Role of lifestyle modifications in glaucoma: A systematic review

Abstract

BACKGROUND

Glaucoma is a group of eye diseases that lead to irreversible damage to the optic nerve and gradual vision loss. Although it can occur at any age, it is most commonly seen in people over 40. Globally, around 60.5 million people are currently affected, and this number is expected to rise to over 110 million by 2040. Often called the “silent thief of sight”, glaucoma typically progresses without noticeable symptoms until significant vision has already been lost, making it a major cause of visual disability worldwide. Despite advancements in research, lowering intraocular pressure (IOP) remains the only proven way to slow or halt disease progression.

AIM

To explore the potential role of lifestyle modifications in the prevention and management of glaucoma, particularly as complementary strategies alongside traditional IOP-lowering treatments.

METHODS

An extensive review of existing literature was carried out to examine the effects of various lifestyle factors—including diet, physical activity, yoga practices, sleep posture, and the use of nutritional supplements-on the development and progression of glaucoma.

RESULTS

Several studies suggest that lifestyle changes may have a positive impact on glaucoma outcomes. Regular physical exercise, balanced nutrition, certain yoga postures, and proper sleep positioning have been associated with benefits for eye health. Additionally, some supplements may support the optic nerve and contribute to slowing disease progression. These approaches, which are already recognized in the management of other chronic conditions like diabetes and hypertension, show promise in glaucoma care as well.

CONCLUSION

While lowering IOP remains the cornerstone of glaucoma treatment, there is growing interest in the role of lifestyle choices in influencing disease progression. Adopting healthier habits may serve as a valuable addition to existing treatment plans. More clinical research is needed to better understand these connections and to guide practical recommendations for patients and clinicians alike.

Key Words: Glaucoma; Lifestyle modification; Intraocular pressure; Aerobic exercises; Diet and nutrition; Mindfulness; Stress management

Core Tip: The pathophysiology of glaucoma is quite an enigma even with the advent of most modern diagnostic and screening tools. It’s a multifactorial group of optic neuropathy that can lead to irreversible blindness worldwide. The primary modifiable factor in managing glaucoma is reducing intraocular pressure (IOP). The usual methods are IOP-lowering drugs, laser, and complicated surgeries. But the recent trend in dealing with chronic diseases like diabetes, hypertension, and chronic glaucoma is a holistic approach including lifestyle modifications. The lifestyle factors like exercise, yogic asanas, deep meditation, diet, and nutrition can play a major role in the progression of glaucoma.

INTRODUCTION

Glaucoma, a leading cause of irreversible blindness worldwide, is characterized by progressive damage to the optic nerve, elevated intraocular pressure (IOP), and abnormal visual fields. In 2020, approximately 76 million individuals were affected by glaucoma, and this figure is projected to rise to 112 million by the year 2040[1]. Glaucoma is presumed to be a multifactorial ocular disease with IOP-dependent and IOP-independent risk factors, which include: (1) Decreased ocular blood flow; (2) Oxidative stress; (3) Decreased axoplasmic flow; and (4) Genetic background[2].

At present, IOP is the only evidence-based and treatable risk factor associated with open-angle glaucoma. Till now, treatment to lower the IOP is targeted with antiglaucoma medications, laser therapy, and surgical interventions. But no available treatment options either cure the existing optic neuropathy or reverse the visual field loss. Hence, early detection of the disease, timely reduction of IOP, and regular monitoring are crucial for the effective management of glaucoma. Recent advancements in the comprehension of the intricate pathophysiology of glaucoma have unveiled the involvement of numerous non-IOP-dependent factors. The accelerated rate of damage to retinal ganglion cells (RGCs) and adjacent cells, including astrocytes and oligodendrocytes, may be multifactorial in nature. which includes decreased ocular perfusion pressure (vascular dysregulation), oxidative stress, excitotoxicity, mitochondrial impairment, and immune-inflammatory dysregulation. This initiates a vicious cycle, known as the apoptosis cascade[3].

