Daily Life Precautions for Glaucoma Patients

Key points at a glance

Key Points at a Glance

• Optic nerve damage due to glaucoma is irreversible, and lifelong intraocular pressure management is the basis of treatment.
• Intraocular pressure is the only modifiable risk factor for glaucoma, and lifestyle can affect intraocular pressure.
• Approximately 40% of patients who are prescribed eye drops for the first time discontinue treatment within one year ¹⁾.
• Fixed-combination eye drops reduce the number of drops and instillations, improving adherence (recommendation grade 1B) ¹⁾.
• Moderate aerobic exercise lowers intraocular pressure and may protect against visual field progression.
• Advanced bilateral visual field defects significantly impair daily activities such as driving, reading, walking, and facial recognition.
• Current scientific evidence for strong lifestyle recommendations is limited, and they cannot replace drug therapy or laser treatment ²⁾.

1. Long-term Management of Glaucoma

Glaucoma is an optic neuropathy characterized by progressive degeneration of retinal ganglion cells and visual field loss ⁴⁾. The optic nerve damage and visual impairment caused by glaucoma are irreversible, and the primary goal of treatment is to preserve current visual function. The prevalence in individuals aged 40 years and older is 5.0% (Tajimi Study), with an estimated 4.65 million patients ¹⁾. Furthermore, the same epidemiological survey found that 89% of glaucoma cases were newly detected, indicating a large number of untreated glaucoma patients ¹⁾.

In primary open-angle glaucoma (POAG), lifelong continuation of drug therapy is assumed. Treatment primarily focuses on lowering intraocular pressure, starting with a single agent and limiting to a maximum of two agents whenever possible. Drug selection considers target intraocular pressure, side effects, instillation frequency, and patient preference. Even with slow progression, complete arrest is rare, and treatment plans must allow for gradual progression over the long term. Younger patients have longer life expectancy and require more aggressive treatment and management with a higher estimate of severity.

While POAG alone rarely leads to severe visual impairment, it has been reported that POAG patients account for the highest proportion among glaucoma patients visiting low-vision clinics. Treatments targeting factors other than intraocular pressure, such as circulation improvement and neuroprotection, are also considered, but intraocular pressure reduction remains the most reliable treatment at present.

Risk Factors

Intraocular pressure is the only modifiable risk factor for glaucoma, and intraocular pressure management is the basis of treatment ²⁾⁴⁾. Other reported risk factors include ⁴⁾⁵⁾:

• Advanced age
• Family history
• Myopia: Classified as having “highly suggestive evidence” in an umbrella review⁹⁾
• Thin central corneal thickness
• Exfoliation syndrome
• Diabetes
• Systemic hypertension: Low diastolic blood pressure may increase glaucoma risk through reduced perfusion pressure⁴⁾
• Obstructive sleep apnea syndrome⁵⁾
• Arteriosclerosis: In a large cohort study (4,713 patients, follow-up 10.5 years), the highest quartile of aortic pulse wave velocity (aPWV) had a 2.62-fold higher risk of developing glaucoma compared to the lowest quartile (HR 2.62, 95% CI 1.52-4.52)⁷⁾

Beros et al. (2024) reported that arterial stiffness measured by a simple oscillometric device may predict the development of glaucoma. The HR per 1 standard deviation increase in aPWV was 1.36 (95% CI 1.14-1.62), suggesting that arteriosclerosis could be a new risk marker for glaucoma⁷⁾.

Q Can glaucoma be cured by changing lifestyle habits?

A

Glaucoma cannot be cured by lifestyle changes alone. Glaucoma is an irreversible optic nerve disorder, and the mainstay of treatment is intraocular pressure management through medication, laser therapy, or surgery. However, moderate exercise and a balanced diet may contribute adjunctively to intraocular pressure control and are important as part of overall health management.

2. Continuing eye drop treatment

Current status and importance of adherence

Non-adherence rates in glaucoma treatment are reported to be 30–80%. Approximately 40% of patients who are prescribed glaucoma eye drops for the first time discontinue treatment within about one year¹⁾. This is attributed to the lack of subjective symptoms and the absence of feedback on treatment effectiveness except during clinic visits¹⁾. Poor adherence is a major factor in glaucoma progression, and it is desirable to select medications that facilitate adherence as well as treatment efficacy (recommendation grade 2B)¹⁾.

Factors contributing to decreased adherence

Obtaining the medication

Cost burden: If the drug price is high, obtaining it becomes difficult. Using generic drugs is effective.

Early refill issues: Instilling more than one drop may cause the medication to run out sooner than expected.

Proper instillation

Physical limitations: Reduced grip strength due to rheumatic or neurological diseases, and limited neck extension make instillation difficult.

