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What patients and clinicians should know about GLP-1s and eye health
By Natalie Noble, OD
Oct. 8, 2025
GLP-1 receptor agonists (RAs) have transformed how we treat type 2 diabetes and obesity. Their benefits—durable blood sugar control, meaningful weight loss and proven cardiovascular protection for certain agents, to name a few—are impressive8-9. The surging popularity of these medications means that more of my patients are taking them, often for weight management rather than diabetes16.
As an optometrist, I routinely ask all patients about their GLP-1 use because these drugs have implications for ocular health that both clinicians and patients should understand.
In my clinic, I estimate at least 10% of patients are taking a GLP-1 in some capacity. Recent data suggest roughly 10% to 15% of U.S. adults report current or past use of GLP-1 medications14, and semaglutide now accounts for most new weight-management prescriptions14,16. Real-world prescribing analyses also show that the majority of GLP-1 users (approximately 80% to 85%) have a diagnosis of type 2 diabetes14.
POTENTIAL OCULAR RISKS
Most patients tolerate GLP-1 drugs well, but I make a point of explaining the ocular risks.
GLP-1 RAs have been variably linked to…
- A higher progression to proliferative diabetic retinopathy2,4,6,15
- New onset diabetic macular edema4,6,15
- Neovascular age-related macular degeneration1,10,14,16
- Nonarteritic anterior ischemic optic neuropathy (NAION)11,18
The greatest risk appears in patients…
- With preexisting nonproliferative diabetic retinopathy
- Who experience rapid glycemic improvement
- Over 50 who have an optic disc at risk
The likely mechanism for progression in these cases is rapid reduction in blood glucose, which can temporarily worsen retinal hypoxia and accelerate retinopathy—a phenomenon observed with other intensive diabetic therapies2.
Recent cohort studies and pharmacovigilance reports have linked semaglutide and other GLP-1 RAs to increased odds of diabetic retinopathy progression, macular edema and optic nerve events6,11,18. However, causality has not been definitely established and absolute risk is low. Careful monitoring remains key.
POTENTIAL OCULAR BENEFITS
In emerging evidence, the same class of drugs shows potential ocular protection. GLP-1 RAs demonstrate anti-inflammatory, antioxidant and neuroprotective effects in the retina, stabilize vascular structures and inhibit abnormal angiogenesis3,5,12,17.
Recent studies suggest that GLP-1 RAs may reduce the risk of:
- Primary open-angle glaucoma7,13
- Neovascular glaucoma and ocular hypertension7,13
- Vitreous hemorrhages and blindness (preclinical evidence)3,5,12,17
- Age-related macular degeneration (protective signals in some cohorts and now confirmed in large observational studies)1,10
- Uveitis (preclinical anti-inflammatory models)3,5
These findings are promising but largely preclinical or retrospective. Long-term, large-scale studies are needed to confirm protective effects in diverse patient groups.
THE PATIENT CONVERSATION
When I learn a patient has started a GLP-1, I discuss both the systemic benefits and the ocular precautions:
“I see you’ve recently started on a GLP-1 medication. These drugs are very effective at lowering blood sugar and reducing cardiovascular risk, which is great for your overall health. At the same time, they can sometimes lead to changes in the eyes—especially if you already have some diabetic retinopathy or your blood sugar drops quickly. That’s why it’s important for us to keep a close eye on your retina. Today’s dilated exam will give us a baseline, and we’ll schedule follow-ups to detect any changes early. If you notice new floaters, blurriness, dark spots or sudden vision loss, call us right away.”
Here are some common questions patients ask after my initial GLP-1 spiel:
Q: Will this medication make my eyes worse?
A: For most people, no. The main concern is for those with existing retinopathy, where there is a small increased risk of progression. Regular monitoring is our best protection2,4,6,15.
Q: How often do I need my eyes checked?
A: At least once a year. More frequent exams are appropriate if retinopathy is present or the patient just started a GLP-1.
Q: Is the risk the same for all GLP-1s?
A: Some studies suggest semaglutide carries higher ocular risk, particularly with preexisting retinopathy6,11. Prudent monitoring is recommended for all GLP-1 agents.
Q: Why would blood sugar improvement make retinopathy worse?
A: Rapid reduction in blood sugar can transiently worsen retinal ischemia and progression risk2. Gradual improvement and coordination with the prescribing physician can reduce that risk.
PRACTICAL STEPS FOR CLINICIANS
- Ask about GLP-1 use during history taking. Consider adding a specific question about GLP-1s on your intake form.
- Establish a baseline dilated retinal exam for any patient starting a GLP-1 or within the first year of treatment.
- Perform baseline fundus photography and macular/optic disc-OCT for high-risk patients.
- This includes patients with existing diabetic retinopathy, macular degeneration, rapid glycemic improvement or an optic disc at risk.
- Increase exam frequency for patients with retinopathy or other risk factors.
- This should be at least every six months, until the patient’s blood sugar, weight and medication dosage stabilize.
- Coordinate care with the patient’s primary care clinician or endocrinologist and encourage gradual titration of therapy when appropriate.
- Counsel patients about side effects and mitigation strategies.
- For example, GLP-1s, particularly semaglutide, commonly cause nausea and constipation. Adjusting the timing of dosage, hydration and diet can help. Taking the injection at night rather than in the morning can help mitigate nausea. I also advise patients to avoid eating fatty or sugary foods in general, but especially in the first 48 hours after the weekly injection.
- While GLP-1s reduce body fat significantly, they can also cause reduction in lean muscle mass over time. Exercise is a necessary adjunct to taking GLP-1s. It aids in maximizing fat loss and improving cardiovascular health and overall wellness. Patients taking a GLP-1 should focus on strength training at least three days a week to maintain and improve lean muscle mass. Consider taking a creatine supplement to help sustain existing lean muscle, as well.
