Aims To investigate the role of ophthalmic imaging markers – namely retinal thickness measures and corneal nerve morphology – in predicting four-year development and worsening of diabetic retinopathy (DR) in type 1 diabetes (T1DM). Methods 126 eyes of 126 participants with T1DM were examined at baseline and after four years. Diabetic retinopathy (DR) was graded using the Early Treatment Diabetic Retinopathy Study scale. HbA 1c , nephropathy, neuropathy, cardiovascular factors, and retinal thickness using optical coherence tomography (OCT) and corneal nerve fiber length (CNFL) using corneal confocal microscopy at baseline were assessed by univariate and step-wise multiple logistic regression, and their diagnostic capabilities for single and combined measures. Results Four-year development of DR was 19% (13 of 68 without DR at baseline). Worsening of DR was seen in 43% (25 of 58 with DR at baseline). When adjusted for potential confounders, a lower CNFL (AUC = 0.637, p = 0.040, 64% sensitivity and 64% specificity at 14.9 mm/mm 2 cut-off), higher triglycerides (AUC = 0.669, p = 0.012, 64% sensitivity, 62% specificity at 0.85 mmol/L) and an elevated vibration threshold (AUC = 0.708, p = 0.002, 96% sensitivity, 40% specificity at 3.55 Hz) were significant predictors for four-year worsening of DR. Conclusions Reduced CNFL, elevated vibration perception threshold and higher triglycerides can predict future worsening of DR.