For years, the clinical script for primary open-angle glaucoma (POAG) has included a gentle nudge toward physical activity. We’ve told patients that a daily walk isn’t just good for the heart; it’s also a “win” for the optic nerve. However, new data suggests that our advice may have been too passive. If we want to impact the course of this disease, we may need to stop talking about movement and start talking about intensity.

A landmark 2026 study by Akarapimand et al has challenged the status quo. By analyzing objective Fitbit data from the NIH All of Us program, researchers found that while glaucoma patients generally take fewer steps than healthy peers, step counts and light activity are not independently associated with glaucoma diagnosis or severity once adjusted for age and comorbidities.¹

In short: Simply “hitting your steps” may offer little to no specific benefit for glaucoma patients, which suggests that low-intensity movement may fail to trigger the physiological shifts that are necessary for ocular protection.

To achieve a meaningful clinical impact, patients may need more than a casual stroll. The benefits of exercise in glaucoma seem to be dose-dependent and intensity-driven. For example:

• The IOP drop: Vigorous aerobic exercise can drop intraocular pressure (IOP) by ~1.7 mmHg to 3 mmHg. This effect is additive to all topical treatments and provides a lifestyle supplemental therapy for patients.^2-4

• Neuroprotection and BDNF: Animal models demonstrate that intense exercise preserves retinal ganglion cell (RGC) function via brain-derived neurotrophic factor (BDNF) pathways. Essentially, high-intensity movement acts as a biochemical shield for the retina, making aged tissues more resilient to pressure-induced stress.⁵

• Vascular perfusion: Higher-intensity activity improves endothelial function and ensures that the optic nerve head remains well perfused even when systemic pressures fluctuate. Higher intensity exercise triggers the release of nitric oxide and other vasodilators, which may stabilize the vascular tone of the vessels that supply the optic nerve.⁶

The Akarapimand study is not without flaws. The research relied heavily on billing and diagnosis codes rather than clinical data. By failing to include optical coherence tomography (OCT) or visual field data, the study may have lacked accuracy and sensitivity. Furthermore, Fitbit data, while objective, may not capture the nuance of resistance training or isometric exercises that could impact IOP. It is also important to note that patients with moderate and advanced glaucoma should be wise in their selection of activities due to reduced peripheral vision, limited depth perception, or both to reduce fall risk while maximizing activity at home or while away.⁷

Nevertheless, we may need to shift patient conversations toward a more high-intensity approach: 

• Vigorous aerobics (the gold standard): 150 minutes per week of activity that raises the heart rate and induces sweating (eg, brisk cycling, swimming, or jogging).

• Strategic timing: Encourage high-intensity bursts in the morning or late evening to counter the time where IOP often climbs.⁸

• The “medication blunt”: Be aware that topical beta-blockers can suppress heart rate and make it harder for patients to reach the intensity required for neuroprotection. If they feel restricted by their fitness level, consider switching to a different class of medication.  

Although any movement is better than sedentary behavior, the weight of evidence may point toward vigorous aerobic activity as the most appropriate lifestyle exercise modification in glaucoma, when it’s safe for patients with more advanced disease. We may need to ask our patients to train for the long-term health of their sight. 

References:

1. Akarapimand P, Hallaj S, Weinreb RN, Baxter SL. Associations between physical activity and glaucoma: analysis of the National Institutes of Health All of Us Research Program. J Glaucoma. 2026;35(1):34-41. doi:10.1097/IJG.0000000000002660
2. Read SA, Collins MJ. The short-term influence of exercise on axial length and intraocular pressure. Eye (Lond). 2011;25(6):767-774. doi:10.1038/eye.2011.54
3. Natsis K, Asouhidou I, Nousios G, Chatzibalis T, Vlasis K, Karabatakis V. Aerobic exercise and intraocular pressure in normotensive and glaucoma patients. BMC Ophthalmol. 2009;9:6. doi:10.1186/1471-2415-9-6
4. Siang JYD, Mohamed MNAB, Ramli NBM, Zahari MB. Effects of regular exercise on intraocular pressure. Eur J Ophthalmol. 2022;32(4):2265-2273. doi:10.1177/11206721211051236
5. Chrysostomou V, Galic S, van Wijngaarden P, Trounce IA, Steinberg, GR, Crowston JG. Exercise reverses age-related vulnerability of the retina to injury by preventing complement-mediated synapse elimination via a BDNF-dependent pathway. Aging Cell. 2016;15(6):1082-1091. doi:10.1111/acel.12512
6. Van Eijgen J, Schuhmann V, Fingerroos EL, et al. High-intensity interval training in patients with glaucoma (HIT-GLAUCOMA): protocol for a multicenter randomized controlled exercise trial. Front Physiol. 2024;15:1349313. doi:10.3389/fphys.2024.1349313
7. Ramulu PY, Mihailovic A, West SK, Gitlin LN, Friedman DS. Predictors of falls per step and falls per year at and away from home in glaucoma. Am J Ophthalmol. 2019;200:169-178. doi:10.1016/j.ajo.2018.12.021
8. Huang AS, Mai AP, Goldberg JL, et al. The benefit of nocturnal IOP reduction in glaucoma, including normal tension glaucoma. Clin Ophthalmol. 2024;18:3153–3160. doi:10.2147/OPTH.S494949

Mike Cymbor, OD, FAAO is director of the Glaucoma Institute of State College and the lead OD at Nittany Eye Associates in State College, Pennsylvania.