What are the risks of eye problems with Ozempic (semaglutide) and how are they managed?

Ozempic Eye Problems: Risks and Management

Ozempic (semaglutide) is associated with an increased risk of diabetic retinopathy complications, particularly in patients with pre-existing retinopathy, and requires baseline eye examination and ongoing monitoring for visual changes. 1

Primary Ocular Risk: Diabetic Retinopathy Complications

The FDA label explicitly warns that diabetic retinopathy complications occur more frequently with Ozempic (3.0%) compared to placebo (1.8%), with the highest risk in patients who already have diabetic retinopathy at baseline (8.2% vs 5.2% placebo). 1

• The absolute risk increase is substantially higher among patients with pre-existing diabetic retinopathy (8.2% with Ozempic vs 5.2% placebo) compared to those without known retinopathy (0.7% vs 0.4% placebo) 1
• This complication is attributed to rapid improvement in glucose control causing temporary worsening of diabetic retinopathy, a phenomenon observed with other intensive glucose-lowering treatments 2, 1
• The long-term effect of semaglutide on diabetic retinopathy has not been established 1

Emerging Concern: Non-Arteritic Anterior Ischemic Optic Neuropathy (NAION)

Recent observational data suggests a potential association between semaglutide and NAION, though this is not yet established as causal:

• A 2024 retrospective cohort study found hazard ratios of 4.28 (95% CI: 1.62-11.29) for NAION in diabetic patients and 7.64 (95% CI: 2.21-26.36) in overweight/obese patients prescribed semaglutide compared to non-GLP-1 RA medications 3
• The cumulative 36-month incidence was 8.9% in diabetic patients on semaglutide versus 1.8% in controls 3
• Case reports describe NAION occurring in otherwise healthy patients on semaglutide for weight loss 4, 5

However, this evidence is observational and requires further study to establish causality. The FDA label does not currently include NAION as a warning 1

Mandatory Pre-Treatment Assessment

Before initiating Ozempic, the American Diabetes Association recommends assessing retinopathy status when intensifying glucose-lowering therapies. 2

• Adults with type 2 diabetes should have an initial dilated eye examination at the time of diabetes diagnosis 2
• Patients with pre-existing diabetic retinopathy require baseline ophthalmologic evaluation before starting semaglutide 2, 1
• Consider the risk-benefit profile carefully in patients with established diabetic retinopathy 2

Monitoring During Treatment

Patients with a history of diabetic retinopathy must be monitored for progression during Ozempic therapy. 1

• Instruct patients to immediately report any changes in vision, including blurred vision, visual distortion, visual field changes, or new floaters 1
• Regular ophthalmologic follow-up is essential for patients with pre-existing retinopathy 1
• New visual symptoms warrant urgent ophthalmologic evaluation to differentiate between diabetic retinopathy progression, NAION, or other etiologies 4, 5

Management of Visual Symptoms

If visual symptoms develop during Ozempic therapy, discontinue the medication and obtain urgent ophthalmologic consultation. 1, 5

• Visual acuity loss, eye pain, photophobia, or visible corneal changes require same-day ophthalmologic assessment 6
• Do not attribute all eye problems to semaglutide without proper ophthalmologic evaluation, as multiple etiologies are possible 2
• Case reports suggest that continuing GLP-1 RA therapy after onset of visual symptoms may lead to progressive visual deterioration 5

Critical Pitfalls to Avoid

• Do not initiate Ozempic in patients with active proliferative diabetic retinopathy without ophthalmology consultation and careful risk-benefit assessment 2, 1
• Do not dismiss unilateral visual symptoms as unrelated to treatment—NAION typically presents unilaterally and requires immediate evaluation 3, 5
• Do not continue therapy if visual symptoms develop without ophthalmologic clearance, as progression may occur 5
• Do not assume the temporary worsening of retinopathy is benign—it requires monitoring and may necessitate treatment modification 2, 1

Contradictory Evidence on Direct Retinal Effects

While clinical trials showed increased retinopathy complications, experimental animal studies suggest semaglutide may have direct protective effects on the retina by reducing neuroinflammation and vascular leakage 7. However, GLP-1 receptors are expressed at very low levels in normal human eyes and were not detected in advanced proliferative diabetic retinopathy 8. The clinical significance of these experimental findings remains uncertain, and the FDA warning based on human trial data takes precedence. 1