NANOSNET

 View Only
Back to discussions
Expand all | Collapse all

Bilateral naion semaglutide

  • 1.  Bilateral naion semaglutide

    Posted 07-16-2025 22:11
    Hi Team. Just saw a pt with bilateral NAAION who has been losing weight on semaglutide. Sigh....

    Sent via the Samsung Galaxy S23 Ultra 5G, an AT&T 5G smartphone
    Get Outlook for Android


  • 2.  RE: Bilateral naion semaglutide

    Posted 07-17-2025 07:56
    can you tell us the interval between the two eyes and how long the patient was on semi glue tide before the first day occurred?
    Sent from my iPhone



    Original Message


  • 3.  RE: Bilateral naion semaglutide

    Posted 07-17-2025 08:01
    Hi!  She was on the medication 3 months, stopped it when right eye developed an inferior altitudinal defect and came to me 3 weeks after. She was referred by an eye doctor who told her OS was fine and she had no complaints OS was swollen. 

    Sent via the Samsung Galaxy S23 Ultra 5G, an AT&T 5G smartphone
    Get Outlook for Android



    Original Message


  • 4.  RE: Bilateral naion semaglutide

    Posted 07-17-2025 08:17
    thanks
    Sent from my iPhone



    Original Message


  • 5.  RE: Bilateral naion semaglutide

    Posted 07-17-2025 08:57
    Would a NANOS registry of such patients (bilateral/rapid sequential, especially) help or is the answer of causation going to come from big data stats only?

    Sangeeta

    Sangeeta Khanna MD
    University of Michigan



    Original Message


  • 6.  RE: Bilateral naion semaglutide

    Posted 07-17-2025 09:13
    I agree with you. To be honest I wasn't very convinced about the semaglutide-NAAION connection. I am a little more convinced. Notably the patient was initially sent to the hospital and dx with optic neuritis and given IV steroids because mri reading. No improvement. The acuity in the right eye is 20/50. No stigmata of GCA (50 yo). I wonder if there is any similarity to those patients who develop an NAAION-like picture while using amiodarone. 
    And I am pretty sure this patient will demonstrate that she had a disk-at-risk appearance of her optic nerves once swelling is down.
    Maybe I should submit this one as a case report. 

    Sent via the Samsung Galaxy S23 Ultra 5G, an AT&T 5G smartphone
    Get Outlook for Android



    Original Message


  • 7.  RE: Bilateral naion semaglutide

    Posted 07-17-2025 09:19
    What kind of case report? Bilateral AION. Come on. The association with semaglutide is spurious at best. There are so many people taking GLP-1 inhibitors and you describe a 50 year old patient with "classical" NAAION. I don't get it? What have we learned from your case that is new?

    +=+=+=+=+=+=+=+=+=+=+=+=+=+=+=+=+=+=+=+=
    Scott Forman, MD
    Senior Fellow North American Neuro-ophthalmology Society

    Adult and Pediatric Neuro-ophthalmology
    Comprehensive Ophthalmology
    Functional Medicine













    Original Message


  • 8.  RE: Bilateral naion semaglutide

    Posted 07-17-2025 09:24
     At this stage of our understanding, until we have a registry, this might be the way to record cases. And i don't think any bilateral simultaneous case associated with semaglutide has been reported? 

    Sent via the Samsung Galaxy S23 Ultra 5G, an AT&T 5G smartphone
    Get Outlook for Android



    Original Message


  • 9.  RE: Bilateral naion semaglutide

    Posted 07-17-2025 09:33
    A registry is a good idea as long as details about the patient, their history and findings are included.
    +=+=+=+=+=+=+=+=+=+=+=+=+=+=+=+=+=+=+=+=
    Scott Forman, MD
    Senior Fellow North American Neuro-ophthalmology Society

    Adult and Pediatric Neuro-ophthalmology
    Comprehensive Ophthalmology
    Functional Medicine












    Original Message


  • 10.  RE: Bilateral naion semaglutide

    Posted 07-17-2025 15:36

    Scott,

     

    I have at least one case of bilateral, simultaneous, or at least quasi-simultaneous, onset NAION case on Ozempic.

