%) Grade 0/1 4（2.8） 313（76.0） Grade 2 53（36.8） 95（26.6） ＜ 0.001 Grade 3/4 87（60.4） 4（16.4） Preoperative Grading of Traction , No. (%) Severe 34（23.6） 111（26.9） Mild or moderate 71（49.3） 191（46.4） 0.720 No traction 39（27.1） 110（26.7） Previous laser , No. (%) 60（41.7） 140（34.0） 0.098 Previous anti‑VEGF within 2 weeks , No. (%) 110（76.4） 339（82.3） 0.123 Surgery indications , No. (%) VH 97（67.4） 262（63.6） 0.416 TRD±VH 47（32.6） 150（36.4） Nuclear sclerosis was assessed at the slit lamp and classified as follows:Grade 0: Clear lens.Grade 1: Early nuclear sclerosis with mild yellow discoloration of the posterior lens in the slit beam.Grade 2: Yellow discoloration throughout the lens.Grade 3: Yellow-brown discoloration throughout the lens.Grade 4: Brown discoloration of the entire lens.Traction was graded based on the extent of fibrovascular tissue and the time and instrumentation required for its removal:Severe: Fibrovascular tissue covering the entire posterior retina and extending beyond, requiring extensive removal.Moderate: Fibrovascular tissue covering most of the posterior retina, requiring significant removal efforts.Mild: Limited epicenters of fibrous tissue, disconnected using a vitreous cutter.No Traction: Complete posterior vitreous detachment. Abbreviation：y,years;PPV&P,Pars plana vitrectomy with cataract phacoemulsification; HbA1c,Glycosylated hemoglobin;IOP,Intraocular Pressure;LogMAR,Logarithm of the Minimum Angle of Resolution;BCVA,Best Corrected Visual Acuity;VH,vitreous hemorrhage; TRD, tractional retinal detachment; VEGF, vascular endothelial growth factor. Table 2.Surgery Procedures and Intraoperative Complications Parameter PPV&P（n=144） PPV（n=412） P Value Surgery Procedures Endotamponade , No. (%) BSS 84（58.3） 245（59.5） Air 6（4.2） 13（3.2） 0.872 Silicone Oil 38（26.4） 115（27.9） C3F8 gas 16（11.1） 39（9.5） Endolaser , No. (%) 139（96.5） 407（98.8） 0.079 TA injection , No. (%) 45（31.3） 100（24.3） 0.101 Intraoperative Complications , No. (%) Posterior capsule tear 5（3.5） 1（0.2） 0.005 Anterior chamber hemorrhage 6（4.2） 2（0.5） 0.005 Corneal edema 9（6.3） 1（0.2） ＜ 0.001 Zonular complications 2（1.4） 0（0.0） 0.067 Abbreviation:PPV&P,Pars plana vitrectomy with cataract phacoemulsification; BSS,balanced salt solution;TA, triamcinolone acetonide. Table 3.Postoperative IOP, BCVA and Complications Parameter PPV&P（n=144） PPV（n=412） P Value Follow-up time , mean (SD), y 29.68（12.01） 30.49（11.79） 0.479 Postoperative IOP, mean (SD), mmHg 14.85（5.28） 14.60（5.15） 0.621 Postoperative BCVA,Snellen(logMAR) , mean (SD) 1.14（0.75） 1.02（0.64） 0.059 BCVA Improvement (ETDRS letters) 26.60（36.82） 28.26（36.84） 0.641 Complications Recurrence (VH) , No. (%)# 42（29.2） 112（27.2） 0.647 Time after surgery , mean (SD), m 10.13（11.40） 13.75（11.58） 0.085 HbA1c, mean (SD),% 7.10（1.59） 7.63（1.76） 0.089 Creatinine , mean (SD), umol/L 136.83（113.08） 128.31（116.91） 0.685 NVG , No. (%) 11（7.6） 33（8.0） 0.887 Time after surgery , mean (SD), m 27.96（12.58） 22.64（10.58） 0.176 HbA1c, mean (SD),% 7.61（1.39） 7.69（1.81） 0.893 Creatinine , mean (SD), umol/L 120.82（70.26） 138.15（148.58） 0.712 Others, No. (%) Corneal edema 15（10.4） 30（7.3） 0.235 Silicone oil in chamber 6（4.2） 3（0.7） 0.011 Inflammatory reaction 8（5.6） 7（1.7） 0.030 Ocular hypertension 22（15.3） 80（19.4） 0.269 Macular edema 19（13.2） 46（11.1） 0.514 Recurrence of RD 17（11.8） 38（9.2） 0.372 Repeat PPV 24（16.7） 54（13.1） 0.290 #, Defined as any postoperative hemorrhage sufficient to obscure the retina and cause vision loss lasting more than three weeks. Abbreviation:PPV&P,Pars plana vitrectomy with cataract phacoemulsification; IOP,Intraocular Pressure;LogMAR,Logarithm of the Minimum Angle of Resolution;BCVA,Best Corrected Visual Acuity;y,years;m,months;ETDRS,Early Treatment Diabetic Retinopathy Study Chart;VH,vitreous hemorrhage;RD,Retinal detachment;HbA1c,Glycosylated hemoglobin;NVG,Neovascular glaucoma. Additional Declarations There is no conflict of interest Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7422427","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Article","associatedPublications":[],"authors":[{"id":507278069,"identity":"0488af7a-8232-445b-9ed5-b488040270f7","order_by":0,"name":"Qiujie Chen","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABEklEQVRIie3RMWsCMRTA8UggLjlvfYdF+xFSAll69HMIXXIcxEVpRweHgKBjVwt+iEKXjlce3CS4Ot4tnRzs0umGnq0IHS6uQvMfQjjyI7wcIT7fBRYuD6sglBGaZZ9V3AspxcJFYHsiLCmfrZHRghnhImJw2nIpA4vJy4Zfg5N0Z3mxe8R2p20VBG9GSuT1rdP4vpFc5cOblUDKeGYgWsc9hUFWkNyMbROBkeryAwGdg2BGKuxo0bLoIA9fv6RfzkEzTF5nXICTDEbseAul4n1ej0/PENgaFa3EsJ7FtEq7NhKwfmTtmCVcph+wq27T/mKzx2pS/8onxGI/jRvJT5yQ9O8X7Tp+JHfnzvh8Pt8/7hs7elfVOvExEgAAAABJRU5ErkJggg==","orcid":"","institution":"The First Affiliated Hospital of Shantou University Medical College","correspondingAuthor":true,"prefix":"","firstName":"Qiujie","middleName":"","lastName":"Chen","suffix":""},{"id":507278070,"identity":"9b22ce9d-0c07-42e4-ab7c-172471439f2b","order_by":1,"name":"Gengjia Li","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Gengjia","middleName":"","lastName":"Li","suffix":""},{"id":507278071,"identity":"6686a01b-901f-4c08-8338-7d88b8547d4b","order_by":2,"name":"Ruibin Wu","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Ruibin","middleName":"","lastName":"Wu","suffix":""},{"id":507278072,"identity":"5637f677-d066-4334-a611-88cd9e61d32b","order_by":3,"name":"Xinyi Zhang","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Xinyi","middleName":"","lastName":"Zhang","suffix":""},{"id":507278073,"identity":"757a9793-a960-43bf-8fe7-a12cecdcc94b","order_by":4,"name":"Mingwei Zheng","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Mingwei","middleName":"","lastName":"Zheng","suffix":""}],"badges":[],"createdAt":"2025-08-21 05:27:15","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7422427/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7422427/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":90812257,"identity":"ae21db23-4b01-4ee5-9702-eb8c5fbf819b","added_by":"auto","created_at":"2025-09-08 12:18:12","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":239558,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eKaplan-Meier Survival Analysis of Postoperative Complications.\u003c/strong\u003e Comparison of the cumulative incidence of (A) recurrent vitreous hemorrhage(VH) and (B) neovascular glaucoma (NVG) between the combined phacoemulsification-vitrectomy (PPV\u0026amp;P) and vitrectomy-alone (PPV) groups. Shaded areas represent 95% confidence intervals (CIs). The number of patients at risk at various time points is detailed below the x-axis. Log-rank tests revealed no significant difference between the groups for either recurrent VH (P=0.466) or NVG (P=0.956).