From the Guidelines
GLP-1 agonists carry a small but significant risk of ocular complications, particularly worsening of diabetic retinopathy, and patients with pre-existing diabetes or diabetic retinopathy should undergo comprehensive eye examinations before starting therapy and regular follow-up examinations during treatment. The primary ocular risk is worsening of diabetic retinopathy, especially during rapid blood glucose reduction in the early treatment phase, as noted in the 2024 study 1. This risk appears highest in patients with poor glycemic control who experience rapid improvement. Other potential ocular side effects include increased risk of retinal vein occlusion, vitreous hemorrhage, and in rare cases, vision loss.
Key Considerations
- Patients with existing diabetic retinopathy should have a comprehensive eye examination before starting GLP-1 agonists and regular follow-up examinations during treatment, as recommended by the 2020 expert consensus decision pathway 1.
- The mechanism behind these complications likely involves rapid blood glucose normalization causing temporary changes in retinal blood flow and vascular integrity.
- If you experience any vision changes while taking GLP-1 agonists, including blurriness, floaters, or vision loss, seek immediate medical attention.
- For patients without diabetes or pre-existing eye conditions, the ocular risk appears minimal, but monitoring is still recommended, as suggested by the 2018 acc expert consensus decision pathway 1.
Ocular Risks and Monitoring
- An increased risk of diabetic retinopathy complications has been noted with semaglutide, predominantly in patients with a prior history of proliferative retinopathy, as reported in the 2018 study 1.
- Patients should have a recent eye examination prior to semaglutide initiation, as recommended by the current guidelines.
- The risks and benefits of semaglutide therapy should be considered carefully in patients with a history of proliferative retinopathy.
From the FDA Drug Label
In a 2-year trial involving patients with type 2 diabetes and high cardiovascular risk, more events of diabetic retinopathy complications occurred in patients treated with OZEMPIC (3.0%) compared to placebo (1. 8%). The absolute risk increase for diabetic retinopathy complications was larger among patients with a history of diabetic retinopathy at baseline (OZEMPIC 8.2%, placebo 5.2%) than among patients without a known history of diabetic retinopathy (OZEMPIC 0.7%, placebo 0. 4%). Rapid improvement in glucose control has been associated with a temporary worsening of diabetic retinopathy. The effect of long-term glycemic control with semaglutide on diabetic retinopathy complications has not been studied. Patients with a history of diabetic retinopathy should be monitored for progression of diabetic retinopathy.
The ocular risk of taking GLP-1 agonists, such as semaglutide, includes an increased risk of diabetic retinopathy complications. Patients with a history of diabetic retinopathy are at a higher risk, with an absolute risk increase of 2.9% compared to placebo.
- Key points:
From the Research
Ocular Risks of GLP-1 Agonists
The use of Glucagon-like peptide-1 (GLP-1) agonists has been associated with various ocular risks, including:
- Diabetic retinopathy (DR): The effect of GLP-1 agonists on DR is controversial, with some studies suggesting a potential increased risk, particularly with rapid correction of hemoglobin A1c levels 3, 4.
- Nonarteritic ischemic optic neuropathy (NAION): GLP-1 agonists may be associated with an increased risk of NAION, although the mechanism remains unclear 3.
- Glaucoma: GLP-1 agonists may have protective effects against glaucoma, possibly due to their anti-inflammatory properties 3.
- Age-related macular degeneration (AMD): GLP-1 agonists may also have protective effects against AMD, although the evidence is limited 3.
- Dry eye disease (DED): GLP-1 agonists may decrease the risk of DED, possibly due to their anti-inflammatory effects 3.
Study Findings
Several studies have investigated the ocular risks associated with GLP-1 agonists, including:
- A 2025 review of the existing evidence on the effects of GLP-1 receptor agonists on various ocular conditions, which found that the effect of GLP-1 agonists on DR is controversial, but may be associated with an increased risk of NAION 3.
- A 2018 cohort study that found no association between GLP-1 receptor agonist use and an increased risk of incident diabetic retinopathy 5.
- A 2024 population-based cohort study that found an increased risk of DR progression in patients with pre-existing DR treated with GLP-1 receptor agonists compared to those treated with sodium-glucose cotransporter 2 inhibitors 4.
- A 2024 retrospective cohort study that found no difference in the risk of vision-threatening diabetic retinopathy, proliferative diabetic retinopathy, or diabetic macular edema between GLP-1 receptor agonist users and controls 6.
- A 2022 meta-analysis of randomized controlled trials that found no association between semaglutide, a GLP-1 receptor agonist, and an increased risk of diabetic retinopathy, although subgroup analysis suggested an increased risk in older patients or those with long diabetes duration 7.
Key Considerations
When considering the ocular risks associated with GLP-1 agonists, it is essential to:
- Monitor patients regularly for ocular adverse events, particularly those with pre-existing ocular conditions or risk factors for ocular disease 3.
- Weigh the potential benefits of GLP-1 agonists against the potential ocular risks, taking into account individual patient factors and medical history 3, 5, 4, 6, 7.