Objective: To compare the risk of incident diabetic retinopathy (DR) after initiation of glucagon-like peptide-1 receptor agonists (GLP-1RA) versus dipeptidyl peptidase-4 inhibitors (DPP-4i) among patients with type 2 diabetes mellitus (T2DM). Methods: An active-comparator new-user retrospective cohort study was conducted using the Yinzhou Regional Health Information Platform in Ningbo, China. Patients with T2DM who received a first prescription for a GLP-1RA or a DPP-4i between September 1, 2022 and August 31, 2025 were included. 1∶1 nearest-neighbor propensity score matching was applied to balance baseline covariates including demographic characteristics, diabetes duration, baseline comorbidities, prior medication history, and the most recent pre-index measurements of glycated hemoglobin and estimated glomerular filtration rate. In the matched cohort, multivariable Cox proportional hazards regression models were used to estimate hazard ratios (HRs) with 95%CIs to evaluate the association between the initiation of the two medications and the risk of incident DR. Sensitivity analyses were performed by varying the washout period, the latency period, and the matching ratio. Results: After matching, 1 839 patients were included in each group. The incidence rates of DR were 13.60 per 1 000 person-years among DPP-4i and 9.95 per 1 000 person-years among GLP-1RA. Initiation of GLP-1RA was not associated with a statistically significant difference in DR risk compared with initiation of DPP-4i (P=0.114). Findings were consistent across sensitivity analyses. Conclusion: In this real-world cohort, DPP-4i initiation of GLP-1RA was not associated with an increased risk of incident DR compared with initiation of in patients with T2DM.
