Glaucoma: Changing mindsets
Summer 2025
by Liz Hillman
Editorial Co-Director
While the treatment mainstays for lowering and/or maintaining a target IOP are achieved with surgery, laser, or pharmaceuticals, patients often ask what else they can do. Several physicians spoke to EyeWorld about lifestyle changes that they recommend as an addition to traditional glaucoma therapies.
Nutrition
When it comes to nutrition, Grace Richter, MD, MPH, said there is evidence that positive nutritional habits can help reduce risk of developing glaucoma, though there isn’t data yet on whether this can slow existing disease. “That doesn’t stop me from discussing nutrition with my severe glaucoma patients, who are on the brink of blindness with very delicate remaining retinal ganglion cells and who have the most at stake,” she said.
Dr. Richter said Level 1 evidence suggests patients should increase dietary nitrates, such as green leafy vegetables and beets, adopt a Mediterranean diet, avoid ultra-processed food, and reduce carbohydrate intake. Level 2 evidence suggests patients increase fat and protein from vegetable sources, replacing carbohydrates, increase fruit and vegetable intake, increase dietary niacin, and avoid a very low fat diet.
“This is a lot of information, and it can be overwhelming to some patients, so I start with an easy and obtainable goal to eat a salad every day,” Dr. Richter said. “For those who are more interested and ready to optimize their diet, I dive into more details.”
Dr. Richter said the Level 1 studies supporting that dietary interventions can reduce risk of developing glaucoma are largely epidemiology based, following participants over many years and understanding dietary habits with detailed food questionnaires.
Though there are no studies to date that look at the effects of dietary interventions on slowing glaucoma progression, Dr. Richter said there are well-studied biological mechanisms showing that certain dietary interventions can reduce oxidative and inflammatory damage and enhance mitochondrial function of retinal ganglion cells. “I think it’s just a matter of time before we have data proving that dietary interventions can slow glaucomatous progression and optimize optic nerve health among those who already have glaucoma,” she said.
Anecdotally, Dr. Richter mentioned a patient she began seeing several years ago who was 49 years old. Early on, this patient admitted to having poor diet and lifestyle habits, but her diagnosis with glaucoma motivated her to make changes to both.
“She started eating a healthy Mediterranean diet and exercising, and she was very adamant about not starting glaucoma treatment until she spent a few months with her new diet. Because her disease was relatively early stage, we agreed on this plan,” Dr. Richter said. “Surprisingly, her visual field defect went away for the next several visual field tests and her intraocular pressure modestly improved. Though her diagnosis was still ‘preperimetric glaucoma,’ she was ecstatic that this had happened. I love learning from my patients, and she opened up my mind to the impact that lifestyle may have on glaucoma.”
Even though nutrition is important for overall health, Dr. Richter said currently the only proven treatment for slowing glaucoma is IOP reduction with drops and/or procedures. Dr. Richter said she describes nutrition as a “supplemental way to optimize optic nerve health, based on newer evidence.”
Exercise
First and foremost, Shan Lin, MD, said that lowering IOP is the only proven way to prevent glaucoma progression, but he said when patients ask what else they could do, he mentions that exercise is an overall positive for their health. “Aerobic exercise is shown to be beneficial in terms of helping to lower intraocular pressure a small amount,” Dr. Lin said.
The mechanisms of action for this include decreased aqueous production, dehydration of the globe, increased outflow, and decreased episcleral venous pressure.
There are some caveats for exercise when a patient has glaucoma, however. Weight training or weight-bearing exercises and certain yoga positions where the head is below the heart tend to increase eye pressure, Dr. Lin said. Additionally, his group published a study that found that an excessive amount of exercise or intensity can increase glaucoma risk compared to moderate exercise.1
Weight loss medications
Qi Cui, MD, PhD, is a clinician-scientist who has focused a lot of her research on neuro-inflammation—how inflammation occurs in the eye and contributes to glaucoma pathogenesis.
Like many, Dr. Cui became interested in GLP-1 receptor agonists, a diabetes drug that has garnered recent interest culturally for its weight loss effects.
“We started looking at this class of medication and found it’s protective against retinal ganglion cell death in an animal model of glaucoma we use in the lab. From there we thought about how this class of medication may be protective against glaucoma for human patients.”
In addition to decreasing activation of inflammatory cells in the retina, Dr. Cui said these drugs decrease insulin resistance, and insulin may be protective in the eye. GLP-1 receptor agonists may also improve mitochondrial function and decrease oxidative stress, both of which have been shown to be beneficial in glaucoma. Dr. Cui said there have been multiple database studies looking at patients who were on these medications for diabetes or weight loss that found a decreased likelihood that these patients developed glaucoma.2
One important factor to research would be the safety and efficacy of the use of GLP-1 receptor agonist medications in a patient without diabetes and without the need for weight loss but who has glaucoma. Dr. Cui said clinical trials are just beginning to investigate this.