\u003c/p\u003e","description":"","filename":"OnlineFigure1.png","url":"https://assets-eu.researchsquare.com/files/rs-7422427/v1/17002b294a48e403ee91abed.png"},{"id":90812259,"identity":"e5f4d17e-b33f-4bc2-bf01-29e0c21baa99","added_by":"auto","created_at":"2025-09-08 12:18:12","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":312042,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eForest Plots of Multivariable Cox Regression Analysis for Complications Within Two Years.\u003c/strong\u003e The plots illustrate the adjusted hazard ratios (aHRs) for predictors of (A) recurrence (VH) and (B) neovascular glaucoma (NVG) within a 2-year postoperative period. Data points represent the aHRs, and horizontal lines indicate the 95% confidence intervals (CIs). The vertical dashed line at an HR of 1.0 signifies no effect. Predictors with CIs that do not cross this line are considered statistically significant.\u003c/p\u003e","description":"","filename":"OnlineFigure2.png","url":"https://assets-eu.researchsquare.com/files/rs-7422427/v1/9d8a67b8fc6c5b137097117e.png"},{"id":91102514,"identity":"768f4398-13e5-48ba-bddf-fa7cfc0e7e82","added_by":"auto","created_at":"2025-09-11 14:59:30","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1971092,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7422427/v1/a9119a74-0e0b-4995-af42-3fdcca8cc673.pdf"}],"financialInterests":"There is no conflict of interest","formattedTitle":"Combined Phacoemulsification and Vitrectomy for Proliferative Diabetic Retinopathy: An Increased Risk of Early Recurrence but Not Long-Term Neovascular Glaucoma","fulltext":[{"header":"Introduction","content":"\u003cp\u003eDiabetic retinopathy (DR) is a leading cause of preventable blindness among working-age adults worldwide\u003csup\u003e\u003cspan additionalcitationids=\"CR2 CR3\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e. Its most advanced stage, proliferative diabetic retinopathy (PDR), is characterized by retinal neovascularization that can lead to vision-threatening complications, including persistent vitreous hemorrhage (VH) and tractional retinal detachment (TRD)\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e. For these severe manifestations, pars plana vitrectomy (PPV) is the definitive surgical intervention, enabling the clearance of hemorrhagic media and the release of vitreoretinal traction\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eA frequent comorbidity in PDR patients is cataract, creating a clinical dilemma: whether to perform PPV alone or combine it with phacoemulsification (PPV\u0026amp;P) in a single session. The rationale for a combined procedure is strong, offering the convenience of a single surgery, faster visual rehabilitation, and avoidance of the technical challenges inherent in operating on a previously vitrectomized eye\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e. Furthermore, removing the cataract provides the surgeon an unobstructed, panoramic view of the posterior segment, which facilitates more meticulous membrane dissection and complete panretinal endophotocoagulation\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eHowever, these benefits are countered by concerns that PPV\u0026amp;P may exacerbate postoperative complications. The extensive surgical manipulation of a combined procedure can intensify the breakdown of the blood-aqueous barrier. This physiological disruption is hypothesized to increase the risk of severe postoperative inflammation, cystoid macular edema, and, most critically, anterior segment neovascularization leading to neovascular glaucoma (NVG)\u0026mdash;a devastating and often intractable complication\u003csup\u003e\u003cspan additionalcitationids=\"CR10\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e. Consequently, the optimal surgical strategy remains a subject of intense debate.\u003c/p\u003e\u003cp\u003ePrevious studies on this topic have yielded conflicting and inconclusive results. While some reports suggest combined surgery does not increase the risk of NVG or recurrent VH\u003csup\u003e\u003cspan additionalcitationids=\"CR13\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e, others associate it with poorer outcomes. These discrepancies may stem from variations in study design, patient populations, follow-up duration, and surgical techniques. Critically, a definitive consensus is lacking on whether the surgical approach independently influences the long-term risk of major complications after accounting for baseline patient and disease characteristics.\u003c/p\u003e\u003cp\u003eTherefore, this large-scale, single-center retrospective study was designed to address this critical knowledge gap. By analyzing a substantial cohort of PDR patients with long-term follow-up, we aimed to rigorously compare the incidence of recurrent vitreous hemorrhage and neovascular glaucoma between patients undergoing PPV alone versus combined PPV\u0026amp;P. Using survival analysis and multivariable Cox regression models, we sought not only to compare outcomes but also to identify independent predictors of these vision-threatening complications, thereby providing stronger evidence to guide clinical decision-making.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cstrong\u003eStudy Design and Ethical Approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis single-center, retrospective cohort study was conducted at the Department of Ophthalmology, The First Affiliated Hospital of Shantou University Medical College, in adherence with the tenets of the Declaration of Helsinki. The study protocol was approved by the institutional review board, which waived the requirement for informed consent due to the retrospective nature of the analysis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePatient Selection and Study Groups\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe reviewed the medical records of patients with proliferative diabetic retinopathy (PDR) who underwent either pars plana vitrectomy (PPV) alone or combined PPV with phacoemulsification (PPV\u0026amp;P) between January 2019 and May 2024. Patients were included if they were aged 18 years or older, had surgical indications for PDR (Persistent vitreous hemorrhage or tractional retinal detachment), and had a minimum follow-up of 12 months.\u003c/p\u003e\n\u003cp\u003eExclusion criteria were: (1) prior vitrectomy or cataract surgery in the study eye; (2) pre-existing rubeosis iridis or neovascular glaucoma (NVG); (3) other significant confounding ocular pathologies, such as age-related macular degeneration (AMD), high myopia (axial length \u0026gt;26 mm or refractive error \u0026gt; \u0026minus;6.0 D), or retinal vascular occlusions; and (4) incomplete follow-up data.\u003c/p\u003e\n\u003cp\u003eBased on the procedure performed, patients were stratified into two cohorts: the PPV\u0026amp;P group and the PPV-alone group. The surgical approach was determined by the surgeon\u0026apos;s clinical judgment and patient preference.