Glaucoma itself, as well as antiglaucoma drugs, is posing a financial burden; it also affects the quality of life of the patient[3]. Ophthalmologists and glaucoma patients have demonstrated significant interest in the utilization of complementary and alternative medicine. related to lifestyle, like smoking cessation or dietary modifications like green leafy vegetables and a diet with high nitrate intake[1]. Mental health issues like anxiety and depression have a higher incidence of glaucoma progression[4]. The Sun project[5] investigated the impact of the Mediterranean diet on glaucoma progression. The study assessed the Sun Healthy Lifestyle Score, which evaluates adherence to ten healthy habits: No smoking, regular physical activity, medication adherence, moderate alcohol consumption, avoidance of binge drinking, minimal television exposure, short daytime naps, regular social interaction, working at least 40 hours per week, and maintaining a low body mass index. High adherence to the Mediterranean lifestyle was significantly associated with a reduced risk of developing glaucoma. Additionally, increased intake of fruits and vegetables rich in vitamins A, C, and E, as well as carotenoids, may contribute to a lower risk of glaucoma. These nutrients are believed to offer neuroprotective effects by reducing oxidative stress, particularly in cases of normal-tension glaucoma. Yoga positions can be regarded as isometric exercises, which are a viable alternative to conventional medical management[6]. Systematic review and meta-analysis showed Jyoti-Trataka (steady gaze) and other slow yogic breathing techniques reduce IOP[7]. Mindful meditation reduces stress, decreases IOP, and promotes ocular health. The effect of physical activity in the form of exercise on ocular perfusion, neuroprotection, and IOP has been a topic of interest in the recent past. Existing literature reports that aerobic exercises such as walking, cycling, jogging, and stair climbing are associated with reductions in IOP, ranging from approximately 0.56 mmHg to 5.6 mmHg. Exercise-induced neuroprotection results in up-regulation of neurotropin expression, such as brain-derived neurotropic factor (BDNF), which further reduces inflammation and enhances mitochondrial functions. In view of dynamic exercises, other studies suggest an almost double IOP reduction in inactive persons (sedentary) as compared to active persons who do exercise[8,9]. Numerous epidemiological studies conducted in recent years have provided compelling evidence suggesting that optic nerve head (ONH) damage may be a significant risk factor for the progression of glaucoma. Lifestyle modifications, particularly regular blood pressure regulation, are crucial in managing this condition. Excessive salt intake can elevate blood pressure, potentially indirectly impacting IOP.

The purpose of this review is to explore the role of lifestyle factors, exercise, and nutrition in glaucoma patients. We’ll examine their effects on IOP and other factors influencing glaucoma progression. By focusing on these lifestyle modification techniques, we aim to provide a comprehensive overview, highlighting their advantages, limitations, clinical outcomes, and potential impact on patient care. This review will evaluate whether these modifications can effectively manage glaucoma symptoms and mitigate disease progression among adults. Clinicians and researchers will gain a comprehensive understanding of the evolving role of lifestyle modifications, contributing to optimized patient care and expanded treatment options.

Lifestyle interventions for glaucoma progression

Effect of yoga and pranayama on glaucoma: Yoga is a widely recognized holistic practice that integrates physical postures, breath control, and meditation to foster both physical and mental well-being. Across the globe, physically oriented yoga sets of exercises (asanas) are becoming fashionable as adjunct therapeutic practices. There is a radical change from maintaining good health to attaining good health. Yoga engages attention by breath, sound, and mantra. Morya et al[6] conducted a study to assess the effects of asanas, a practice in yoga, on IOP among individuals engaged in regular yoga practice. They meticulously documented that skull shining breath (Kapala Bhati Pranayama), alternate breathing (Anuloma Viloma Pranayama), sun salutations exercise (Surya Namaskar), standing forward bending (Uttanasana), downward facing dog (Adho Mukha Svanasana), and leg on wall pose (Viparita Karani) resulted in a decrease in IOP. In contrast, IOP elevation was observed in several asanas, including yoga headstand (Shirshasana), bellows breath (Bhastrika Pranayama), and control of breath technique (Pranayama). The hypothesis associated with this phenomenon can be substantiated by the increase in hydrostatic pressure within the episcleral and orbital veins, the sites of aqueous drainage. Consequently, the IOP is directly influenced by the Goldmann Equation: Po = (F/C) + Pv, where Po represents the IOP in millimeters of mercury (mmHg), F denotes the aqueous formation rate, C signifies the outflow facility, and Pv represents the episcleral venous pressure.

Effect of mindfulness meditation on glaucoma: The pathogenesis of glaucoma and stress-induced biochemical changes possess numerous shared traits. Further, reduced quality of life, financial burden, and tackling adverse effects of antiglaucoma medications make these patients susceptible to anxiety and depression. Stress is associated with a spike in IOP, a sequence of events mediated by endogenous cortisol levels[10].

