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Abstract

Glucagon-like peptide-1 receptor agonists (GLP-1 RAs) have moved from second-line diabetes medications toward the frontline of type 2 diabetes, obesity, and cardiometabolic care.1 A meta-analysis of 10 randomized cardiovascular outcomes trials (n = 71,351) demonstrated that longacting GLP-1 RAs reduce major adverse cardiovascular events by 14%, all-cause mortality by 12%, and composite kidney outcomes by 17%.2 With GLP-1 RAs usage increasing, ophthalmology is also increasingly encountering patients who have recently started GLP-1 RAs therapy, often alongside substantial improvements in glycemic control.

In the context of GLP-1 RAs ocular complications, two specific topics currently dominate conversations: (1) worsening diabetic retinopathy (DR) soon after treatment initiation, most prominently observed in SUSTAIN-6, and (2) concern for non-arteritic anterior ischemic optic neuropathy (NAION) following a 2024 observational report and other multicenter analyses.3–6

This review summarizes what is established, what is emerging, and what remains speculative. We also discuss a potential framework for ophthalmologists, that being recognizing higher risk scenarios, counseling patients appropriately, and avoiding premature assumptions of causation.

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