What the diabetologist needs to know about the risk of non-arteritic anterior ischaemic optic neuropathy and GLP-1 receptor agonist use in patients with type 2 diabetes

May 18, 2025Diabetes & metabolism

What diabetes doctors should know about the risk of sudden optic nerve damage with GLP-1 medicines in type 2 diabetes

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Abstract

The relative increase in NAION risk associated with GLP-1 receptor agonist use, mainly semaglutide, ranged from nonsignificant to fourfold.

The absolute number of patients affected by NAION remains low among those using GLP-1 receptor agonists.
No causal link has been established between GLP-1 receptor agonist use and NAION due to the retrospective design of the main studies.
Mechanistic hypotheses have been proposed but none have been formally demonstrated to date regarding the relationship between GLP-1 receptor agonists and NAION.
Profound metabolic and blood flow changes induced by GLP-1 receptor agonists may trigger NAION in patients with specific anatomical risk factors.
Cautious use of GLP-1 receptor agonists is advised, particularly in patients with ocular risk factors.

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AIM: Recent findings have raised concern about a potential association between semaglutide use and non-arteritic anterior ischaemic optic neuropathy (NAION), a rare form of permanent vision loss. This report provides a critical analysis of the current knowledge of GLP-1 receptor agonist (RA) use and risk of NAION in patients with type 2 diabetes (T2D).

METHODS: A literature search strategy was conducted for all English-language literature with a systematic review of key references up to April 2025.

RESULTS: Across studies including patients with T2D, the relative increase in NAION risk associated with the use of a GLP-1 RA, mainly semaglutide, ranged from nonsignificant to fourfold, while the absolute number of affected patients remained low. Given the retrospective design of the main studies, no causal link could be established between the use of GLP-1RAs and NAION. Some mechanistic hypotheses have been put forward without any being formally demonstrated to date. The profound metabolic and haemodynamic changes induced by GLP-1RAs might be the trigger of NAION in predisposed patients with an optic "disc-at-risk", a potent anatomical risk factor easily detected by ocular examination.

CONCLUSION: Pending studies clarifying this risk, these findings call for cautious use of GLP-1 RAs, particularly in patients with ocular risk factors. Given the widespread use of GLP-1RAs, clinicians should be aware of this potential risk, without overshadowing the remarkable benefit of GLP-1RAs in patients with type 2 diabetes.

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What the diabetologist needs to know about the risk of non-arteritic anterior ischaemic optic neuropathy and GLP-1 receptor agonist use in patients with type 2 diabetes

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