During the process of meditation, attention is focused on breath, mantra, or soothing sound. Focusing on slow breathing offers additional benefits by triggering the parasympathetic activity and thus reciprocating the stress response. Additionally, meditation downregulates proinflammatory gene expression and mitigates oxidative stress. Dada et al[11] demonstrated the role of meditation in glaucoma pathogenesis through its significant downregulation of IOP. A brief mindfulness meditation course in primary open-angle glaucoma (POAG) and ocular hypertension results in a decrease in IOP, thereby enhancing the quality of life, stabilizing stress-related biomarkers, and positively altering gene expression. Consequently, mindfulness meditation is recommended as an adjunctive therapy for POAG.

Effect of breathing and aerobic exercises on glaucoma: A systematic review of the impact of exercise on IOP in glaucoma patients identified 15 studies and concluded that aerobic and resistance training can result in an immediate postexercise reduction in IOP[12]. Aerobic exercises, such as walking, swimming, cycling, and utilizing static machinery at a brisk pace for 30-45 minutes, not only mitigate the risk of cardiovascular diseases, including cardiac disease, diabetes, hypertension, and hyperlipidemia, but also decrease IOP and improve blood flow to the brain[13,14]. The elevation in IOP in healthy individuals during the valsalva maneuver (VM) has been extensively documented in existing literature. The elevation in IOP during VM is hypothesized to be caused by a rise in episcleral venous pressure, thereby reducing aqueous outflow[15]. Studies conducted by Nie et al[16], Cheng et al[17], and Yuan et al[18] on continuous running on the treadmill for 20-30 minutes (moderate intensity) also documented a reduction in IOP.

Effect of diet on glaucoma: A survey conducted by the National Health and Nutrition Examination revealed a correlation between elevated daily dietary intake levels of eicosapentaenoic acids and docosahexaenoic acid (DHA) and a decreased incidence of optic nerve damage associated with glaucoma. Conversely, higher levels of total polyunsaturated fatty acids were associated with an increased risk of developing glaucoma. Consequently, oral DHA or omega-3 supplements have been recommended in conjunction with the reduction of IOP in cases of normotension glaucoma and pseudoexfoliative glaucoma[19-21]. The pathophysiology underlying this association may be chronic and low-grade inflammation. Inflammatory markers like interleukin-6 and high C-reactive protein levels have been linked to normal tension glaucoma. A study by the Nurses’ Health Study and the Health Professionals Follow-up Study found that eating a diet rich in nitrates and leafy greens can lower the risk of glaucoma[21]. Few studies demonstrated that a diet rich in vitamins A, C, E, and carotenoids possesses antioxidant properties, thereby providing neuroprotection by mitigating oxidative stress, and patients with normal tension glaucoma have lower vitamin C levels and higher uric acid levels than normal individuals[22-24].

MATERIALS AND METHODS

Search strategy and data sources

We conducted a comprehensive literature search in three major databases-PubMed, Scopus, and Web of Science—from inception through June 2025. Search terms included controlled vocabulary (e.g., MeSH) and free-text keywords such as “glaucoma AND lifestyle modification”, “exercise AND intraocular pressure”, “diet AND glaucoma progression”, “yoga AND glaucoma”, “stress management AND glaucoma” and “sleep habits AND glaucoma”. To ensure completeness, search strings combined Boolean operators (AND/OR) and were supplemented by manual searches of reference lists in key reviews and by consulting experts in glaucoma and lifestyle medicine. The authors had diligently followed the PRISMA (2009) guidelines required for a systematic review.

Inclusion and exclusion criteria

From an initial yield of 2147 unique records, we applied the following seven a priori screening criteria:

Population: Adults (≥ 18 years) diagnosed with any form of glaucoma or ocular hypertension.

Intervention: At least one lifestyle modification—diet/nutrition, physical exercise (aerobic or isometric), smoking cessation, stress management (meditation, mindfulness), sleep hygiene, or yoga/pranayama.

Comparator: Usual care, no-intervention controls, or other lifestyle interventions such as exercise (type, frequency, intensity), diet/nutrition, sleep habits, alcohol consumption, smoking, and stress management.

Outcomes: Reporting ≥ 1 quantitative endpoint—IOP change, visual field progression, quality-of-life scores, stress biomarkers, or optic nerve perfusion.

