GLP-1 Receptor Agonists and the Ocular Surface: A Narrative Review of Restoration, Remodeling, and Clinical Implications

Glucagon-like peptide 1 receptor agonists (GLP-1RAs) have become a recurring topic in ophthalmology, yet most reviews emphasize posterior segment and neuro-ophthalmic disease while giving comparatively little attention to the ocular surface. In this review, we frame the relevant target not as isolated anterior structures but as a proposed metabolic surface unit composed of the lacrimal gland, tear film, conjunctiva, meibomian glands, corneal epithelium, corneal nerves, and the periocular tissues that support lid-globe function, and we argue that current evidence is best understood as restoration versus remodeling. Preclinical work provides the clearest biologic rationale: liraglutide studies have reported reduced lacrimal gland inflammation and fibrosis, and improved tear secretion, corneal epithelial migration, and nerve regeneration, while a semaglutide study in aged mice suggests lacrimal structural rescue through attenuation of senescence-associated inflammatory, oxidative, and fibrotic programs. Human evidence remains limited and largely observational, with retrospective diabetic cohorts showing lower rates of dry eye disease and superficial keratitis and a small clinical study showing better Schirmer testing and tear breakup time in GLP-1RA users. At the same time, emerging oculoplastic and imaging studies, particularly from obesity and weight loss populations, suggest periocular volume loss, brow descent, and dermatochalasis which may alter lid support, blink mechanics, and tear distribution. For anterior segment clinicians, the practical implication is that GLP-1RA exposure should prompt phenotype-based assessment of both ocular surface status and periocular geometry, although these recommendations remain expert extrapolations rather than guideline-level evidence. Current data are therefore consistent with a dual thesis: GLP-1RAs may be associated with biologic restoration at the lacrimal-corneal-neural axis and with structural remodeling of the periocular scaffold, although direct mechanistic support is presently stronger for the former than for the latter.