AIM: To identify factors associated with adherence to annual eye examinations among adults with diabetes mellitus (DM) in Malaysia. METHODS: Data from community-dwelling adults aged ≥18y with known DM, defined as those who had previously been informed by a doctor or assistant medical officer of their diagnosis were analyzed using the National Health and Morbidity Survey 2023, a population-based cross-sectional survey conducted using a two-stage stratified random sampling design. Locally validated questionnaire on diabetic eye screening was administered through face-to-face interviews from July until September 2023. Adults with known DM were asked three key questions about eye examinations: whether their eyes had been examined using clinical tools (illustrated with images of a direct ophthalmoscope, slit lamp or fundus camera), the timing of their last eye examination (if applicable), and whether they had been referred to an ophthalmology clinic for DM-related complications, serving as a proxy for diabetic retinopathy (DR) referrals. Complex sample analysis, incorporating sample weights and the study’s design, were used to describe respondents’ baseline characteristics by urban or rural localities. Multivariable binary logistic regression with adjusted odds ratio (aOR) and 95% confidence interval (CI) was performed. RESULTS: Among 1554 adults with known DM in Malaysia, 58.8% had never undergone an eye examination and only 29.5% complied with the recommended annual eye check-ups. Additionally, 25.8% of DM patients were referred to an ophthalmology clinic for DR. Referral to ophthalmology clinic for DR (aOR=4.63, 95%CI: 3.27, 6.55), insulin use (aOR=1.93, 95%CI: 1.37, 2.72), secondary education (aOR=1.71, 95%CI: 1.03, 2.85) and DM duration ≥10y (aOR=1.48, 95%CI: 1.02, 2.16) were associated with higher odds of annual eye examinations. Chinese (aOR=0.50, 95%CI: 0.29, 0.87) and Indian (aOR=0.47, 95%CI: 0.29, 0.78) ethnicities had lower odds of undergoing annual eye examinations compared to Malay ethnicity. Similarly, those with a monthly household income of ≥RM10 000 (aOR=0.45, 95%CI: 0.21, 0.95) were less likely to get their eyes examined yearly. CONCLUSION: Fewer than one-third of adults with DM in Malaysia adhere to the recommended annual eye examinations, with lower compliance observed among Chinese or Indian ethnicities and those with higher household incomes. Targeted educational campaigns for Chinese, Indian, and higher-income adults with DM may encourage regular eye exams and reduce preventable vision loss from DR in Malaysia.