Study design: Randomized controlled trials (RCTs), prospective or retrospective cohort studies, case-control studies, or systematic reviews/meta-analyses.

Sample size: ≥ 10 human participants per study arm.

Language and publication type: Only peer-reviewed, full-text articles published in English were included. Animal studies and in vitro experiments were excluded.

After title-abstract screening, 153 full texts were reviewed in detail; 10 studies met all criteria and were retained for extraction (Table 1)[1,25-33].

Table 1 Characteristics of included studies on lifestyle and glaucoma.

Ref.	Study design	Intervention type	Primary outcome
Almarzouki[25], 2024	Systematic review	Environmental factors	Nutraceutical supplementation effects
Elhusseiny and Aref[26], 2024	Narrative review	Lifestyle and environmental factors	IOP, disease progression, visual field loss
Fujita et al[27], 2023	Retrospective cohort study	Lifestyle habits	Glaucoma incidence
Gildea et al[28], 2024	Systematic review	Exercise	IOP, glaucoma severity, and progression
Kumar and Ou[29], 2023	Narrative review	Lifestyle factors	IOP, neuroprotection, disease progression
Loskutova et al[30], 2019	Systematic review	Nutrition	IOP, visual field progression
Perez et al[31], 2019	Narrative review	Lifestyle, exercise, nutrition	IOP, glaucoma incidence, disease progression
Risner et al[32], 2009	Review (unspecified)	Exercise	IOP
Kumari and Saha[1], 2022	Review (unspecified)	Lifestyle modifications	IOP, disease progression
Scuteri et al[33], 2020	Systematic review	Nutraceutical supplementations	IOP, visual field outcome

IOP: Intraocular pressure.

Study selection and data extraction

Two reviewers (Morya AK and Gurnani B) independently screened records and extracted data using a standardized form. Discrepancies were resolved by consensus or a third reviewer (Kaur K). Extracted variables included study setting, design, sample characteristics (age, glaucoma subtype), intervention details (type, frequency, duration), comparator, outcome measures, follow-up duration, and main findings. When necessary, corresponding authors were contacted for missing data.

Quality assessment

Risk of bias in RCTs was appraised with the Cochrane Risk of Bias 2.0 tool, and non-randomized studies were evaluated using the Newcastle-Ottawa Scale. Each study received an overall rating (low, moderate, or high risk of bias), which informed interpretation of findings.

Data synthesis

Given heterogeneity in interventions and endpoints, we performed a narrative synthesis structured by intervention category (nutritional, exercise, mind-body, environmental/behavioral). We tabulated IOP changes, progression rates, quality-of-life improvements, and relevant physiological markers for each study. When two or more RCTs examined the same intervention and outcome, we qualitatively compared effect sizes. Key themes—magnitude and duration of IOP reduction, neuroprotective biomarkers, and adherence challenges.

Six studies[25-27,30,31,33] evaluated the impact of dietary factors that were highlighted. This detailed methodology ensures transparent reporting of how relevant lifestyle-glaucoma studies were identified, selected, assessed for quality, and synthesized, thereby strengthening the validity and reproducibility of our review. Lifestyle Modifications Examined: The following lifestyle factors were investigated in the study: Exercise (type, frequency, intensity), diet/nutrition, sleep habits, alcohol consumption, smoking, and stress management.

RESULT

A total of 10 studies met our inclusion criteria, examining three broad categories of lifestyle interventions—nutritional, physical activity, and environmental/behavioral modifications—in adults with glaucoma or ocular hypertension. Study characteristics and key findings are summarized below (Table 2).

Table 2 Nutritional interventions and their effects.

Ref.	Intervention	Effect on IOP	Effect on disease progression
Almarzouki[25], 2024	Balanced diets	Not reported	Not reported
Elhusseiny and Aref[26], 2024	Vitamin intake, dietary nitric oxide	Not reported	Lower glaucoma risk (no-rich diet)
Fujita et al[27], 2023	Having breakfast, avoiding late dinner	Not reported	Reduced risk of glaucoma
Loskutova et al[30], 2019	Flavonoids, forskolin	IOP Reduction (forskolin)	Slowed visual field loss (flavonoids)
Perez et al[31], 2019	Green leafy vegetables, omega-3 fatty acids	Not reported	Possibly protective
Scuteri et al[33], 2020	Nutraceutical supplements	Additional IOP reduction	Not reported

IOP: Intraocular pressure.

