Glucagon-like Peptide-1 Receptor Agonists and the Eye: A Review of Ocular Implications and Clinical Guidelines

Abstract

Glucagon-like peptide-1 receptor agonists (GLP-1RAs), including semaglutide, liraglutide, dulaglutide, and the dual GIP/GLP-1 agonist tirzepatide, have become major agents in the management of type 2 diabetes mellitus and obesity. The eye contains GLP-1 receptors across multiple compartments, from the retinal ganglion cell layer to the trabecular meshwork, making it a biologically relevant site for both the benefits and risks of this drug class. As prescriptions grow rapidly in India, which carries the world’s largest diabetes burden, ophthalmologists must be ready to counsel, screen, and manage patients on these drugs. This narrative review synthesises preclinical and clinical evidence on the ocular implications of GLP-1RAs and tirzepatide across diabetic retinopathy, nonarteritic anterior ischaemic optic neuropathy (NAION), glaucoma, age-related macular degeneration (AMD), dry eye disease, and idiopathic intracranial hypertension (IIH), and offers practical clinical guidelines for ophthalmologists. A comprehensive literature search was conducted across PubMed, Embase, and Web of Science from inception to April 2026 using the terms “GLP-1 receptor agonist,” “semaglutide,” “tirzepatide,” “diabetic retinopathy,” “NAION,” “glaucoma,” “AMD,” “dry eye,” and “neuroprotection.” Major clinical trial reports, large retrospective cohort studies, pharmacovigilance analyses, and society guidelines were included. GLP-1RAs produce anti-inflammatory, antioxidant, and neuroprotective effects in ocular tissues. Diabetic retinopathy can worsen paradoxically in the short term after initiating these drugs, particularly in patients with pre-existing moderate-to-severe nonproliferative retinopathy. NAION has emerged as a rare but serious concern with semaglutide specifically: the European Medicines Agency and World Health Organization issued safety alerts in 2025. Conversely, GLP-1RAs are consistently associated with reduced glaucoma incidence, lower intraocular pressure, a possible protective effect against dry AMD, and emerging evidence of benefit in IIH. Ophthalmologists should play an active role in the care of patients on GLP-1RAs. Baseline retinal assessment, risk stratification by retinopathy severity, patient education about visual symptoms, and structured follow-up are essential. Prospective Indian studies are needed.