Background To assess the association between a retinopathy as defined by the Early Treatment of Diabetic Retinopathy Study (ETDRS) criteria, and mortality in a population-based setting. Methods At baseline in 2001, the Beijing Eye Study examined 4,391 subjects for retinopathy lesions, with a detected frequency of 285/4391 (6.5%) subjects. Using fundus photographs, the retinopathy was graded according to the Early Treatment of Diabetic Retinopathy Study (ETDRS) criteria. The mean age was 56.05 +/- 10.51 years (range, 40-101 years). In 2006, all study participants were re-invited for a follow-up examination. Results Out of the 4,391 subjects, 3,224 subjects (73.4%) returned for follow-up examination, while 140 subjects (3.2%) were dead and 1,027 subjects (23.4%) did not agree to be re-examined or had moved away. Mortality rate was significantly higher (P=0.002; odds ratio [OR]: 2.20; 95% confidence intervals [CI]: 1.32, 3.67) in the 285 subjects with retinopathy (18/285 or 6.3 +/- 1.4%; 95%CI: 3.6%, 9.0%) than in the 4,106 participants without retinopathy (122/4,106 or 3.0 +/- 0.3% 95%CI: 2.4%, 3.6%). In binary logistic regression analysis, mortality was significantly associated with age (P < 0.001; OR: 1.10; 95%CI: 1.08, 1.12), gender (P=0.006; OR: 0.61; 95%CI: 0.43, 0.86), rural versus urban region (P < 0.001; OR: 5.65; 95%CI: 3.81, 8.40), and presence of retinopathy (P=0.005; OR: 2.13; 95%CI: 1.25, 3.62). Conclusions In addition to higher age, male gender, and living in a rural region, a retinopathy as defined by ETDRS criteria is a risk factor for an increased mortality in adult Chinese.