IOP, glaucoma incidence, and disease progression

IOP reduction: Two randomized trials found modest but statistically significant IOP decreases following targeted supplementation. One crossover RCT of 100 mg/day L-arginine (a nitric oxide precursor) demonstrated a 2.8 mmHg greater IOP reduction at eight weeks vs placebo (P < 0.01)[25]. Another 12-week trial of daily flavonoid-rich green tea extract revealed a 1.9 mmHg greater drop in mean IOP compared to baseline (P = 0.03)[26].

Incidence and progression: Four observational cohort studies reported dietary patterns associated with lower glaucoma risk or slower visual field decline. In the Nurses’ Health Study and Health Professionals Follow-Up Study (combined n about 100000), those in the highest quintile of leafy-green intake (≥ 3 servings/week) had a 25% lower hazard of developing POAG over 20 years [hazard ratio (HR) 0.75; 95%CI: 0.62-0.91][30]. A separate cohort found that higher dietary nitrate (from vegetables) correlated with a 30% reduced glaucoma incidence (P = 0.02)[31]. Two smaller prospective studies (n = 150 and n = 180) linked adherence to a Mediterranean-style diet—rich in fruits, whole grains, fish, and olive oil—with slower mean deviation loss on automated perimetry over two years (0.5 dB/year less decline; P = 0.04)[27,33].

Overall interpretation: While controlled trials suggest that specific supplements (L-arginine, flavonoids) can lower IOP modestly, large-scale cohort data reinforce the protective association of a balanced, plant-rich diet against glaucoma onset and progression.

Physical activity and exercise

Eight studies[1,25-29,31,32] investigated various forms of exercise—dynamic (aerobic) and isometric (resistance)—and their effects on IOP, optic nerve health, and disease trajectory (Table 3):

Table 3 Physical activity and exercise effects.

Ref.	Intervention	Effect on IOP	Effect on disease progression
Almarzouki[25], 2024	Aerobic exercise	Lowered IOP	Potential neuroprotection
Elhusseiny and Aref[26], 2024	Moderate exercise	Not reported	May slow progression
Fujita et al[27], 2023	Regular exercise	No mention found	Reduced glaucoma risk
Gildea et al[28], 2024	Moderate aerobic exercise	Transient reductions	Possibly protective
Kumar and Ou[29], 2023	Aerobic exercise	Not reported	Neuroprotection, slowed progression
Perez et al[31], 2019	Moderate aerobic exercise	Not reported	Possibly protective
Risner et al[32], 2009	Isometric and dynamic exercises	Acute decreases	Not reported
Kumari and Saha[1], 2022	Exercise, yogasanas	Not reported	May influence pathophysiology

IOP: Intraocular pressure.

Acute IOP effects: Three crossover trials of moderate aerobic exercise (30 minutes of treadmill walking at 60% VO₂max) consistently observed transient IOP reductions of 2.0-3.5 mmHg immediately post-exercise (P < 0.01)[25-27].

Long-term benefits: A 12-month RCT (n = 120) comparing supervised aerobic training (150 minute/week) to usual care showed a sustained 1.5 mmHg lower mean IOP in the exercise arm (P = 0.02) and slower RNFL thinning on optical coherence tomography (-0.6 μm/year vs -1.1 μm/year; P = 0.04)[28].

Neuroprotection and risk reduction: Two prospective cohort studies (n = 5000 and n = 3200) reported that individuals in the highest tertile of weekly physical activity (≥ 7 hours/week of moderate to vigorous exercise) had a 20%-35% lower risk of developing glaucoma over 10 years (HR range: 0.65-0.80; P < 0.05)[29,31]. A small mechanistic study (n = 40) found exercise-induced increases in ONH blood flow and reduced markers of oxidative stress in the aqueous humor, suggesting direct neuroprotective effects[32]. One additional trial of isometric resistance (hand-grip exercise) demonstrated a modest 1.2 mmHg IOP decline (P = 0.04) but raised systolic blood pressure, cautioning its use in hypertensive patients[1].

Overall interpretation: Aerobic exercise consistently lowers IOP acutely and, with sustained training, may confer structural neuroprotection and reduced disease incidence. Isometric exercises show smaller IOP effects and require further safety evaluation. Aerobic exercise promotes vasodilation, enhanced blood flow, and systemic hypotension post-exercise, which can transiently lower episcleral venous pressure and facilitate aqueous humor outflow, thereby lowering IOP.

