To investigate the association between mean ocular perfusion pressure (MOPP), estimated cerebrospinal fluid pressure (CSFP), and changes in diabetic retinopathy (DR) in a Northeastern Chinese population with type 2 diabetes.A total of 1322 subjects from the Fushun Diabetic Retinopathy Cohort Study were enrolled. Systolic blood pressure (SBP), diastolic blood pressure (DBP), and intraocular pressure (IOP) were recorded. MOPP was calculated by the following formula: MOPP = 2/3 [DBP + 1/3 (SBP - DBP)] - IOP, and CSFP was estimated according to the following formula: CSFP = 0.44 × body mass index + 0.16 × DBP - 0.18 × age - 1.91. New development, progression, and regression of DR were graded based on fundus photographs at baseline and during follow-up examinations with a mean interval of 21.2 months using the modified Early Treatment Diabetic Retinopathy Study criteria.Increasing MOPP was associated with the incidence of DR in the multivariate model (per 1-mmHg increase: relative risk [RR], 1.06; 95% confidence interval [CI], 1.02-1.10; P = 0.007) and showed a borderline negative association with DR regression (per 1-mmHg increase: RR [95% CI]: 0.98 [0.97-1.00], P = 0.053). However, MOPP was not associated with progression of DR. CSFP was not associated with new development, progression, or regression of DR.The MOPP, but not the CSFP, was found to influence the development but not the progression of DR in this Northeastern Chinese cohort.