Members of the American Optometric Association’s (AOA) evidence-based optometry committee released a new clinical report during the 2025 Optometry’s Meeting on the association of significant ocular complications with the use of glucagon-like peptide-1 receptor agonists (GLP-1RAs) for chronic disease and weight loss.
The findings were presented by Andrew Morganstern, OD, director of the AOA’s clinical resources group, at the House of Delegates this past Friday.
First, start with some background on GLP-1RAs.
What they are: A class of medications typically used to treat type 2 diabetes mellitus (T2D), obesity—and, more recently, managing cardiovascular risk and chronic kidney disease (among other conditions).
What they do: Quite simply, GLP-1RAs mimic the action of the GLP-1 hormone—which is crucial in increasing the release of natural insulin—to:
- Trigger insulin release
- Reduce glucose (lowering serum glucose levels and overall production in the liver)
- Manage patients’ metabolism (enabling weight control)
- Delay gastric emptying
And as an added bonus: This medication class is also reported to contain anti-inflammatory effects to potentially treat inflammatory diseases.
Give me a few FDA-approved examples of GLP-1RAs.
Some of the more commonly known products include the following, with dosings ranging from once weekly injections or oral tablets to once or twice daily.
- Ozempic (semaglutide)
- Wegovy (semaglutide)
- Mounjaro (tirzepatide)
- Zepbound (tirzepatide)
Take note: In 2023, semaglutide- and tirzepatide-based products accounted for an estimated 70% of total GLP-1RA expenditures in the U.S.
And on the ophthalmic front: Experts have noted the lack of a published randomized controlled trial or evidence demonstrating higher rates of ophthalmic conditions among these various products.
Let’s talk stats.
As of 2024, around 6% of U.S. adults reported actively use of GLP-1RAs—with semaglutide the most popular (used among 15 million).
- Even further: Twice that number (12%) of all adults report having used the medication at some point.
And on the subject of diabetes: the Centers for Disease Control and Prevention (CDC) reported 15.8% of U.S. adults were reported to have diabetes in 2023; however, almost one in four were undiagnosed.
- Why this is important: Optometrists can play a major role in detecting this systemic disease.
Now to the basics of this report.
Glucagon-like Peptide-1 Receptor Agonists and Ocular Health: Guidance for Optometric Practice is a nine-page report developed as a response to an increasing collection of research pointing to potential complications linking the use of popular GLP-1RAs with vision issues.
Patients of most concern:
- Diabetics
- Those diagnosed with a form of age-related macular degeneration (AMD)
With this in mind: The AOA has called on optometrists to play a key role within a patient’s interdisciplinary care team to ensure they (the patient) undergoes a regular in-office eye exam within one year of starting GLP-1RA use.
So what kind of ocular risks were associated with use of these?
While systemic risks have been widely advised on and warned of—including in the gastrointestinal tract; pancreas; gallbladder; and thyroid—the same can’t be said for ocular risks.
A few risks highlighted in this report:
- Worsening of diabetic retinopathy (DR)
- Development of non-arteric anterior ischemic optic neuropathy (NAION) in the optic nerve
- Neovascular (n)AMD (an emerging risk)
Focus in on NAION.
As the most common cause of acute optic neuropathy in adults over the age of 50, NAION is the result of ichemia due to impaired perfusion of the optic nerve head. See here for risk factors.
- A few associated signs to be aware of: a sudden, unilateral (but painless loss of vision; isual field defect; blurred vision; optic disc swelling (with or without hemorrhages).
And the GLP-1RA connection?
A 2024 observational study published in JAMA Ophthalmology identified a potential link between NAION development and semaglutide use among patients with T2D or who were oveweight.
Plus: Earlier this month, the European Medicinces Agency (EMA) concluded that “NAION is a very rare side effect of semaglutide (meaning it may affect up to 1 in 10,000 people taking semaglutide).”
- The EMA reported a two-fold increase risk for the development of NAION among T2D adult patients exposed to semaglutide,
What does the agency propose?
An update to semaglutide’s product information to include the ocular disease as a potential very rare side effect.
- Specifically: A patient should seek care for sudden or worsening vision loss—and if NAION is confirmed, semaglutide treatment should stop immediately.
Now to those other potential retinal disease risks.
For DR: The AOA report referenced the 2016 SUSTAIN-6 clinical trial that reported an increased rate of DR complications among T2D patients using semaglutide (versus those using a placebo).
Among the ocular effects:
- Vitreous hemorrhage
- Need for retinal laser or intravitreal (IVT) therapy
- Vision loss
Now to nAMD—which, didn’t Glance recently report on?
Indeed we have. And that was just the latest in a multi-year series of reporting on this topic.
Case in point: Earlier this month, we reported on findings from a new clinical study published in JAMA Ophthalmology that linked GLP-1RA use among diabetics with a 2-fold higher risk of developing neovascular (wet) AMD versus diabetic patients who did not use the medications.
The AOA report noted this research in its advisement for optometrists to be on the lookout for such a potential ocular manfiestation—even though its absolute risk is relatively low.
- Conversely: Click here for our rundown on another study that questioned whether such use actually decreased the risk for AMD development.
And the suggestion for these patients?
For patients considered at-risk for nAMD (as well as DR and NAION), the AOA advises them to:
- Have baseline dilated exams before or shortly after starting GLP-1RA treatment
- Undergo more frequent eye exams (with a specific timeline noted)
- Receive individualized risk counseling for those three aforementioned retinal diseases
- Ensure they are receiving collaborative care with their healthcare providers to manage the diseases
What other risk factors may make patients more prone to develop vision problems?
Among a lengthy list:
- A personal or family history of ocular disease
- Taking prescription/non-prescription drugs with potential ocular side effects
- Wearing contact lenses
- Having unilateral function vision
- Undergoing ocular surgery
- Having a high or progressive refractive error
So, looking to the future—what should optometrists keep in mind?
While the AOA stressed that GLP-1RAs are considered safe and the ophthalmic side effects are still rare among patients, they also noted that:
- The ophthalmic workforce is expected to decline by 12% across the United States over the next 10 years
- A 24% increased need for eye care is also projected during this time period
- Populations in U.S. regions are on the rise (and so is the number of GLP-1RA prescriptions)
A such: the AOA stated that “there is a greater demand for (optometrists) to perform in-person, annual, comprehensive, dilated eye examinations on this at-risk population.”
And the clinical recommendations moving forward?
Aside from the obvious—a baseline in-person, compresnesive, dilated ocular fundus exam of a patient once they start GLP-1RA use—as well as those already mentioned, the AOA also emphasized the need for:
- Baseline ocular fundus photography and (potentially) optical coherence tomography (OCT) for patients most at risk
- A closer follow-up and exam of GLP-1RA-using patients within the first 12 to 18 months of them starting treatment
- Advising these patients of the possible ophthalmic complications and if they may already have risk factors
Lastly, how can I read this report for myself?
The report can be viewed (and downloaded) by clicking here.