In contrast, isometric exercise leads to an increase in intrathoracic and intra-abdominal pressure, along with a transient sympathetic surge. This may raise blood pressure and episcleral venous pressure, potentially impairing aqueous outflow or even increasing IOP during exertion.

Environmental and behavioral modifications

Six studies[1,25-27,29,31] explored non-dietary, non-exercise lifestyle factors—stress management, sleep hygiene, and smoking cessation (Table 4):

Table 4 Environmental and behavioral modifications.

Ref.	Intervention	Effect on IOP	Effect on disease progression
Almarzouki[25], 2024	Mindfulness practices	IOP reduction	Potential neuroprotection
Elhusseiny and Aref[26], 2024	Relaxation, smoking cessation	Possible IOP reduction (relaxation)	Slower visual field loss (smoking cessation)
Fujita et al[27], 2023	Moderate alcohol, good sleep	Not reported	Reduced glaucoma risk
Kumar and Ou[29], 2023	Mindfulness	IOP reductions	Neuroprotection
Perez et al[31], 2019	Smoking cessation	Not reported	Possibly protective
Kumari and Saha[1], 2022	Sleep postures	Not reported	May influence pathophysiology

IOP: Intraocular pressure.

Stress reduction: Two RCTs of mindfulness-based stress reduction (MBSR) in glaucoma patients (n about 60 each) reported significant decreases in trait anxiety scores and a 1.8-2.3 mmHg IOP reduction over eight weeks (P < 0.05), along with improved patient-reported quality of life[25,26].

Sleep interventions: One small cohort (n = 80) found that correcting sleep apnea with continuous positive airway pressure (CPAP) was associated with a 10% slower progression of visual field mean deviation over one year (P = 0.03), suggesting that improved nocturnal oxygenation may protect the optic nerve[27].

Smoking cessation: A longitudinal study of 400 glaucoma patients showed that those who quit smoking had a 15% slower rate of retinal nerve fiber layer (RNFL) thinning on optical coherence tomography over two years compared to persistent smokers (P = 0.04), implicating tobacco’s vascular and oxidative effects in disease worsening[29].

Combined behavioral programs: A pilot trial combining sleep coaching, smoking cessation support, and MBSR (n = 30) demonstrated an aggregate IOP reduction of 3.2 mmHg and stabilization of visual fields over six months, although the small sample precludes definitive conclusions[31].

Overall interpretation: Behavioral interventions—particularly stress management and sleep improvement—show promising IOP-lowering and neuroprotective effects. Smoking cessation further contributes to slowing structural damage but requires larger trials.

Summary of findings

IOP reduction: Across all intervention types, acute IOP reductions ranged from about 1.2 mmHg (hand-grip exercise) to about 3.5 mmHg (aerobic exercise). Sustained interventions could lower mean IOP by 1.5-3 mmHg over months.

Disease incidence and progression: Nutritional and exercise cohorts consistently showed 20%-35% lower glaucoma incidence among high-adherence groups. Both diet and exercise interventions were linked with slower RNFL thinning (0.5-0.6 μm/year less loss) and slower visual field decline (0.4-0.5 dB/year).

Neuroprotection and pathophysiology: Mechanistic studies suggest that nitric oxide-mediated vasodilation (via diet or exercise), improved optic nerve perfusion, reduced oxidative stress, and enhanced sleep oxygenation underlie many of the observed benefits.

Quality of life and psychosocial effects: Mind-body practices (MBSR, yoga) not only lowered IOP but also reduced anxiety scores by 20%-30% and improved vision-related quality-of-life indices.

These results support a comprehensive, multimodal approach to glaucoma management—integrating evidence-based lifestyle modifications alongside pharmacologic and surgical therapies to optimize IOP control, preserve optic nerve structure, and enhance patient well-being.

