Objective:

NA

Background:

Nonarteritic anterior ischemic optic neuropathy (NAION) is characterized by sudden, painless vision loss, often associated with vascular risk factors. While clinical trials and real-world studies of glucagon-like peptide-1 receptor agonists (GLP-1RA)—commonly used for diabetes and obesity management—have not reported a significant increase in NAION risk, we present two cases that suggest a potential association and frequent misdiagnosis.

Design/Methods:

NA

Results:

The first case is a 56-year-old man who experienced sudden, painless vision loss in his left eye, initially treated as a complication of Lyme disease. Despite comprehensive evaluations including MR imaging, malignancy screening, inflammatory and autoimmune panels, and temporal artery biopsy, no underlying cause was identified. Fundoscopic confirmation of NAION led to plasmapheresis treatment, which did not improve his vision. Notably, he had a history of right-eye NAION after using semaglutide, and his recent episode occurred after starting tirzepatide. The second case involves a 57-year-old woman with sudden, progressive vision loss in her right eye, initially misdiagnosed as a vitreous hemorrhage. A week later, she developed vision symptoms in her left eye. Despite unremarkable imaging, serological tests, and temporal artery biopsy, a review of her history revealed 10 months of semaglutide use as the likely trigger, even though her vascular risk factors were well controlled.

Conclusions:

A thorough history is essential when assessing vision loss in patients using GLP-1RA, as NAION can be misattributed to pre-existing vascular risk factors. This creates a diagnostic challenge, especially since GLP-1RA users often have multiple coexisting vascular risks. Potential mechanisms include changes in blood flow dynamics, fluid shifts, individual predispositions (e.g., small cup-to-disc ratio), and underlying vascular conditions. Further research is needed to identify which factors increase the risk of NAION in this population.