If Dr. Cui has a patient with suboptimal diabetic control who is at risk for glaucoma, she said she would talk to them about the possible benefits of GLP-1 receptor agonists. She would tell these patients there’s substantial evidence that GLP-1 receptor agonists may be protective against glaucoma in diabetic patients and would advise that they consider these drugs to improve both diabetic control and potentially decrease their risk of developing glaucoma.
Sleep
Kaweh Mansouri, MD, said there is not currently conclusive evidence regarding sleep modifications and glaucoma management. As noted in a 2019 review, some sleep positions “appear to be associated with higher intraocular pressure, although the association between sleep position and glaucoma progression is not as clear.”3
“We know that IOP is often at its highest during the nocturnal sleep period, and therefore, whenever there is progression despite normal daytime IOPs, I aim to obtain nighttime IOP measurements, either through an IOP-sensing contact lens, an intraocular sensor, in a sleep laboratory, or by providing patients with a self-tonometer,” Dr. Mansouri said, adding that glaucoma surgery generally flattens nocturnal IOP increases and seems to be protective in patients at high risk for progression or documented progression.
Dr. Mansouri said getting a good amount of high-quality sleep can help with overall health and glaucoma.
Meditation and yoga
“A question I get asked a lot from my patients is ‘What can I do in addition to my drops in order to help my glaucoma?’” said Monica Ertel, MD. “I’ve made an effort to focus on nutrition changes, exercise changes but also mindfulness and meditation.”
When it comes to yoga and meditation, Dr. Ertel said there is more beneficial data on meditation, but she offered some advice for yogis who have glaucoma. She tells them that any time their heart is below their hips or their feet are above their head, if they’re lying on the floor, this can put them at risk for optic nerve-damaging IOP spikes. These positions should be avoided or modified, Dr. Ertel said.
Meditation, on the other hand, is a “no brainer,” Dr. Ertel said. “There are only potential benefits and no potential risks with meditation.”
Dr. Ertel said meditation can reduce cortisol levels and intraocular pressure and improve things like brain-derived neurotrophic factors, inflammatory cytokines, and it changes gene regulation.4 Research has shown a benefit from meditating as little as 30 minutes a day, and she recommended apps like Calm and Headspace for guided meditations.
“It’s remarkable that meditation has such a physiologic impact on our bodies, and I think it speaks to how much stress plays a role in a lot of our disease processes and how we ignore the role that stress plays,” Dr. Ertel said.
About the physicians
Qi Cui, MD, PhD
Associate Professor of Ophthalmology
University of Pennsylvania
Philadelphia, Pennsylvania
Monica Ertel, MD
Assistant Professor of Ophthalmology
University of Colorado Anschutz Medical Campus
Denver, Colorado
Shan Lin, MD
Glaucoma Center of San Francisco
San Francisco, California
Kaweh Mansouri, MD
Adjoint Professor
Department of Ophthalmology
University of Colorado Anschutz Medical Campus
Denver, Colorado
Grace Richter, MD, MPH
Partner
Southern California Permanente Medical Group
Kaiser Permanente Los Angeles Medical Center
Los Angeles, California
References
- Lin SC, et al. The relation between exercise and glaucoma in a South Korean population-based sample. PLoS One. 2017;12:e0171441.
- Sterling J, et al. Glucagon-like peptide 1 receptor agonist use is associated with reduced risk for glaucoma. Br J Ophthalmol. 2023;107:215–220.
- Kaplowitz K, et al. Relationship between sleep position and glaucoma progression. Curr Opin Ophthalmol. 2019;30:484–490.
- Dada T, et al. Mindfulness meditation reduces intraocular pressure, lowers stress biomarkers and modulates gene expression in glaucoma: a randomized controlled trial. J Glaucoma. 2018;27:1061–1067.
Relevant disclosures
Cui: None
Ertel: None
Lin: None
Mansouri: AbbVie, Alcon, Implandata, iStar Medical, New World Medical, Santen, Théa Pharma, Zeiss
Richter: None
Contact
Cui: Qi.Cui@pennmedicine.upenn.edu
Ertel: monica.ertel@cuanschutz.edu
Lin: sl@glaucomasf.com
Mansouri: kwmansouri@gmail.com
Richter: gracerichter@gmail.com