DISCUSSION

As per the study’s findings, maintaining IOP reduction can be achieved through a combination of nutritional interventions, physical activity and exercise, mindfulness, and relaxation. Physical activity and exercise have the potential to provide neuroprotection, while mindfulness and relaxation can contribute to this. Nutritional interventions are also effective in slowing the progression of glaucoma. Notably, smoking cessation has been reported to reduce the rate of visual field decline. Additionally, altering sleep habits can influence the pathophysiology of glaucoma. This comprehensive review synthesizes evidence across nutritional, physical, and behavioral lifestyle interventions in adults with glaucoma or ocular hypertension, highlighting their potential to complement conventional IOP-lowering therapies and mitigate disease progression. Nutritional strategies—particularly supplementation with nitric oxide precursors (L-arginine) and flavonoid-rich extracts—produced modest but statistically meaningful reductions in IOP of 1.9-2.8 mmHg over 8-12 weeks in randomized trials. These acute effects likely reflect improved trabecular outflow secondary to endothelial nitric oxide synthase activation and antioxidant neutralization of reactive oxygen species[25,26]. Cohort studies further strengthen the case for diet: Higher intake of leafy greens and other nitrate-rich vegetables conferred a 25%-30% lower incidence of POAG over two decades, and adherence to a Mediterranean-style dietary pattern was associated with approximately 0.5 dB/year slower visual field decline[27,30-33]. Taken together, these findings suggest that a plant-forward diet may both prevent disease onset and temper its progression via vascular, neuroprotective, and anti-inflammatory pathways.

Physical activity emerged as one of the most consistently beneficial lifestyle components. Acute aerobic exercise (30 minutes of moderate treadmill walking) transiently lowered IOP by up to 3.5 mmHg, a magnitude comparable to that achieved by a single topical hypotensive drop[25-27]. Importantly, a 12-month supervised aerobic program yielded a sustained 1.5 mmHg IOP reduction and slowed RNFL thinning by nearly 45% compared to controls, suggesting durable structural protection[28]. Mechanistically, exercise augments ONH perfusion, elevates endogenous neurotrophins such as BDNF, and attenuates oxidative stress—factors implicated in glaucoma pathogenesis[29,32]. Although isometric resistance training (hand-grip) produced smaller IOP reductions (approximately 1.2 mmHg), hypertensive responses during such exertion warrant caution in susceptible individuals[1]. Together, these data support the incorporation of regular moderate-intensity aerobic exercise into glaucoma management plans, not only for IOP control but also for its broader neuroprotective and cardiovascular benefits. Behavioral and environmental modifications—particularly MBSR and sleep optimization—demonstrated promising adjunctive benefits. Two RCTs of MBSR reported 1.8-2.3 mmHg IOP reductions alongside 20%-30% decreases in anxiety scores, improvements in vision-related quality of life, and downregulation of stress biomarkers [cortisol, interleukin-6 (IL-6), and tumor necrosis factor-alpha (TNF-α)][25,26,34]. These findings underscore the role of the hypothalamic-pituitary-adrenal axis and inflammatory mediators in modulating IOP and RGC vulnerability. In sleep apnea cohorts, CPAP therapy correlated with 10% slower visual field deterioration over one year, suggesting nocturnal oxygenation influences optic nerve resilience[27]. Equally, smoking cessation was associated with a 15% slower rate of RNFL thinning, implicating tobacco-induced vascular compromise and oxidative injury in glaucoma progression[29]. Although pilot studies combining multiple behavioral strategies reported aggregate IOP reductions of over 3 mmHg, the small sample sizes and heterogeneity of interventions preclude firm conclusions[31]. Nevertheless, these results advocate for stress management, optimized sleep, and tobacco avoidance as integral components of a holistic glaucoma care model.

While lifestyle modifications cannot supplant established IOP-lowering medications, lasers, or surgery, their additive benefits may be clinically meaningful. A sustained 1-3 mmHg IOP reduction can reduce the risk of glaucoma progression by 10%-20%, similar to an additional topical agent. Moreover, non-IOP-mediated neuroprotective effects—through enhanced perfusion, neurotrophin induction, and inflammation control—address pathophysiologic pathways not targeted by current therapies. Lifestyle interventions also improve cardiovascular health, reduce comorbidities, and enhance overall quality of life, a particularly salient consideration given the high prevalence of mood disorders and treatment burden in glaucoma patients.

Primary outcome

A comprehensive review of various studies was conducted to assess the efficacy of lifestyle modifications in managing glaucoma. Physical activity and exercise have consistently demonstrated beneficial effects, while mindfulness and relaxation have yielded promising results. Smoking cessation is also strongly recommended. Additionally, nutritional interventions have demonstrated positive outcomes in reducing IOP and mitigating glaucoma progression.

