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Purpose: To investigate structure-function associations between contrast sensitivity (CS) and widefield swept-source optical coherence tomography angiography (WF SS-OCTA) vascular metrics across stages of non-proliferative (NPDR) and proliferative diabetic retinopathy (PDR), without diabetic macular oedema., Methods: Prospective cross-sectional study in 140 eyes of 99 patients: 33 mild NPDR, 24 moderate/severe NPDR, 15 PDR, 33 diabetic without DR (DMnoDR) and 46 control eyes. Mixed-effects multivariable regression models to evaluate associations between quantitative contrast sensitivity function (Adaptive Sensory Technology) and vessel density (VD) and vessel skeletonised density (VSD) in the superficial capillary plexus (SCP) and deep capillary plexus (DCP) on same-day imaging with WF SS-OCTA (Plex Elite 9000, Carl Zeiss Meditec)., Results: Standardised β coefficients for area under the logarithm of contrast sensitivity function curve (AULCSF) versus visual acuity (VA) at 3×3 mm scans: SCP VSD (β=0.32, p<0.001 vs -0.18, p=0.044), DCP VSD (β=0.30, p<0.001 vs -0.21, p=0.02), SCP VD (β=0.25, p=0.004 vs -0.13, p=0.129), DCP VD (β=0.26, p=0.003 vs -0.19, p=0.034). AULCSF was significantly reduced in mild NPDR (β=-0.28, p<0.001) and DMnoDR (β=-0.19, p=0.005) versus controls, while VA was not significantly different. AULCSF performed better than VA in differentiating between controls and DMnoDR (0.69 vs 0.50), controls and mild NPDR (0.76 vs 0.61) and controls and moderate/severe NPDR (0.89 vs 0.73)., Conclusions: DR-induced microvascular changes on OCTA are associated with larger changes on CS than in VA. CS is affected earlier than VA in the course of DR and performed better in discriminating between controls, DMnoDR and across DR stages., Competing Interests: Competing interests: No conflicting relationship exists for any author. FV, GB, RK, YC, IG, JYM and RZ—no disclosures. NAP is a consultant for Atheneum, Alcon, Allergan, Alimera, Eyepoint, Lifesciences, Guidepoint and GLG. DW holds a patent through Massachusetts Eye and Ear. DH is a consultant for Allergan, Genentech and Omeicos Therapeutics, and has received financial support from the National Eye Institute, Lions VisionGift, Commonwealth Grant, Lions International, Syneos and the Macular Society. JWM is a consultant for Heidelberg Engineering, Sunovion, KalVista Pharmaceuticals and ONL Therapeutics; holds a patent through and has received financial support from ONL, Valeant Pharmaceuticals/Massachusetts Eye and Ear; and has received financial support from Lowy Medical Research Institute. LK has received research support from the National Eye Institute and CureVac; and has a financial arrangement with Pykus Therapeutics. DV is a consultant for Valitor and Olix Pharmaceuticals; is a consultant for Valitor and Olix Pharmaceuticals; and has received financial support from the National Eye Institute and by grants from the National Institute of Health (R01EY025362 and R21EY0203079), Research to Prevent Blindness, Loefflers Family Foundation, Yeatts Family Foundation and Alcon Research Institute. JBM is a consultant for Alcon, Allergan, Carl Zeiss, Sunovion and Genentech., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)