AIM: To identify risk factors for postoperative blindness in patients with primary rhegmatogenous retinal detachment (RRD) at their first presentation to a tertiary center, using a large clinical database to improve understanding of this adverse outcome. METHODS: Electronic health records of patients with primary RRD from the Eye Hospital of Wenzhou Medical University were retrospectively analyzed. Postoperative blindness was defined according to the World Health Organization (WHO) criteria for legal blindness. Potential risk factors included demographic characteristics, preoperative clinical features, and surgical variables. Univariable and multivariable logistic regression analyses were performed to calculate odds ratios (ORs) and 95% confidence intervals (CIs) for each risk factor. RESULTS: A total of 532 patients were included in the cohort, of whom 62 (12.0%; 28 males, 34 females) developed postoperative blindness at the final follow-up. Among these 62 patients, 30 had high myopia and 32 did not. The mean age of participants was 49.0±16.4y, with 275 subjects (52%) being male and 133 patients (25%) having the condition in the right eye. In the multivariable model for all patients, the following factors were associated with an increased risk of postoperative blindness: higher preoperative logarithm of the minimum angle of resolution visual acuity (logMAR VA; OR=1.09 per 0.1 logMAR unit increase, 95%CI 1.03-1.15); inferior or superior retinal breaks (OR=2.42, 95%CI 1.12-5.24); and macular holes or superior retinal breaks (OR=8.46, 95%CI 3.45-20.75). In the subgroup of patients with high myopia, risk factors for postoperative blindness included: pseudophakia/aphakia versus phakia (OR=6.33, 95%CI 1.41-28.31); macular holes or superior retinal breaks (OR=15.15, 95%CI 3.07-74.85); and proliferative vitreoretinopathy (PVR; OR=21.41, 95%CI 2.14-214.57). In the subgroup of patients without high myopia, increased risk of postoperative blindness was associated with: higher preoperative logMAR VA (OR=1.11 per 0.1 logMAR unit increase, 95%CI 1.04-1.18); and inferior or superior retinal breaks (OR=2.90, 95%CI 1.19-7.06). CONCLUSION: Using a large real-world clinical database, we identified distinct risk factors for postoperative blindness in patients with primary RRD-including differences between those with and without high myopia. These findings emphasize the need to target specific risk factors in clinical practice to mitigate and reduce the incidence of postoperative blindness in this patient population.