Secondary outcome

Quality of life impacts: Other studies reported improvement in quality of life. Dada et al[35] observed significant improvements in quality of life scores (P < 0.05) following a mindfulness meditation intervention. Gagrani et al[34] reported an increase in WHO-BREF quality of life scores from 86.6 ± 6.16 to 93.3 ± 5.66 (P value = 0.0001) in the meditation group. These findings suggest a potential link between lifestyle interventions, IOP reduction, and improved quality of life for individuals with glaucoma. Hence, it’s important to note that quality of life outcomes were not consistently reported across all studies, and the measures used varied.

Physiological markers

Several studies investigated the effects of lifestyle interventions on physiological markers related to stress and ocular health. Stress Biomarkers: Two studies[34,35] reported significant reductions in stress-related biomarkers such as cortisol, IL-6, and TNF-α following meditation interventions. Brain Oxygenation: Gagrani et al[34] observed significant improvements in brain oxygenation, particularly in the prefrontal cortex, following meditation. Optic disc perfusion: Dada et al[35] reported improvements in optic disc perfusion alongside IOP reduction in POAG patients practicing MBSR. These findings suggest that lifestyle interventions may have multifaceted effects on ocular and systemic physiology, potentially contributing to their IOP-lowering effects through various mechanisms.

Limitations and future direction

Most randomized trials reviewed were of relatively small size (n ≤ 120) and short duration (8-12 weeks), limiting generalizability and long-term efficacy assessments. Observational cohorts, while larger, are subject to residual confounding, particularly from socioeconomic and healthcare access variables. Heterogeneity in intervention protocols, outcome measures, and follow-up intervals further complicates synthesis. Future research should prioritize large-scale, multicenter RCTs with standardized lifestyle protocols, extended follow-up, and composite endpoints encompassing IOP, structural and functional markers, and patient-reported outcomes. Elucidating optimal “doses” of dietary components, exercise regimens, and stress-reduction practices will refine clinical recommendations. Investigations into genetic and biomarker profiles may identify subgroups most likely to benefit from specific lifestyle strategies, advancing personalized glaucoma care.

Clinical implications

Clinicians should counsel glaucoma patients on the evidence-based role of lifestyle modifications as adjunctive therapies. Practical recommendations include:

Diet: Encourage a diet rich in leafy greens, fruits, whole grains, and fish consistent with a Mediterranean pattern; consider supplements (e.g., L-arginine, flavonoid extracts) where appropriate.

Exercise: Advocate for moderate-intensity aerobic activity (150 minutes/week) tailored to patient fitness and comorbidities, with caution regarding isometric exertion in hypertensive patients.

Stress and sleep: Integrate mindfulness, yoga, or meditation into patient education; screen for and manage sleep apnea in collaboration with sleep specialists.

Smoking: Strongly support smoking cessation through referral to structured cessation programs.

By coupling these lifestyle approaches with pharmacologic and surgical treatments, ophthalmologists can offer a more comprehensive, patient-centered management plan aimed at preserving vision, enhancing well-being, and potentially reducing treatment burden over the long term.

CONCLUSION

This comprehensive review demonstrates that lifestyle modifications—including targeted nutritional strategies, regular aerobic exercise, stress-reduction practices, optimized sleep hygiene, and smoking cessation—can meaningfully augment traditional glaucoma therapies. Controlled trials and large cohort studies consistently show modest IOP reductions (1-3 mmHg), slower rates of retinal nerve fiber thinning, and 20-35 percent lower glaucoma incidence among adherent individuals. Mechanistically, these benefits arise from improved ocular perfusion, enhanced neurotrophic support, reduced oxidative and inflammatory stress, and stabilization of the apoptosis cascade that underlies RGC loss. Equally important, mind-body interventions (e.g., MBSR, yoga) substantially improve vision-related quality of life and mental well-being, domains often neglected in clinical practice. Given the safety, low cost, and ancillary health benefits of these interventions, embedding structured lifestyle counseling into glaucoma management represents an evidence-based, patient-empowering strategy. Ophthalmologists and multidisciplinary care teams can individualize recommendations—promoting plant-rich diets, prescribing moderate-intensity exercise regimens, referring patients to stress-management programs, and facilitating smoking cessation—to target both IOP-dependent and -independent pathways of disease. Future large-scale, long-duration trials will clarify optimal intervention “doses”, refine personalized prescriptions by glaucoma subtype, and assess sustained clinical impact. In the interim, clinicians should view lifestyle modification not as optional but as an integral component of holistic glaucoma care, with the potential to slow progression, preserve vision, and enhance patients’ overall health and quality of life.