     

    I am not asserting cause-and-effect, just responding to the issue that you raise, which is a good one.

     

    I also have had several sequential NAION cases with a fairly short separation in time (i.e. weeks to a few months) between involvement of the two eyes. Again, I am not asserting cause-and-effect, just reporting the news !

     

    joe

     

    Joseph Rizzo, MD

    Simmons Lessell Professor of Ophthalmology

    Director, Neuro-Ophthalmology Service

    Mass Eye and Ear / Harvard Medical School

     




    Original Message


  • 11.  RE: Bilateral naion semaglutide

    Posted 07-17-2025 15:41
    Sidebar here… If you have “NA-AION” in an older patient with no GCA symptoms and normal inflammatory markers, and he goes on to get AION in the other eye in short order, and no disk at risk, should that prompt a TAB?

    Mitch


    Original Message


  • 12.  RE: Bilateral naion semaglutide

    Posted 07-17-2025 15:49
    Mitch, I think you could. I also use visual acuity as a parameter. NAION should always be CF or better(classically I find a temporal island). Vision of HM, LP or NLP is arteritic until proven otherwise. The one exception is the end stage renal patient. They can be blind from nAION, 
    Also, obviously if there's pallid edema, need a TA biopsy regardless of the other parameters 

    Floyd 

    P.S. The few cases I've seen like this were negative, though, on biopsy ��




    Original Message


  • 13.  RE: Bilateral naion semaglutide

    Posted 07-17-2025 15:57
    I have done a biopsy on those, but I would have remembered one being positive because it would really suck and be memorable. Sometimes I even consider doing a biopsy if the fellow eye has no disk at risk before the second AION, but I haven’t gone that far yet, and generally of course we see these after the AION where it’s impossible to know if the first eye has such a nerve. In fact, I’m not sure what percentage of of disk at risk eyes have a fellow disk at risk eye, but it feels like it’s the great majority.


    Mitch


    Original Message


  • 14.  RE: Bilateral naion semaglutide

    Posted 07-17-2025 16:41
    Mitch, I'm being a little lazy here, but as I Drance did an epidemiologic study and assuming the patients do not have unilateral glaucoma from an acquired source, 95% of people have a cup within 0.1 of each other. 
    I have to say, I really would consider it in a patient without a disc at risk. So after Hoyt's observation "disc at risk" prompting Roy Beck studying and proving it, a few years later, Hoyt published a case of NAION in someone without a disc at risk. So it does happen.





    Original Message


  • 15.  RE: Bilateral naion semaglutide

    Posted 07-17-2025 17:00
    Just to make it crystal clear, I’m by no means spring-loaded to get a TAB just because at AION #1 the other eye doesn’t have a disk at risk, but I do seriously consider it, even if zero other cancers such as pallid edema, symptoms, and of course markers, if the second involved eye had a disk at risk.

    I haven’t seen many patients with AION where I have at least seen the involved eye with my own eyes prior to the AION. But I have seen some, including the second eye for the patient with a first AION (without my own observation prior to the injury), and I have seen MANY NA-AION with normal cupping. I haven’t done very many biopsies on that basis alone.

    Mitch


    Original Message


  • 16.  RE: Bilateral naion semaglutide

    Posted 07-17-2025 17:54
    How do you define normal cupping. They found disk at risk included up to 0.3. 





    Original Message


  • 17.  RE: Bilateral naion semaglutide

    Posted 07-18-2025 09:36
    I personally define it as <0.2 i.e. in the spectrum of crowded, elevated “pseudopapilledema” disk to 0.1. I wish I had catalogued every one I’ve seen over the years for all these interesting parameters, but anecdotally I’d say that the fellow eye is overwhelmingly 0.2 or less.

    If it’s a compartment syndrome problem at its core, then it makes sense to almost never see NA-AION in a 0.6 or more cup, that’s been my experience. My concern is that perhaps it’s remiss to not be spring-loaded to get a TAB in all cases where the affected eye is known to have a C/D of 0.3 or more especially when older regardless of inflammatory markers (and no symptoms of GCA of course).


    Original Message


  • 18.  RE: Bilateral naion semaglutide

    Posted 07-17-2025 16:44
    I have to correct that. The figure is 97.5% are within 0.2 of each other.



