Ozempic and Vision Concerns: Evidence-Based Assessment
Direct Answer
The FDA-approved label for Ozempic (semaglutide) includes a specific warning about diabetic retinopathy complications, particularly in patients with pre-existing retinopathy, but there is no established causal link to blindness itself. 1 The concern stems primarily from one cardiovascular outcomes trial showing increased retinopathy complications, but this appears related to rapid glycemic improvement rather than a direct drug effect on the eye.
FDA-Labeled Warning on Diabetic Retinopathy Complications
The official Ozempic prescribing information warns that in a 2-year trial, diabetic retinopathy complications occurred in 3.0% of semaglutide-treated patients versus 1.8% on placebo. 1 The absolute risk increase was substantially larger among patients with pre-existing diabetic retinopathy at baseline (8.2% vs 5.2%) compared to those without known retinopathy history (0.7% vs 0.4%). 1
The FDA label explicitly states that rapid improvement in glucose control has been associated with temporary worsening of diabetic retinopathy, and recommends that patients with a history of diabetic retinopathy should be monitored for progression. 1
This warning appears in the "Warnings and Precautions" section but notably does not include blindness as an outcome. 1
Meta-Analysis Findings on Retinopathy Risk
A 2022 meta-analysis of 23 randomized trials involving 22,096 patients found that semaglutide overall was not associated with increased diabetic retinopathy risk (RR 1.14,95% CI 0.98-1.33). 2 However, important subgroup findings emerged:
When compared specifically to placebo (excluding active comparators), semaglutide showed increased retinopathy risk (RR 1.24,95% CI 1.03-1.50). 2
Patients aged ≥60 years had increased risk (RR 1.27,95% CI 1.02-1.59). 2
Patients with diabetes duration ≥10 years had increased risk (RR 1.28,95% CI 1.04-1.58). 2
Mechanism: Rapid Glycemic Improvement vs. Direct Drug Effect
The American College of Cardiology guidelines note that diabetic retinopathy complications were reported with injectable semaglutide, but emphasize it is unclear if this is a direct drug effect or due to rapid improvement in blood glucose control. 3
GLP-1 receptor expression in human eyes is minimal—detected only in a small fraction of neurons in the ganglion cell layer in normal eyes, and not detected at all in advanced proliferative diabetic retinopathy. 4
A 32-week randomized trial found no changes in retinal arteriolar or venular oxygenation, vessel diameter, or vascular autoregulation with semaglutide treatment. 5 Semaglutide increased central retinal thickness by only ~1% (3.8 μm), a change of uncertain clinical significance. 5
Contradictory Evidence: Potential Protective Effects
Interestingly, one 2024 case report documented complete regression of proliferative diabetic retinopathy within 6 weeks of semaglutide initiation, despite minimal changes in glycemic control, suggesting a potential independent protective role. 6 This directly contradicts the concern about worsening retinopathy and highlights the complexity of semaglutide's effects on retinal vasculature.
Non-Arteritic Anterior Ischemic Optic Neuropathy (NAION) Concern
A 2025 case report described a 55-year-old woman who developed NAION after four months of semaglutide therapy, initially misdiagnosed as diabetic papillopathy. 7 However, this represents a single case report and cannot establish causation—the patient had multiple vascular risk factors including type 2 diabetes, hypertension, and hyperlipidemia. 7
Clinical Monitoring Recommendations
Based on current evidence, patients starting Ozempic should receive the following ophthalmologic surveillance:
Baseline dilated comprehensive eye examination before initiating semaglutide, particularly for patients with known diabetic retinopathy, diabetes duration ≥10 years, or age ≥60 years. 8, 2
More frequent monitoring (every 3-6 months initially) for patients with pre-existing diabetic retinopathy during the first year of treatment when glycemic improvement is most rapid. 1, 3
Annual examinations for patients without baseline retinopathy, consistent with standard diabetes care guidelines. 8
Immediate ophthalmologic referral for any new visual symptoms including blurred vision, floaters, or visual field defects. 3
Common Pitfall to Avoid
Do not confuse acute hyperglycemia-induced blurred vision (which is reversible and caused by osmotic lens changes) with diabetic retinopathy complications. 9 Patients may experience temporary vision changes when starting semaglutide due to rapid glycemic shifts affecting lens refraction—this typically resolves within weeks and does not represent retinopathy progression. 9
Bottom Line for Clinical Practice
The "growing concern for blindness" related to Ozempic is not supported by high-quality evidence. 2 The FDA warning addresses diabetic retinopathy complications (not blindness), primarily in patients with pre-existing retinopathy, and likely reflects the well-established phenomenon of early worsening with rapid glycemic improvement rather than direct drug toxicity. 1, 3 The cardiovascular and mortality benefits of semaglutide in appropriate patients substantially outweigh the small increased risk of retinopathy complications, particularly when proper ophthalmologic monitoring is implemented. 3