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Objective: To determine whether peripheral diabetic retinopathy (DR) lesions identified on ultrawide field (UWF) imaging are associated with increased DR progression. Design: Prospective, longitudinal cohort. Participants: Two hundred eyes of 100 participants previously enrolled in a comparative instrument vali-dation study. Methods: Baseline mydriatic 7-standard field Early Treatment Diabetic Retinopathy Study (ETDRS) photo-graphs and UWF images were obtained. On UWF images, DR lesions with a greater extent outside versus inside standard ETDRS fields were defined as predominantly peripheral lesions (PPLs). Follow-up ETDRS photographs were obtained 4.20.3 years after baseline. Baseline and follow-up DR severity were graded from ETDRS photographs. Main Outcome Measures: Rates of 2-step or more progression and progression to proliferative DR (PDR) in eyes with PPLs compared with eyes without PPLs identified on UWF imaging at baseline. Results: In eyes without PDR (n 109) at baseline, 56 (51%) had at least 1 field with PPLs and 43 (39%) had DR progression. Compared with eyes without PPLs, eyes with PPLs had a 3.2-fold increased risk of 2-step or more DR progression (6 [11%] vs. 19 [34%]; P 0.005) and a 4.7-fold increased risk for progression to PDR (