    On Thursday, July 17, 2025, 4:40 PM, jfecwarren@aol.com <jfecwarren@aol.com> wrote:

    Mitch, I'm being a little lazy here, but as I Drance did an epidemiologic study and assuming the patients do not have unilateral glaucoma from an acquired source, 95% of people have a cup within 0.1 of each other. 
    I have to say, I really would consider it in a patient without a disc at risk. So after Hoyt's observation "disc at risk" prompting Roy Beck studying and proving it, a few years later, Hoyt published a case of NAION in someone without a disc at risk. So it does happen.


    I have done a biopsy on those, but I would have remembered one being positive because it would really suck and be memorable. Sometimes I even... -posted to the "NANOSNET" community

    NANOSNET

    Post New Message
    Re: Bilateral naion semaglutide
    Reply to Group Reply to Sender
    Jul 17, 2025 3:57 PM
    Mitchell Gossman
    I have done a biopsy on those, but I would have remembered one being positive because it would really suck and be memorable. Sometimes I even consider doing a biopsy if the fellow eye has no disk at risk before the second AION, but I haven't gone that far yet, and generally of course we see these after the AION where it's impossible to know if the first eye has such a nerve. In fact, I'm not sure what percentage of of disk at risk eyes have a fellow disk at risk eye, but it feels like it's the great majority.


    Mitch

      Reply to Group Online   Reply to Group via Email   View Thread   Recommend   Forward   Flag as Inappropriate   Post New Message via Email  
    -------------------------------------------
    Original Message:
    Sent: 7/17/2025 3:49:00 PM
    From: Floyd Warren
    Subject: RE: Bilateral naion semaglutide

    Mitch, I think you could. I also use visual acuity as a parameter. NAION should always be CF or better(classically I find a temporal island). Vision of HM, LP or NLP is arteritic until proven otherwise. The one exception is the end stage renal patient. They can be blind from nAION, 
    Also, obviously if there's pallid edema, need a TA biopsy regardless of the other parameters 

    Floyd 

    P.S. The few cases I've seen like this were negative, though, on biopsy ��






     
    You are subscribed to "NANOSNET" as jfecwarren@aol.com. To change your subscriptions, go to My Subscriptions. To unsubscribe from this community discussion, go to Unsubscribe.



    Original Message


  • 19.  RE: Bilateral naion semaglutide

    Posted 07-17-2025 17:05
    Just saw a case today of a 44 yo with Type 2 DM and disc at risk, who  started Ozempic, in 3 months A1c went from 8.4 to 6.2 and he developed bilateral vision changes with disc edema and nerve fiber bundle defects. Workup negative and behaving like bilateral NAION on follow up. 
    We know that diabetic retinopathy can get worse with rapid changes so stands to reason that micro vascular disease of nerve head could do too. 

    Is that the mechanism or another or none- the question remains!

    S




    Original Message


  • 20.  RE: Bilateral naion semaglutide

    Posted 07-19-2025 09:35
    I was away on vacation, missed the thread earlier about bilateral NAION on ozempic. At Henry Ford, we have seen 3 cases of bilateral simultaneous or within a week interval of bilateral NaION - two had diabetes, one of whom had stopped ozempic 3 months before the disease, while the other one was still taking it. For the third patient, ozempic had been started for obesity and NAION occurred while taking it, without any other vascular risk factors. We had presented a poster in NaNOS for the 3 cases. 

    The cause/ association is still uncertain and it has become difficult when patients want us to write a letter in support for ozempic, esp in cases of IIH and obesity..I have usually advised them to consider lifestyle changes or talk to their PCP about other weight lowering medications to avoid GLP-1 agonists. For diabetes, I still discuss the risk versus benefit and let the patient decide. 

    Poonam Bansal
    Henry Ford Health System
    Detroit, Michigan


    Sent from my iPhone



    Original Message


  • 21.  RE: Bilateral naion semaglutide

    Posted 07-19-2025 16:34
    Did all 3 patients have discs at risk? 





