Toll-like receptor 4 (TLR4) is an important mediator of innate immunity. Type 2 diabetes (DM2) might be associated with changed innate immune response. We investigated whether the polymorphisms in the TLR4 gene are associated with diabetic retinopathy (DR). The study group of 864 patients with DM2 and 420 healthy individuals were genotyped. In the patient group 352 subjects were diagnosed with DR. Out of the remaining 512, 140 had DM2 for > or = 10 years but no DR. In the DM2 group 7.4% of patients were heterozygous for the Asp299Gly polymorphism compared with 6.5% controls. For Thr399Ile polymorphism there were 7.2% heterozygotes vs 6.2% controls. In most cases, the linkage disequilibrium between the minor alleles Gly299 and Ile399 was confirmed. Increased frequency of both heterozygous genotypes was observed in patients with retinopathy (11.2% for the Asp299Gly). The frequency of the G allele was significantly higher in patients with early onset retinopathy (n = 80) vs patients without DR (odds ratio = 5.0, and 95% confidence interval = 2.33-10.71). In contrast, in the entire retinopathy group, the odds ratio for the G allele was 1.88 (95% confidence interval = 0.93-3.79). In the multivariate logistic regression analysis, the G allele of Asp299Gly was an independent risk factor of early onset DR (p < 0.001). In conclusion, our results suggest an association between the Asp299Gly polymorphism of the TLR4 gene and early onset of DR in the DM2 patients. Thus the G allele may be a predictor of increased risk of retinopathy.