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSurgical Procedures\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll surgeries were performed by experienced vitreoretinal surgeons.A standardized 23-gauge three-port PPV was executed on all cases, with scleral incisions sutured postoperatively to ensure wound integrity. The procedure involved a core vitrectomy, induction of posterior vitreous detachment if not already present, and meticulous removal of vitreous and epiretinal membranes using delamination, segmentation, and peeling techniques to relieve all traction. Comprehensive panretinal endophotocoagulation (PRP) was applied from the posterior pole to the ora serrata, with scleral depression as needed to ensure complete peripheral treatment. The choice of intravitreal tamponade\u0026mdash;balanced salt solution, air, C3F8 gas, or silicone oil\u0026mdash;was at the surgeon\u0026apos;s discretion based on intraoperative findings.\u003c/p\u003e\n\u003cp\u003eFor patients in the PPV\u0026amp;P group, phacoemulsification was performed prior to vitrectomy, followed by the implantation of a foldable acrylic intraocular lens into the capsular bag.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Collection and Outcome Measures\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eRelevant preoperative, intraoperative, and postoperative data were extracted from patient medical records. Preoperative variables included demographics, systemic markers (serum creatinine, HbA1c), ocular history, recent anti-VEGF use, and primary surgical indications. Intraoperative variables included the grades of lens sclerosis and proliferative traction, tamponade agent, laser parameters, and any complications.\u003c/p\u003e\n\u003cp\u003eThe primary outcomes were the incidence of recurrent vitreous hemorrhage and the development of NVG. Recurrence was defined as any postoperative hemorrhage obscuring the retina for over three weeks or the development of a recurrent retinal detachment. NVG was defined as iris neovascularization with elevated intraocular pressure (IOP). Secondary outcomes included changes in best-corrected visual acuity (BCVA) and IOP, and rates of postoperative complications like ocular hypertension (IOP \u0026gt;25 mmHg). Time-to-event was calculated from the surgery date to the diagnosis date of a primary outcome.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStatistical Analysis\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eStatistical analyses were performed using SPSS software (version 25.0). Continuous variables were compared using independent samples t-tests, while categorical variables were compared using the chi-squared (\u0026chi;\u0026sup2;) or Fisher\u0026rsquo;s exact test. Time-to-event data for recurrence and NVG were analyzed using the Kaplan-Meier method with the log-rank test for curve comparison. Multivariable Cox proportional hazards regression models were constructed to identify independent predictors for outcomes within a 2-year follow-up period. For all analyses, a two-sided P value of less than 0.05 was considered statistically significant.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003eBaseline Demographics and Clinical Characteristics\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA total of 556 eyes from 556 patients were included, with 144 in the PPV\u0026amp;P group and 412 in the PPV-alone group. Patients in the PPV\u0026amp;P group were significantly older than those in the PPV-alone group (mean [SD] age, 58.39 [10.15] vs. 50.97 [9.70] years, respectively).\u003c/p\u003e\n\u003cp\u003eThe two groups were well-matched at baseline, with no significant differences in systemic health markers (serum creatinine, HbA1c), history of prior laser treatment, IOP, BCVA, surgical indications, preoperative anti-VEGF use, or the grade of proliferative traction (P \u0026gt; 0.05 for all). As anticipated by the surgical grouping, lens opacity was significantly more severe in the PPV\u0026amp;P group (P \u0026lt; 0.001) (Table 1).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSurgical and Postoperative Outcomes\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIntraoperative management, including the choice of tamponade agent, application of retinal laser, and use of intravitreal triamcinolone, was comparable between groups (P \u0026gt; 0.05). However, the PPV\u0026amp;P group experienced a significantly higher rate of intraoperative complications, including posterior capsule tear, anterior chamber hemorrhage, and corneal edema (P \u0026lt; 0.01 for all) (Table 2).\u003c/p\u003e\n\u003cp\u003eThe mean follow-up duration was 29.68 [12.01] months for the PPV\u0026amp;P group and 30.49 [11.79] months for the PPV-alone group. Postoperative outcomes were largely similar, with no significant differences in final IOP, BCVA improvement, or the overall rates of recurrence(VH) (29.2% vs. 27.2%), neovascular glaucoma (NVG), or the need for repeat PPV (P \u0026gt; 0.05 for all). However, the PPV\u0026amp;P group had a significantly higher incidence of postoperative inflammatory reactions and silicone oil in the anterior chamber (P \u0026lt; 0.05) (Table 3).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTime-to-Event\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAnalysis Kaplan-Meier analysis revealed no significant difference in the overall cumulative risk of recurrence(VH) (log-rank P = 0.466) or NVG (log-rank P = 0.956) between the groups over the entire follow-up period (Figure 1). The estimated 2-year risk for recurrence(VH) was 27.1% in the PPV\u0026amp;P group and 23.7% in the PPV-alone group (P = 0.240). The 2-year risk for NVG was 4.1% in the PPV\u0026amp;P group and 5.6% in the PPV-alone group(P = 0.329). Although the survival curves for both outcomes appeared to diverge after three years, these long-term findings are limited by the small number of patients remaining at risk.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eIndependent Predictors of Postoperative Complications\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMultivariable Cox regression analysis was performed for the 2-year follow-up period to identify independent predictors of major complications.\u003c/p\u003e\n\u003cp\u003eFor recurrence(VH) , significant predictors included undergoing PPV-alone surgery (adjusted Hazard Ratio [aHR], 0.64; 95% CI, 0.43-0.96) and older age (aHR, 0.98; 95% CI, 0.96-0.99), both of which were protective. Conversely, the presence of severe preoperative traction was a significant risk factor (aHR, 2.31; 95% CI, 1.45-3.68) (Figure 2A).