    Original Message


  • 22.  RE: Bilateral naion semaglutide

    Posted 07-19-2025 20:26
    I think a NANOS registry would be helpful if for no other to clarify if patients with GLP-1A assoc NAION are similar to our other NAION patients and to educate our members about absolute risk increase so we can better counsel patients. If patients under age 40 are not developing GLP-1A assoc NAION then we don't need to be telling IIH patients to not take these meds which will likely have major quality of life improvement. With largest multicenter data suggesting GLP-1A associated NAION is around 14.5 per 100,000, and from the Rochester population study the incidence of naoin in patients over age 50 is 10.2 per 100,000, you are talking about 4 patients per 100,000 increase, or a number needed to harm of 25,000. The number needed to treat for the intended diseases is going to be dramatically lower.

    Further, we don't have any evidence to tell us if it increases the risk of bilateral development or vision outcomes.

    Best, 

    Drew 




    Original Message


  • 23.  RE: Bilateral naion semaglutide

    Posted 07-19-2025 22:06
    Here here. 

    Sent via the Samsung Galaxy S23 Ultra 5G, an AT&T 5G smartphone
    Get Outlook for Android



    Original Message


  • 24.  RE: Bilateral naion semaglutide

    Posted 07-19-2025 23:32
    We need an organized study similar to what was done for PDE-1 work. 

    Dave Kaufman 




    Original Message


  • 25.  RE: Bilateral naion semaglutide

    Posted 07-22-2025 15:24
    It's difficult to say with bilateral swelling, but in 2 patients - one disc was less swollen and did appear to show disc at risk. All 3 were in the age group of > 50 and male patients. 

    Poonam

    Sent from my iPhone



    Original Message


  • 26.  RE: Bilateral naion semaglutide

    Posted 08-06-2025 15:29
    I've been thinking about the benefits vs. risks of semiglutide, especially since the recent article on semiglutides conferring lower risk of dementia. Yet, unable to answer the question of "what is the threshold" if any regarding its link to NAION? Is there a higher incidence in certain types of patients?  I would like to know if there is a dose dependency (Smaller stature person, with too high of a dose?  Or is the metabolic swing too quick during the time period that the patient lost vision?  Were they experiencing hypoglycemia? Or were they asymptomatic? Were they asleep?).  Did the person have a disc at risk? Did they have disc drusen?  What did the configuration of the optic nerve tell us about the blood vessel flow?  Is there a right angle that is too sharp of arteriolar vessel turning at the optic nerve to increase risk of derangement during metabolic swings?  
    Should we be counseling patients to start with a 1/4 or 1/2 dose in certain optic nerve configurations? Or if the patients we seeing this more in are prone to metabolic swings, ie did they have the largest glucose/potassium/osmotic drops in shortest periods of time?). 

    If anyone begins a registry, I hope that we can capture more than big data points, but also nuance that may help us better observe what is going on in these patients.  

    Best,
    Barbara




    Original Message


  • 27.  RE: Bilateral naion semaglutide

    Posted 07-17-2025 15:35
    Scott, also the case with the PDE meds for ED. The overwhelming majority of people use it, but epidemiology suggests there is a small increased risk of nAION with their use, too.





    Original Message


  • 28.  RE: Bilateral naion semaglutide

    Posted 07-17-2025 09:27
    PS she had lost 30# before the naaion started. She was no longer overweight and had no other risk factors, other than what might prove disk at risk. I might not even have mentioned her if she were also obese, with DM HTN HLD OSA and  smoked. 

    Sent via the Samsung Galaxy S23 Ultra 5G, an AT&T 5G smartphone
    Get Outlook for Android



    Original Message


  • 29.  RE: Bilateral naion semaglutide

    Posted 07-17-2025 15:31
    Scott, why do you say that it is spurious? We don't know that it's fake. Also the argument that's so many people are on it doesn't really fly; the overwhelming majority of people with discs at risk never get an AION, but I think most of us believe that association is real. I would agree it's unproven, but to label it spurious is incorrect, I feel.




