What eye problems can Ozempic (semaglutide) cause?

Eye Problems Associated with Ozempic (Semaglutide)

Ozempic primarily causes worsening of diabetic retinopathy complications, particularly in patients with pre-existing retinopathy, and requires baseline eye examination before initiation. 1

Primary Ocular Risk: Diabetic Retinopathy Complications

Risk Profile and Mechanism

• Semaglutide increases the risk of diabetic retinopathy complications, with 3.0% of treated patients experiencing events compared to 1.8% on placebo in a 2-year cardiovascular outcomes trial 1
• The absolute risk is substantially higher in patients with pre-existing diabetic retinopathy (8.2% with semaglutide vs 5.2% placebo) compared to those without known retinopathy history (0.7% vs 0.4%) 1
• The worsening appears related to rapid A1C reduction rather than direct drug toxicity, a phenomenon observed with other intensive glucose-lowering treatments 2, 3

Specific Retinopathy Complications

• Progression to proliferative diabetic retinopathy (PDR) has been documented, though recent large-scale observational data suggests the risk may be similar to other GLP-1 receptor agonists 4
• Treatment-requiring diabetic macular edema (DME) can occur, with some evidence suggesting lower risk compared to certain other diabetes medications 4
• Visual acuity loss, eye pain, and photophobia require same-day ophthalmologic assessment 2

Non-Arteritic Anterior Ischemic Optic Neuropathy (NAION)

• Emerging case reports link semaglutide to NAION, a rare but serious cause of vision loss from compromised optic nerve blood flow 5
• The temporal relationship between semaglutide initiation and NAION onset suggests potential causality, particularly in patients with pre-existing vascular risk factors 5
• This represents a potentially severe complication requiring immediate ophthalmologic evaluation if suspected 5

Mandatory Pre-Treatment Assessment

Required Baseline Evaluation

• All patients must undergo dilated eye examination before starting semaglutide, as recommended by the American Diabetes Association 2, 3
• Assess retinopathy status specifically when intensifying glucose-lowering therapy with GLP-1 receptor agonists 2, 3
• Document presence and severity of any diabetic retinopathy, as this stratifies risk 1

High-Risk Patient Identification

• Patients with proliferative retinopathy require particular caution and closer monitoring 3, 6
• Those with poor baseline glycemic control (high A1C) face increased vulnerability to retinopathy worsening 7
• Patients currently using insulin are at higher risk for complications 7

Monitoring Protocol During Treatment

Frequency of Eye Examinations

• If any level of diabetic retinopathy is present at baseline, repeat dilated retinal examinations at least annually 3
• If no retinopathy is present and glycemia is well controlled, screening every 1-2 years may be considered 3
• If retinopathy is progressing or sight-threatening, more frequent examinations by an ophthalmologist are required 3

Risk Mitigation Strategy

• Consider more gradual improvement in glycemic control in patients with established retinopathy to minimize worsening risk 3
• Optimize blood pressure and serum lipid control concurrently to reduce retinopathy progression risk 3
• Monitor patients with history of diabetic retinopathy specifically for progression 1

Critical Clinical Pitfalls to Avoid

• Do not attribute all eye problems in semaglutide users to the medication without proper ophthalmologic evaluation 2
• Do not assume the retinopathy worsening is permanent—it may represent temporary deterioration associated with rapid glycemic improvement 2
• Current pretreatment assessment in clinical practice is inadequate, with studies showing only 1.8% of patients receive appropriate disease history screening despite 98.6% having relevant conditions 8
• Never share Ozempic pens between patients due to blood-borne pathogen transmission risk 1

Additional Ocular Considerations

• The FDA label does not establish causality between semaglutide and medullary thyroid carcinoma, but patients should be counseled about neck mass symptoms (dysphagia, dyspnea, persistent hoarseness) 1
• Long-term effects of semaglutide on diabetic retinopathy complications have not been fully studied 1
• Patients with severe gastrointestinal reactions (nausea, vomiting, diarrhea) may develop acute kidney injury, which can indirectly affect ocular health 1