\u003c/p\u003e\n\u003cp\u003eFor the development of NVG, the surgical approach was not a significant factor. The primary risk factors were the presence of severe preoperative traction (aHR, 5.08; 95% CI, 1.66-15.51) and older age (aHR, 1.07; 95% CI, 1.02-1.12) (Figure 2B).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study contributes nuanced evidence to the long-standing debate over the optimal surgical management for proliferative diabetic retinopathy (PDR) with coexisting cataracts. Our primary finding is that while the overall, long-term incidence of major complications did not differ between combined phacoemulsification with pars plana vitrectomy (PPV\u0026amp;P) and PPV-alone, a time-dependent analysis revealed a critical distinction: combined surgery was associated with a significantly higher risk of recurrence(VH) specifically within the first two postoperative years.\u003c/p\u003e\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\u003ch2\u003eRecurrent Vitreous Hemorrhage: An Early Risk for Combined Surgery\u003c/h2\u003e\u003cp\u003eOur multivariable Cox regression analysis identified PPV-alone as an independent protective factor against recurrence(VH) within a 2-year timeframe (aHR, 0.64). This result substantiates the hypothesis that the greater surgical trauma of a combined procedure potentiates a more significant breakdown of the blood-ocular barrier, leading to a transient, heightened inflammatory state. This early postoperative period is critical, as fragile neovascular tissue is most susceptible to bleeding\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e. The significantly higher incidence of postoperative inflammatory reactions observed in our PPV\u0026amp;P group lends clinical support to this pathophysiological mechanism.\u003c/p\u003e\u003cp\u003eInterestingly, our Kaplan-Meier analysis showed this increased risk was front-loaded. Beyond three years, the recurrence curve for the PPV\u0026amp;P group flattened, while the risk in the PPV-alone group continued to ascend gradually. Although long-term data must be interpreted cautiously due to patient attrition, this trend suggests that once the initial inflammation from combined surgery resolves, the re-bleeding risk diminishes. Conversely, patients who undergo PPV-alone may face a delayed risk from subsequent cataract progression, which can impede fundus visualization for monitoring and supplementary laser, potentially allowing undetected neovascular activity to cause late-onset hemorrhage.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\u003ch2\u003eNeovascular Glaucoma: Challenging Traditional Dogma\u003c/h2\u003e\u003cp\u003eA pivotal finding of our study is the lack of any significant association between combined surgery and an increased risk of neovascular glaucoma (NVG). For decades, a primary argument against PPV\u0026amp;P has been the fear that removing the crystalline lens\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e\u0026mdash;a supposed barrier to the anterior diffusion of vasoproliferative factors like VEGF\u0026mdash;would precipitate catastrophic anterior segment neovascularization\u003csup\u003e\u003cspan additionalcitationids=\"CR15 CR16 CR17 CR18\" citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e. Our results, consistent with several contemporary studies\u003csup\u003e\u003cspan additionalcitationids=\"CR13\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e, challenge this dogma. The 2-year NVG risks were low and statistically indistinguishable between groups. This suggests that with modern surgical techniques\u0026mdash;including thorough removal of the vitreous scaffold, complete relief of traction, and extensive panretinal endophotocoagulation\u0026mdash;the theoretical risk conferred by phacoemulsification is effectively negated.\u003c/p\u003e\u003cp\u003eInstead of surgical strategy, our analysis identified severe preoperative traction and older age as the most potent independent predictors for NVG. This underscores a crucial paradigm shift: the primary driver of NVG is not the absence of the lens but the severity of the underlying retinal ischemia. Incomplete traction removal or insufficient photocoagulation leaves a powerful ischemic stimulus intact, which is the true engine of neovascularization. The association with older age is a novel finding that may reflect a reduced vasoregenerative capacity or increased endothelial susceptibility to ischemic insults in elderly patients.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e\u003ch2\u003eClinical Implications and Surgical Decision-Making\u003c/h2\u003e\u003cp\u003eOur findings have direct implications for clinical practice, supporting a move away from a rigid, risk-averse stance on PPV\u0026amp;P toward a more individualized approach\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eFor patients with visually significant cataracts, the benefits of a combined procedure\u0026mdash;superior intraoperative visualization facilitating more complete surgery and faster visual rehabilitation\u0026mdash;likely outweigh the transiently increased risk of early postoperative recurrence(VH), especially since our data show the long-term risk of NVG is not elevated.\u003c/p\u003e\u003cp\u003eFor patients with a clear or only mildly opaque lens, performing PPV-alone may be the more prudent approach to minimize the risk of early recurrent hemorrhage, with a staged phacoemulsification performed later if needed.\u003c/p\u003e\u003cp\u003eRegardless of the approach, the surgical focus must remain on addressing the fundamental pathology. Meticulous removal of all vitreoretinal traction\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e and comprehensive panretinal photocoagulation are paramount in preventing both recurrent VH and NVG\u003csup\u003e\u003cspan additionalcitationids=\"CR24 CR25\" citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e. The severity of preoperative traction, as identified in our study, should be a primary factor in guiding surgical strategy and patient counseling.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec17\" class=\"Section2\"\u003e\u003ch2\u003eLimitation\u003c/h2\u003e\u003cp\u003eThis study has several limitations. First, its retrospective, single-center design is susceptible to inherent selection and ascertainment bias. The non-randomized allocation of surgical approach, based on surgeon and patient preference, is a key potential confounder. Second, while the follow-up was substantial, it may be insufficient to capture very late-onset complications, and patient attrition limits the reliability of findings beyond two to three years. Therefore, a large-scale, multicenter randomized controlled trial is still necessary to definitively confirm these findings and provide the highest level of evidence.