Objective To evaluate the association between diabetic retinopathy (DR) and mean ocular perfusion pressure (MOPP) in patients with type 2 diabetes mellitus (T2DM). Methods Patients from the Fushun Diabetic Retinopathy Cohort Study (FS-DIRECT), a communitybased prospective cohort study conducted in northeast China, were included in this study. The presence and severity of DR were determined by grading fundus photographs according to the Early Treatment Diabetic Retinopathy Study (ETDRS) retinopathy scale. Systolic and diastolic blood pressure (SBP and DBP) were recorded using an electronic sphygmomanometer. Intraocular pressure (IOP) was measured using an iCare rebound tonometer. MOPP was calculated using the formula MOPP = 2/3 [DBP + 1/3 (SBP - DBP)] - IOP. Results In total, 1,857 patients who had gradable fundus photography and MOPP data were enrolled in this study. Male patients had a higher MOPP than female patients (52.25 +/- 8.75 vs. 50.96 +/- 8.74 mmHg, P = 0.002). Overall, both male and female patients with any type of DR, non-proliferative DR (NPDR), or non-sight-threatening DR (non-STDR) had significantly higher MOPP relative to patients without DR. Increased MOPP (per 1 mmHg) was in turn associated with the presence of any type of DR [odds ratio (OR) = 1.03, 95% confidence interval (CI) : 1.02-1.04], NPDR (OR = 1.03 95% CI: 1.02-1.04), and non-STDR (OR = 1.03, 95% CI: 1.01-1.04) after adjusting for confounders. Increased MOPP (per 1 mmHg) was also associated with an increased likelihood of macular edema (OR = 1.02, 95% CI: 1.01-1.04). Conclusions The results suggest that increased MOPP was associated with DR and macular edema in northeastern Chinese patients with T2DM.