GLP-1 RAs are powerful medications with multi-system benefits. As an eye care professional, my responsibility is to recognize both the ocular benefits and the small but very real risks, set a baseline, monitor closely, educate patients and partner with the prescribing team. Early detection and timely management remain the best ways to protect vision while patients gain the systemic advantages these medications offer.
References
1. Allan KC, Joo JH, Kim S, et al. Glucagon-Like Peptide-1 Receptor Agonist Impact on Chronic Ocular Disease Including Age-Related Macular Degeneration. Ophthalmology. 2025;132(7):748-757. doi:10.1016/j.ophtha.2025.01.016. PMID: 39863057
2. Bethel MA, Patel RA, Merrill P, et al. HbA1c change and diabetic retinopathy during GLP-1 receptor agonist cardiovascular outcome trials: A meta-analysis and meta-regression. Diabetes Care. 2021;44(1):290-296. doi:10.2337/dc20-1506
3. Bucolo C, Gozzo L, Longo L, Mansueto S, Vitale DC, Drago F. Long-lasting anticataract and antiglaucoma action of GLP-1 receptor agonists: Molecular mechanisms and clinical perspectives. Front Neurosci. 2022;16:824054. doi:10.3389/fnins.2022.824054
4. Cai C, Liu Y, Yang H, et al. Association of GLP-1 receptor agonist use with risk of diabetic retinopathy complications: A systematic review and meta-analysis. JAMA Netw Open. 2023;6(7):e2324480. doi:10.1001/jamanetworkopen.2023.24480
5. Hernández C, Bogdanov P, Solà-Adell C, et al. Topical GLP-1 receptor agonist eye drops protect the retina in experimental diabetes. Diabetes. 2016;65(1):172-187. doi:10.2337/db15-0443
6. Kolomeyer AM, Xu J, Ebrahimi KB, et al. Impact of GLP-1 receptor agonists and SGLT-2 inhibitors on diabetic retinopathy: Real-world analysis. Am J Ophthalmol. 2024;258:95-103. doi:10.1016/j.ajo.2024.01.021
7. Lee JW, Park S, Lee J, et al. Association of GLP-1 receptor agonist use with incidence of glaucoma: A meta-analysis. Invest Ophthalmol Vis Sci. 2024;65(2):14. doi:10.1167/iovs.65.2.14
8. Marso SP, Bain SC, Consoli A, et al. Semaglutide and cardiovascular outcomes in patients with type 2 diabetes. N Engl J Med. 2016;375(19):1834-1844. doi:10.1056/NEJMoa1607141
9. Marso SP, Daniels GH, Brown-Frandsen K, et al. Liraglutide and cardiovascular outcomes in type 2 diabetes. N Engl J Med. 2016;375(4):311-322. doi:10.1056/NEJMoa1603827
10. Rachitskaya AV, Yuan A, Singh RP, et al. Association between GLP-1 receptor agonist use and reduced risk of age-related macular degeneration: A retrospective cohort study. Ophthalmology Sci. 2024;4(1):100369. doi:10.1016/j.xops.2023.100369
11. Sharma RA, Stulpin B, Esposti S, et al. GLP-1 receptor agonists and risk of nonarteritic anterior ischemic optic neuropathy. JAMA Netw Open. 2024;7(2):e2356113. doi:10.1001/jamanetworkopen.2023.56113
12. Sterling JK, Adetunji MO, Guttha S, et al. GLP-1 receptor agonist NLY01 reduces retinal neuroinflammation and protects against retinal ganglion cell loss in experimental glaucoma. Neurobiol Dis. 2020;137:104752. doi:10.1016/j.nbd.2020.104752
13. Tanna AP, Keenan TDL, Cantor LB, et al. Risk of glaucoma in patients without diabetes using a GLP-1 receptor agonist for weight loss. Am J Ophthalmol. 2024;266:51-59. doi:10.1016/j.ajo.2024.04.016
14. Ukhanova M, Wozny JS, Truong CN, Ghosh L, Krause TM. Trends in Glucagon-Like Peptide 1 Receptor Agonist Prescribing Patterns. Am J Manag Care. 2025;31(8):e228-e234. doi:10.37765/ajmc.2025.89778. PMID: 40829097
15. Wang Y, Wang X, Xie D, et al. GLP-1 receptor agonists and risk of diabetic retinopathy: A systematic review and meta-analysis. Front Endocrinol (Lausanne). 2023;14:1228453. doi:10.3389/fendo.2023.1228453
16. Wharton S, Lingvay I, Bogdanski P, et al. Oral Semaglutide at a Dose of 25 Mg in Adults With Overweight or Obesity. N Engl J Med. 2025;393(11):1077-1087. doi:10.1056/NEJMoa2500969. PMID: 40035205
17 Yang X, Cheng B, Pan X, et al. Neuroprotective role of GLP-1 analog for retinal ganglion cells via mitophagy control. Front Pharmacol. 2020;11:589114. doi:10.3389/fphar.2020.589114
18. Zhou J, Bai J, Li H, et al. Global pharmacovigilance analysis links GLP-1 receptor agonists to optic nerve and retinal adverse events. Front Pharmacol. 2023;14:1104231. doi:10.3389/fphar.2023.1104231
For more on co-management, read “The Changes in Our OD-MD Practice That Yielded 35% More Revenue.”
Read more Practice Management articles on Review of Optometric Business here.
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Natalie Noble, OD, is a practice owner and optometrist at Noble Vision Center, now a part of AEG Vision, in Greensburg, Penn. To contact her: nnoble@eyecarespecialtiespa.com. |