\u003c/p\u003e\u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn conclusion, this study demonstrates that while combined PPV and phacoemulsification is associated with an increased risk of recurrent vitreous hemorrhage within the first two postoperative years, it does not increase the long-term risk of neovascular glaucoma. The most critical determinant of postoperative outcomes is not the surgical strategy for the lens, but rather the severity of the baseline proliferative disease and the thoroughness of the vitrectomy and endophotocoagulation. This evidence should empower surgeons to tailor their approach based on the individual patient's cataract status and retinal pathology, rather than an unsubstantiated fear of devastating complications from a combined procedure.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflicts of Interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no conflicts of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability Statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data supporting the findings of this study are available from the corresponding author upon reasonable request. Due to their size, the raw datasets cannot be deposited in a public repository but can be accessed following a justified inquiry.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFinancial support:\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eNone.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFinancial Disclosure:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe sponsor or funding entity played no part in the conception or execution of this research. All authors declare no financial or conflicting interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eContributors:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eGenjia Li: Data curation,Original draft, Methodology, Formal analysis. Qiujie Chen: Writing \u0026ndash; review \u0026amp; editing,Supervision, Project administration.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eYau JW, Rogers SL, Kawasaki R, Lamoureux EL, Kowalski JW, Bek T\u003cem\u003e et al.\u003c/em\u003e Global prevalence and major risk factors of diabetic retinopathy. \u003cem\u003eDiabetes Care \u003c/em\u003e2012; \u003cstrong\u003e35\u003c/strong\u003e(3)\u003cstrong\u003e: \u003c/strong\u003e556-564.\u003c/li\u003e\n\u003cli\u003eLee R, Wong TY, Sabanayagam C. Epidemiology of diabetic retinopathy, diabetic macular edema and related vision loss. \u003cem\u003eEye Vis (Lond) \u003c/em\u003e2015; \u003cstrong\u003e2: \u003c/strong\u003e17.\u003c/li\u003e\n\u003cli\u003eChong DD, Das N, Singh RP. 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Progression of diabetic retinopathy and rubeotic glaucoma following cataract surgery. \u003cem\u003eEye (Lond) \u003c/em\u003e1995; \u003cstrong\u003e9 ( Pt 6): \u003c/strong\u003e728-738.\u003c/li\u003e\n\u003cli\u003eChung TY, Chung H, Lee JH. Combined surgery and sequential surgery comprising phacoemulsification, pars plana vitrectomy, and intraocular lens implantation: comparison of clinical outcomes. \u003cem\u003eJ Cataract Refract Surg \u003c/em\u003e2002; \u003cstrong\u003e28\u003c/strong\u003e(11)\u003cstrong\u003e: \u003c/strong\u003e2001-2005.\u003c/li\u003e\n\u003cli\u003eSchachat AP, Oyakawa RT, Michels RG, Rice TA. Complications of vitreous surgery for diabetic retinopathy. II. Postoperative complications. \u003cem\u003eOphthalmology \u003c/em\u003e1983; \u003cstrong\u003e90\u003c/strong\u003e(5)\u003cstrong\u003e: \u003c/strong\u003e522-530.\u003c/li\u003e\n\u003cli\u003eSchiff WM, Barile GR, Hwang JC, Tseng JJ, Ceki\u0026ccedil; O, Del Priore LV\u003cem\u003e et al.\u003c/em\u003e Diabetic vitrectomy: influence of lens status upon anatomic and visual outcomes. \u003cem\u003eOphthalmology \u003c/em\u003e2007; \u003cstrong\u003e114\u003c/strong\u003e(3)\u003cstrong\u003e: \u003c/strong\u003e544-550.\u003c/li\u003e\n\u003cli\u003eNawaz IM, Rezzola S, Cancarini A, Russo A, Costagliola C, Semeraro F\u003cem\u003e et al.\u003c/em\u003e Human vitreous in proliferative diabetic retinopathy: Characterization and translational implications. \u003cem\u003eProg Retin Eye Res \u003c/em\u003e2019; \u003cstrong\u003e72: \u003c/strong\u003e100756.\u003c/li\u003e\n\u003cli\u003eYeh PT, Yang CM, Yang CH, Huang JS. Cryotherapy of the anterior retina and sclerotomy sites in diabetic vitrectomy to prevent recurrent vitreous hemorrhage: an ultrasound biomicroscopy study. \u003cem\u003eOphthalmology \u003c/em\u003e2005; \u003cstrong\u003e112\u003c/strong\u003e(12)\u003cstrong\u003e: \u003c/strong\u003e2095-2102.\u003c/li\u003e\n\u003cli\u003eTseng HY, Wu WC, Hsu SY. Comparison of vitrectomy alone and combined vitrectomy, phacoemulsification and intraocular lens implantation for proliferative diabetic retinopathy. \u003cem\u003eKaohsiung J Med Sci \u003c/em\u003e2007; \u003cstrong\u003e23\u003c/strong\u003e(7)\u003cstrong\u003e: \u003c/strong\u003e339-343.\u003c/li\u003e\n\u003cli\u003eTang Y, Shi Y, Fan Z. The mechanism and therapeutic strategies for neovascular glaucoma secondary to diabetic retinopathy. \u003cem\u003eFront Endocrinol (Lausanne) \u003c/em\u003e2023; \u003cstrong\u003e14: \u003c/strong\u003e1102361.\u003c/li\u003e\n\u003cli\u003eMohite AA, Perais JA, McCullough P, Lois N. Retinal Ischaemia in Diabetic Retinopathy: Understanding and Overcoming a Therapeutic Challenge. \u003cem\u003eJ Clin Med \u003c/em\u003e2023; \u003cstrong\u003e12\u003c/strong\u003e(6).\u003c/li\u003e\n\u003cli\u003eHayreh SS. Neovascular glaucoma. \u003cem\u003eProg Retin Eye Res \u003c/em\u003e2007; \u003cstrong\u003e26\u003c/strong\u003e(5)\u003cstrong\u003e: \u003c/strong\u003e470-485.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTable 1.Baseline Characteristics and Surgery Indications\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" align=\"\" width=\"543\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 273px;\"\u003e\n \u003cp\u003eParameter\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003ePPV\u0026amp;P（n=144）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003ePPV（n=412）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e\u003cem\u003eP\u0026nbsp;\u003c/em\u003eValue\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 273px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge, mean (SD), y\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e58.39（10.15）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003e50.97（9.70）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e＜\u003c/strong\u003e\u003cstrong\u003e0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 273px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSex, No. (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 