Background Vision loss is an important public health issue in China, but a detailed understanding of national and regional trends in its prevalence and causes, which could inform health policy, has not been available. This study aimed to assess the prevalence, causes, and regional distribution of vision impairment and blindness in China in 1990 and 2019. Methods Data from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019 were used to estimate the prevalence of moderate and severe vision impairment and blindness in China and compare with other Group of 20 (G20) countries. We used GBD methodology to systematically analyse all available demographic and epidemiological data at the provincial level in China. We compared the age-standardised prevalences across provinces, and the changes in proportion of vision loss attributable to various eye diseases in 1990 and 2019. We used two different counterfactual scenarios with respect to population structure and age-specific prevalence to assess the contribution of population growth and ageing to trends in vision loss. Findings In 2019, the age-standardised prevalence was 257% (uncertainty interval [UI] 228-286) for moderate vision impairment, 025% (022-029) for severe vision impairment, and 048% (043-054) for blindness in China, which were all below the global average, but the prevalence of moderate and severe vision impairment had increased more rapidly than in other G20 countries from 1990 to 2019. The prevalence of vision loss increased with age, and the main causes of vision loss varied across age groups. The leading causes of vision impairment in China were uncorrected refractive error, cataract, and macular degeneration in both 1990 and 2019 in the overall population. From 1990 to 2019, the number of people with moderate vision impairment increased by 13367% (from 1965 to 4592 million), those with severe vision impairment increased by 14714% (from 189 to 467 million), and those with blindness increased by 6435% (from 529 to 869 million); in each case, 2016% of the increase could be explained by population growth. The contributions to these changes by population ageing were 8722% for moderate vision impairment, 11606% for severe vision impairment, and 9922% for blindness, and the contributions by age-specific prevalence were 2629% for moderate vision impairment, 1091% for severe vision impairment, and -5504% for blindness. The prevalence and specific causes of vision loss differed across provinces. Interpretation Although a comprehensive national policy to prevent blindness is in place, public awareness of visual health needs improving, and reducing the prevalence of moderate and severe vision impairment should be prioritised in future work. Copyright (c) 2020 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY-NC-ND 4.0 license.