Objective <p>The purpose of this study was to investigate the association between the stress hyperglycemia ratio (SHR) and the occurrence of neovascular glaucoma (NVG) in patients with proliferative diabetic retinopathy (PDR). We aimed to explore the potential role of SHR as a biomarker for NVG risk and to identify demographic and clinical modifiers of this association.</p> Methods <p>We conducted a retrospective cohort study using electronic health records from our hospital over a 10-year period from 2010 to 2020. Patients diagnosed with PDR were included, with exclusions for those without diabetes-related NVG or incomplete SHR data. The SHR was calculated using admission blood glucose and HbA1c levels. Logistic regression and Cox proportional hazards modeling were used to assess the association between SHR and NVG, adjusting for potential confounders.</p> Results <p>A total of 1,245 patients were identified, of which 378 (30.3%) had PDR with NVG. The mean SHR for the entire cohort was 2.9, with a higher mean SHR observed in the PDR with NVG group (3.2 vs. 2.7, <i>p</i> &lt; 0.001). Multivariate logistic regression analysis revealed a significant association between SHR and NVG (OR 2.5, 95% CI 1.9 to 3.3, <i>p</i> &lt; 0.001). Subgroup analysis showed a stronger association between SHR and NVG risk in males (HR 1.4, 95% CI 1.1 to 1.7, <i>p</i> = 0.01) and patients over 65 years old (HR 1.5, 95% CI 1.2 to 1.9, <i>p</i> = 0.001). The association was also more pronounced in patients with a diabetes duration exceeding 15 years (HR 1.4, 95% CI 1.1 to 1.8, <i>p</i> = 0.01).</p> Conclusion <p>Our study demonstrated a significant association between SHR and NVG with PDR patients, with certain subgroups showing a stronger association. These findings suggest that glycemic variability, as measured by SHR, may play a critical role in the development of NVG and could inform tailored clinical strategies for the prevention and management of NVG in high-risk patients.</p>