    Original Message


  • 30.  RE: Bilateral naion semaglutide

    Posted 07-17-2025 16:07
    Maybe I should look up the definition of spurious.
    +=+=+=+=+=+=+=+=+=+=+=+=+=+=+=+=+=+=+=+=
    Scott Forman, MD
    Senior Fellow North American Neuro-ophthalmology Society

    Adult and Pediatric Neuro-ophthalmology
    Comprehensive Ophthalmology
    Functional Medicine












    Original Message


  • 31.  RE: Bilateral naion semaglutide

    Posted 07-17-2025 13:27
    As was mentioned earlier, there is an association between cataract surgery and NAION. I had several patients who developed NAION after uneventful cataract surgery.

    One of them lost vision 2 days after surgery (saw 20/20 for 2 days!). No PMR. normal ESR' Negative TAB. She had disc-at-risk, so I advised her to wait for the second eye surgery (I told her there is a risk that it will happen again). But her vision was very low in that eye, so she decided to risk it. After 2-3 days of perfect vision - same story: NAION and VA of 4m FC

    • Nonarteritic Anterior Ischemic Optic Neuropathy After Cataract Surgery: A Systematic Review and Meta-Analysis. This is a highly relevant and recent meta-analysis that consolidates findings from multiple studies. It's often cited as strong evidence for the increased risk.

      • Reference: Chen JJ, et al. Nonarteritic Anterior Ischemic Optic Neuropathy After Cataract Surgery: A Systematic Review and Meta-Analysis. J Neuroophthalmol. 2023 Mar 1;43(1):17-28. doi: 10.1097/WNO.0000000000001625. Epub 2022 Jun 23. (You can often find this on PubMed or ResearchGate).

    Population-Based Studies / Large Cohort Studies:

    • A Population-Based Study of Anterior Ischemic Optic Neuropathy following Cataract Surgery. These studies look at large datasets to determine incidence rates and associations.

      • Reference: McCulley TJ, et al. A Population-Based Study of Anterior Ischemic Optic Neuropathy following Cataract Surgery. Transl Vis Sci Technol. 2020 Sep 28;9(11):34. doi: 10.1167/tvst.9.11.34. eCollection 2020 Dec. (Available on PubMed Central, PMC).c

    So it is rare but it happens.

    Maybe it's one of those cases

    Michael


    --

    Michael Paul M.D

    Eye diseases and Surgery

    Director Emeritus

    Ophthalmic Plastic and Reconstructive Surgery

       ,Orbital and Lacrimal Surgery Service 

    Neuro-Ophthalmology

    Dept  of Ophthalmology

    Edith Wolfson Medical Center

    Holon, Israel

    972-3-5049554

    Fax: 972-3-5018703


    Sent with Mailsuite  ·  Unsubscribe
    		 17.07.25, 20:07:41



    Original Message


  • 32.  RE: Bilateral naion semaglutide

    Posted 07-17-2025 15:42
    It is NOT clear that amiodarone increases the risk of nAION, as many case reports conflate and/or mistake amiodarone optic neuropathy for nAION. There is even a case report of "amiodarone nAION" that is much more likely a post-CABG nAION! But now it's in the literature as the former, rather than the latter. I would file it in the fiction section 





    Original Message


  • 33.  RE: Bilateral naion semaglutide

    Posted 07-17-2025 12:13
    Sangeeta, I wouldn’t think big data could really retrospectively prove causation, only strong associations, and there have been population studies in multiple journals by now. I think there might need to be some pathophysiologic research that shows a causative mechanism as well as a prospective study for me to truly buy it.
    I’ve had a run of patients with bilateral simultaneous or sequential NAION who are on Semaglutide, but honestly, it feels like half of veterans I see are on semaglutide in general, and most (except for 2) have vascular risk factors as well. Almost none of them want to stop the medication. I am definitely worried but trying not to over-associate, especially since I see the same resolution of disc edema and/or incomplete recovery whether we stop it or not.
    I would be eager to participate in anyone’s trial that is looking into this further.
    Kim


    Original Message


  • 34.  RE: Bilateral naion semaglutide

    Posted 07-17-2025 17:07
    I think a NANOS registry will capture cases, but not the number of people on the medication overall and will miss cases seen by other physicians who are non- members. So in that regard, I think big data is the answer.
    That said, at least with a NANOS registry, we can see if it seems to occur only in disc at risk patients or all, regardless of c:d.  This would likely not be retrievable by big data.



    Original Message


Related Content