ASRS 2025: The risk of sight-threatening diabetic retinopathy with GLP-1 RA use

Andy J. Barkmeier, MD, an associate professor of ophthalmology and vitreoretinal surgery at Mayo Clinic in Rochester, Minnesota, presented findings on GLP-1 medications and their relationship to diabetic retinopathy complications at the 2025 ASRS meeting in Long Beach, California.

He began by explaining that GLP-1 medications had become increasingly popular among patients with type 2 diabetes due to substantial evidence demonstrating their cardiovascular and kidney benefits. The uptake of these medications was rapidly rising as more cardiovascular outcome trials confirmed their systemic advantages. However, Barkmeier noted that the SUSTAIN-6 trial, which examined semaglutide, had revealed a concerning finding alongside its cardiovascular benefits: an increased risk of diabetic retinopathy complications. This increased risk occurred in the context of rapid hemoglobin A1c lowering and weight loss, leaving researchers uncertain whether this was a medication-specific effect or simply related to the significant systemic improvements, similar to what had been observed in previous studies like the DCCT.

The challenge was that existing cardiovascular outcome trials had examined only specific patient subsets over short periods, focusing on those with high cardiovascular risk. This limited the generalizability of the findings to broader patient populations using these medications in routine clinical practice. To address this gap, Barkmeier's team conducted a study examining a more representative population of patients who received different GLP-1 medications in real-world clinical settings. They specifically looked for differences in diabetic retinopathy outcomes, including treatment for diabetic macular edema and proliferative diabetic retinopathy. The study yielded reassuring results: no differences were found between any of the GLP-1 medications regarding the risk of treatment for diabetic macular edema or proliferative diabetic retinopathy.

Importantly, the findings did not replicate the increased diabetic retinopathy complications risk seen in the SUSTAIN-6 trial, even for semaglutide, one of the most commonly prescribed medications in this class. Barkmeier concluded that these findings provided reassurance to both patients and prescribers, allowing them to select the most appropriate GLP-1 medication without concern about theoretical increased diabetic retinopathy risks.