Editor’s Column May 2026
Save as PDFThis month, the American Academy of Ophthalmology (AAO) released a joint consensus statement with the North American Neuro-Ophthalmology Society (NANOS) to provide a report about the risk of non-arteritic anterior ischemic optic neuropathy (NAION) in patients on glucagon-like peptide-1 receptor agonists (GLP-1 RAs). It’s a very interesting article, and I’d encourage you to click over and read it. The statement describes several studies performed over the last couple of years that looked at correlations between the use of the medications and the development of NAION. Most – not all – of the studies found a correlation, but there were differences and limitations found in each study. The first line of the Discussion summarizes their point: “Taken in total, we believe that the currently available evidence suggests a possible association between semaglutide and NAION. If present, the degree of risk elevation is…. in the range of about 2-fold elevated risk. Further studies are needed to confirm this risk, and causality has not been established.” It goes on to say they do not support “immediately stopping semaglutide in the setting of a confirmed diagnosis of NAION” but rather “recommend careful weighing of risks and benefits and discussion between the patient and their care team to make an informed decision about whether to start, continue, or discontinue semaglutide for patients who develop NAION or for those with certain risk factors.”
The statement is a great example of the importance of proper data analysis, rather than a reactive response to a headline. The lack of a proven mechanism for NAION would warrant caution against blanket statements, and since the incidence of NAION is so low overall, even a several-fold increase in relative risk translates into only a small absolute risk difference. When I read the statement, I was reminded of twenty years ago, when phosphodiesterase type 5 inhibitors (PDE5is) were first being prescribed for erectile dysfunction (ED), and we first started talking about their risk of NAION. It seemed like at first these meds were nowhere, and then suddenly they were everywhere, and you would read a case report about cyanopsia or NAION and wonder if we were going to see a tidal wave of PDE5i-related NAION cases. Statements were made back then, articles about possible links made it into the mainstream press, and we all just waited. Now, with twenty years of hindsight, we know that a temporary cyanopsia can occur with PDE5i use, but a substantial risk of NAION was never really shown. The risk factors of ED and NAION (similar to the reasons for being prescribed GLP-1 RAs and NAION) have so much overlap that it’s difficult to show a separate, increased risk. Today, PDE5is are some of the most-commonly prescribed medications in the world, and there isn’t much compelling evidence to suggest an increased incidence of NAION. If anything, just like the GLP statement writes, if there is a significant relative risk elevation, there isn’t necessarily a significant change in absolute risk.
Joey Kane, as always, is already on top of this, and his column in this issue presents two cases of patients with optic nerve conditions who are on GLP-1 RAs. I urge you to give it a read; he does a great job of using cases he sees at his hospital to illustrate situations that any of us could find ourselves in. Our patients are relying on their doctors to stay current with the medical literature about what is recommended for their medical conditions, and that includes staying current on what potential side effects might occur with their medications. There is no finish line in being a doctor; you have to keep reading. After you read Dr. Kane’s column, click over to our featured article in this issue: a case of lymphoma masquerading as a hordeolum by Len Koh et al. It’s a fascinating but tragic case that emphasizes the importance of close follow-up and a willingness to rethink a differential diagnosis if there’s no improvement. We benefit from the candor of the group from the Spokane VAMC so we could learn something for the sake of our future patients.
Dr. Rett is the Editor-in-Chief of the Journal of Medical Optometry and the secretary for the American Board of Certification in Medical Optometry. He is the Chief of Optometry at VA Boston and sits on the national Field Advisory Board for Tele Eyecare at the VA. He is adjunct clinical faculty at several optometry schools, lectures nationally and enjoys writing about eyecare whenever and wherever.