273px;\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e82（56.9）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003e270（65.5）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e0.066\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 273px;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e62（43.1）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003e142（34.5）\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 273px;\"\u003e\n \u003cp\u003eHbA1c, mean (SD),%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e7.46（1.67）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003e7.50（1.76）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e0.803\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 273px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCreatinine\u003c/strong\u003e, mean (SD), umol/L\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e125.51（118.36）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003e121.04（111.57）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e0.684\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 273px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePreoperative IOP, mean (SD),\u0026nbsp;\u003c/strong\u003emmHg\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e13.19（1.66）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003e13.21（1.65）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e0.929\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 273px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePreoperative\u0026nbsp;\u003c/strong\u003eBCVA,Snellen(logMAR)\u003cstrong\u003e, mean (SD)\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e1.67（0.62）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003e1.58（0.57）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e0.115\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 273px;\"\u003e\n \u003cp\u003ePreoperative lens nuclear sclerosis\u003cstrong\u003e, No. (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 273px;\"\u003e\n \u003cp\u003eGrade 0/1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e4（2.8）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003e313（76.0）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 273px;\"\u003e\n \u003cp\u003eGrade 2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e53（36.8）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003e95（26.6）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e＜\u003c/strong\u003e\u003cstrong\u003e0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 273px;\"\u003e\n \u003cp\u003eGrade 3/4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e87（60.4）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003e4（16.4）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 273px;\"\u003e\n \u003cp\u003ePreoperative Grading of Traction\u003cstrong\u003e, No. (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 273px;\"\u003e\n \u003cp\u003eSevere\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e34（23.6）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003e111（26.9）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 273px;\"\u003e\n \u003cp\u003eMild or moderate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e71（49.3）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003e191（46.4）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e0.720\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 273px;\"\u003e\n \u003cp\u003eNo traction\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e39（27.1）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003e110（26.7）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 273px;\"\u003e\n \u003cp\u003ePrevious\u0026nbsp;laser\u003cstrong\u003e, No. (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e60（41.7）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003e140（34.0）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e0.098\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 273px;\"\u003e\n \u003cp\u003ePrevious anti‑VEGF within 2 weeks\u003cstrong\u003e, No. (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e110（76.4）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003e339（82.3）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e0.123\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 273px;\"\u003e\n \u003cp\u003eSurgery indications\u003cstrong\u003e, No. (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 273px;\"\u003e\n \u003cp\u003eVH\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e97（67.4）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003e262（63.6）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e0.416\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 273px;\"\u003e\n \u003cp\u003eTRD\u0026plusmn;VH\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e47（32.6）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003e150（36.4）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eNuclear sclerosis was assessed at the slit lamp and classified as follows:Grade 0: Clear lens.Grade 1: Early nuclear sclerosis with mild yellow discoloration of the posterior lens in the slit beam.Grade 2: Yellow discoloration throughout the lens.Grade 3: Yellow-brown discoloration throughout the lens.Grade 4: Brown discoloration of the entire lens.Traction was graded based on the extent of fibrovascular tissue and the time and instrumentation required for its removal:Severe: Fibrovascular tissue covering the entire posterior retina and extending beyond, requiring extensive removal.Moderate: Fibrovascular tissue covering most of the posterior retina, requiring significant removal efforts.Mild: Limited epicenters of fibrous tissue, disconnected using a vitreous cutter.No Traction: Complete posterior vitreous detachment.\u003c/p\u003e\n\u003cp\u003eAbbreviation：y,years;PPV\u0026amp;P,Pars plana vitrectomy with cataract phacoemulsification; HbA1c,Glycosylated hemoglobin;IOP,Intraocular Pressure;LogMAR,Logarithm of the Minimum Angle of Resolution;BCVA,Best Corrected Visual Acuity;VH,vitreous hemorrhage; TRD, tractional retinal detachment; VEGF, vascular endothelial growth factor.