PURPOSE: To evaluate the risk of diabetic retinopathy progression and systemic vascular events, including death, in patients with nonproliferative diabetic retinopathy (NPDR) with obstructive sleep apnea (OSA). DESIGN: Retrospective cohort study. METHODS: Electronic chart query using TriNetX, an electronic health records network comprising data from over 124 million patients. Patients with NPDR with and without OSA were identified. Patients were excluded if they had a history of proliferative disease (proliferative diabetic retinopathy), diabetic macular edema, or prior ocular intervention (intravitreal injection, laser, or pars plana vitrectomy). Propensity score matching was performed to control for baseline demographics and comorbidities. The rate of progression to vision-threatening complications, need for ocular intervention, and systemic events was measured at 1, 3, and 5 years. RESULTS: A total of 11 931 patients in each group were analyzed after propensity score matching. There was an elevated risk of proliferative diabetic retinopathy in the OSA cohort at 1 (risk ratio [RR]: 1.34, P <
.001), 3 (RR: 1.31, P <
.001), and 5 years (RR: 1.28, P <
.001). There was an elevated risk of diabetic macular edema in the OSA group at all time points: 1 (RR: 1.31, P <
.001), 3 (RR: 1.19, P<
.001), and 5 years (RR: 1.18, P <
.001). With respect to ocular interventions, there was an increased risk of intravitreal injection in patients with OSA at 1 (RR: 1.59, P <
.001), 3 (RR: 1.58, P <
.001), and 5 years (RR: 1.54, P <
.001), and similar trends were noted with laser photocoagulation, but not vitrectomy. Regarding systemic events, patients with NPDR with OSA had a greater risk of stroke (1 year RR: 1.80, P <
.001
3 years RR: 1.56, P <
.001
and 5 years RR: 1.49, P <
.001), myocardial infarction (1 year RR: 1.51, P <
.001
3 years RR: 1.46, P <
.001
and 5 years RR: 1.43, P <
.001), and death (1 year RR: 1.31, P <
.001
3 years RR: 1.19, P <
.001
and 5 years RR: 1.15, P <
.001). CONCLUSIONS: There is an increased rate of diabetic retinopathy progression to vision-threatening complications, need for ocular intervention, and systemic complications, including death, for patients with OSA. We emphasize the need for improved screening measures of patients with NPDR and potential OSA.