Objective: To investigate the prevalence and influencing factors of diabetic retinopathy (DR) among middle-aged and elderly patients with diabetes mellitus, so as to provide evidence for the prevention of diabetic complications Methods: From September to December 2025, patients with diabetes mellitus aged ≥50 years from 6 counties (cities) in Aksu Prefecture, Xinjiang Uygur Autonomous Region were selected as study participants using a multi-stage stratified random sampling method. Basic information, lifestyle behaviors and disease information were collected through questionnaires, physical examinations and laboratory tests. DR was diagnosed by ophthalmologists through fundus examinations. Factors affecting DR among middle-aged and elderly patients with diabetes mellitus were analyzed using a multivariable logistic regression model. Results: A total of 1 278 middle-aged and elderly patients with diabetes mellitus were surveyed, with a mean age of (63.46±7.77) years. There were 649 males (50.78%) and 629 females (49.22%). A total of 277 patients were diagnosed with DR, with a prevalence of 21.67% (95%CI: 19.42%-23.93%). Multivariable logistic regression analysis showed that patients with diabetes duration of ≥5 years (5-<10 years, OR=1.608, 95%CI: 1.095-2.361; ≥10 years, OR=2.289, 95%CI: 1.640-3.195), hypertension (OR=1.974, 95%CI: 1.463-2.664), dyslipidemia (OR=4.429, 95%CI: 3.021-6.493), and history of eye disease (OR=1.751, 95%CI: 1.275-2.404) had a higher risk of DR. Conclusions The prevalence of DR among middle-aged and elderly patients with diabetes mellitus was relatively high. Diabetes duration, hypertension, dyslipidemia, and history of eye disease were its influencing factors. It is necessary to strengthen the management of blood glucose, blood pressure and blood lipids, and regular fundus screening.