\u003c/p\u003e\n\u003cp\u003eTable 2.Surgery Procedures and Intraoperative Complications\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" align=\"\" width=\"555\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 276px;\"\u003e\n \u003cp\u003eParameter\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003ePPV\u0026amp;P（n=144）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003ePPV（n=412）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e\u003cem\u003eP\u0026nbsp;\u003c/em\u003eValue\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 276px;\"\u003e\n \u003cp\u003eSurgery Procedures\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 276px;\"\u003e\n \u003cp\u003eEndotamponade\u003cstrong\u003e, No. (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 276px;\"\u003e\n \u003cp\u003eBSS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003e84（58.3）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e245（59.5）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 276px;\"\u003e\n \u003cp\u003eAir\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003e6（4.2）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e13（3.2）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e0.872\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 276px;\"\u003e\n \u003cp\u003eSilicone Oil\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003e38（26.4）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e115（27.9）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 276px;\"\u003e\n \u003cp\u003eC3F8 gas\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003e16（11.1）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e39（9.5）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 276px;\"\u003e\n \u003cp\u003eEndolaser\u003cstrong\u003e, No. (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003e139（96.5）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e407（98.8）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e0.079\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 276px;\"\u003e\n \u003cp\u003eTA injection\u003cstrong\u003e, No. (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003e45（31.3）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e100（24.3）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e0.101\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 276px;\"\u003e\n \u003cp\u003eIntraoperative Complications\u003cstrong\u003e, No. (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 276px;\"\u003e\n \u003cp\u003ePosterior capsule tear\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003e5（3.5）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e1（0.2）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.005\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 276px;\"\u003e\n \u003cp\u003eAnterior chamber hemorrhage\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003e6（4.2）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e2（0.5）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.005\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 276px;\"\u003e\n \u003cp\u003eCorneal edema\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003e9（6.3）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e1（0.2）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e＜\u003c/strong\u003e\u003cstrong\u003e0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 276px;\"\u003e\n \u003cp\u003eZonular complications\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003e2（1.4）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0（0.0）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e0.067\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eAbbreviation:PPV\u0026amp;P,Pars plana vitrectomy with cataract phacoemulsification; BSS,balanced salt solution;TA, triamcinolone acetonide.\u003c/p\u003e\n\u003cp\u003eTable 3.Postoperative IOP, BCVA and Complications\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" align=\"\" width=\"555\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 276px;\"\u003e\n \u003cp\u003eParameter\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003ePPV\u0026amp;P（n=144）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003ePPV（n=412）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e\u003cem\u003eP\u0026nbsp;\u003c/em\u003eValue\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 276px;\"\u003e\n \u003cp\u003eFollow-up time\u003cstrong\u003e, mean (SD), y\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003e29.68（12.01）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e30.49（11.79）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e0.479\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 276px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePostoperative IOP, mean (SD),\u0026nbsp;\u003c/strong\u003emmHg\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003e14.85（5.28）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e14.60（5.15）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e0.621\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 276px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePostoperative\u0026nbsp;\u003c/strong\u003eBCVA,Snellen(logMAR)\u003cstrong\u003e, mean (SD)\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003e1.14（0.75）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e1.02（0.64）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e0.059\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 276px;\"\u003e\n \u003cp\u003eBCVA Improvement (ETDRS letters)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003e26.60（36.82）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e28.26（36.84）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e0.641\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 276px;\"\u003e\n \u003cp\u003eComplications\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 276px;\"\u003e\n \u003cp\u003eRecurrence (VH)\u003cstrong\u003e, No. (%)#\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003e42（29.2）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e112（27.2）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e0.647\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 276px;\"\u003e\n \u003cp\u003eTime after surgery\u003cstrong\u003e, mean (SD), m\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003e10.13（11.40）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e13.75（11.58）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e0.085\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 276px;\"\u003e\n \u003cp\u003eHbA1c, mean (SD),%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003e7.10（1.59）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e7.63（1.76）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e0.089\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 276px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCreatinine\u003c/strong\u003e, mean (SD), umol/L\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003e136.83（113.08）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e128.31（116.91）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e0.685\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 276px;\"\u003e\n \u003cp\u003eNVG\u003cstrong\u003e, No. (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003e11（7.6）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e33（8.0）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e0.887\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 276px;\"\u003e\n \u003cp\u003eTime after surgery\u003cstrong\u003e, mean (SD), m\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003e27.96（12.58）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e22.64（10.58）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e0.176\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 276px;\"\u003e\n \u003cp\u003eHbA1c, mean (SD),%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003e7.61（1.39）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e7.69（1.81）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e0.893\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 276px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCreatinine\u003c/strong\u003e, mean (SD), umol/L\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003e120.82（70.26）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e138.15（148.58）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e0.712\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 276px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOthers, No. (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 276px;\"\u003e\n \u003cp\u003eCorneal edema\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003e15（10.4）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e30（7.3）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e0.235\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 276px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSilicone oil in chamber\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003e6（4.2）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e3（0.7）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.011\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 276px;\"\u003e\n \u003cp\u003eInflammatory reaction\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003e8（5.6）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e7（1.7）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.030\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 276px;\"\u003e\n \u003cp\u003eOcular hypertension\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003e22（15.3）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e80（19.4）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e0.269\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 276px;\"\u003e\n \u003cp\u003eMacular edema\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003e19（13.2）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e46（11.1）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e0.514\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 276px;\"\u003e\n \u003cp\u003eRecurrence of RD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003e17（11.8）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e38（9.2）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e0.372\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 276px;\"\u003e\n \u003cp\u003eRepeat PPV\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003e24（16.7）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e54（13.1）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e0.290\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e#, Defined as any postoperative hemorrhage sufficient to obscure the retina and cause vision loss lasting more than three weeks.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAbbreviation:PPV\u0026amp;P,Pars plana vitrectomy with cataract phacoemulsification; IOP,Intraocular Pressure;LogMAR,Logarithm of the Minimum Angle of Resolution;BCVA,Best Corrected Visual Acuity;y,years;m,months;ETDRS,Early Treatment Diabetic Retinopathy Study Chart;VH,vitreous hemorrhage;RD,Retinal detachment;HbA1c,Glycosylated hemoglobin;NVG,Neovascular glaucoma.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Proliferative diabetic retinopathy, Pars plana vitrectomy, Phacoemulsification, Neovascular glaucoma, Vitreous hemorrhage, Surgical outcomes","lastPublishedDoi":"10.21203/rs.3.rs-7422427/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7422427/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003ePurpose:\u003c/strong\u003e To compare the long-term incidence of recurrent vitreous hemorrhage(VH) and neovascular glaucoma (NVG) in patients with proliferative diabetic retinopathy (PDR) undergoing pars plana vitrectomy (PPV) alone versus combined PPV and phacoemulsification (PPV\u0026amp;P).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e This large, single-center, retrospective cohort study analyzed 556 eyes (144 PPV\u0026amp;P, 412 PPV-alone) with a minimum 12-month follow-up. Kaplan-Meier survival analysis and multivariable Cox proportional hazards regression models were used to compare outcomes and identify independent predictors for complications within a 2-year follow-up period.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e Over the entire follow-up, the overall incidence of recurrence(VH) and NVG did not differ significantly between the groups. However, multivariable Cox regression analysis for the first two years revealed that PPV-alone was a significant protective factor against recurrence (adjusted Hazard Ratio [aHR], 0.64; 95% CI, 0.43-0.96), while severe preoperative traction was a major risk factor (aHR, 2.31; 95% CI, 1.45-3.68). For NVG development within two years, the surgical approach was not a significant factor. Instead, severe preoperative traction (aHR, 5.08; 95% CI, 1.66-15.51) and older age (aHR, 1.07; 95% CI, 1.02-1.12) were the primary independent risk factors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e Combined PPV with phacoemulsification is associated with an increased risk of recurrence(VH) within the first two postoperative years but does not increase the risk of neovascular glaucoma. The severity of baseline proliferative disease, particularly the degree of traction, is a more critical determinant of postoperative complications than the surgical strategy regarding the lens. This supports tailoring the surgical approach based on individual patient cataract status and retinal pathology.\u003c/p\u003e","manuscriptTitle":"Combined Phacoemulsification and Vitrectomy for Proliferative Diabetic Retinopathy: An Increased Risk of Early Recurrence but Not Long-Term Neovascular Glaucoma","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-08 12:18:07","doi":"10.21203/rs.3.rs-7422427/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"639442ad-4e25-40e0-a8f7-abf06cc0d375","owner":[],"postedDate":"September 8th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":53881356,"name":"Health sciences/Diseases/Eye diseases"},{"id":53881357,"name":"Health sciences/Risk factors"}],"tags":[],"updatedAt":"2025-09-19T04:08:23+00:00","versionOfRecord":[],"versionCreatedAt":"2025-09-08 12:18:07","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7422427","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7422427","identity":"rs-7422427","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}