Bottle operability: The force required to dispense one drop varies by bottle. Multiple drops may be used or wasted.

Daily maintenance

Forgetfulness: This is especially problematic in elderly patients with multiple chronic diseases.

Asymptomatic nature: Since most cases are asymptomatic, some patients do not feel the need to instill daily.

Side effects: Without explanation of local side effects (redness, pigmentation, etc.), some patients may discontinue use.

Practical guidance for the elderly

In elderly patients, problems with instillation technique and forgetting to instill are major causes of poor adherence. Many elderly patients have difficulty tilting their head back due to spinal deformity, so instructing them to instill while lying down improves success rates.

• Adjusting instillation posture: Instruct instillation in a supine position.
• Illustrated instructions: Clearly show which eye drops to use at different times of day.
• Explaining to family and requesting cooperation: Check the home environment (living alone or with family, presence of a caregiver) and ask for help with reminders (directly, by phone, or using alarms).
• Reducing the number of eye drops and frequency: Arrange them to be taken at times convenient for the caregiver.

Medication adjustments

Currently, the first-line drug is prostaglandin analogs (PGAs), which are the most widely used due to their excellent intraocular pressure-lowering effect and once-daily dosing (recommendation grade 1A)¹⁾. Second-line options include beta-blockers, but in cases where systemic side effects are a concern, such as in elderly patients, beta-blockers should be avoided and CAIs (carbonic anhydrase inhibitors), alpha-2 agonists, or ROCK inhibitors should be selected.

Five fixed-combination eye drops are available, allowing multiple drugs to be administered without increasing the number or frequency of drops, which is advantageous for maintaining adherence (recommendation grade 1B)¹⁾. However, forgetting to use a fixed-combination drop results in a greater loss of intraocular pressure-lowering effect than with a single agent, so adherence monitoring is even more important.

Eye drop aids

There are aids useful for patients with physical limitations.

Type of aid	Purpose	Features
Eye drop guide	Alignment	Fixes lower eyelid, guides gaze
Bottle aid	Grip assistance	Clip-on type
Drop volume regulator	Reduction of waste	Reduces drop volume by over 60%

Strategies to improve adherence

The glaucoma treatment guidelines recommend the following five items (2B)¹⁾:

1. Provide thorough explanation of the disease, treatment goals, methods, and side effects
2. Choose the least burdensome treatment with minimal side effects
3. Tailor treatment to the patient’s individual lifestyle
4. Provide correct instruction on eye drop instillation
5. Collect information from the patient about their adherence status

Evidence shows that providing written explanations, appointment management, and reminder notifications significantly improve treatment continuation rates¹⁾. The EGS 6th edition also recommends simplification, education, effective communication, and use of alarms/messages²⁾.

Identifying non-adherence

• Ask about yesterday’s eye drop time: If the patient cannot answer smoothly, they may not be continuing instillation
• Observe eye drop instillation: Watch the patient actually instill drops in the examination room to identify technical issues
• Check eye drop consumption: If consumption is slower than expected, the drops may not be used

When intraocular pressure control is insufficient or visual function impairment progresses, it is necessary to re-evaluate adherence (recommendation level 2B)¹⁾. In cases where drug therapy cannot be adequately performed due to side effects or poor adherence, laser therapy or invasive surgery are options¹⁾.

Q Can fixed-combination eye drops help improve adherence?

A

Fixed-combination eye drops can deliver two drug components in one bottle, reducing the number of eye drops and instillation frequency. The glaucoma practice guidelines also state that they are useful for improving adherence when multiple drugs are used (recommendation level 1B). However, the loss of intraocular pressure-lowering effect when a dose is missed is greater than with single agents, so confirming adherence becomes more important.

3. Exercise and Daily Activities

Effects of Aerobic Exercise

Recommended Exercises

Walking and cycling: A mild increase in intraocular pressure is observed during activity, but a decrease in intraocular pressure persists afterward.

Running: Intraocular pressure decreases by about 2 mmHg but returns to baseline within 30 minutes after exercise ends.

Suppression of visual field progression: Each 5,000 steps of walking or 2.5 hours of non-sedentary time per day reduces visual field progression by 10%.

Protective effect on the retina: Increased physical activity slows the thinning rate of the ganglion cell-inner plexiform layer.

Exercises Requiring Caution

Weightlifting: Isometric holding causes a temporary increase in intraocular pressure. It has been reported that intraocular pressure can reach about 41 mmHg during leg press.

Yoga (inverted poses): Poses where the head is lower than the heart (e.g., downward dog) significantly increase intraocular pressure. In headstands, intraocular pressure approximately doubles.

High-intensity workouts: Daily intense exercise is associated with a higher prevalence of glaucoma compared to exercising three days a week. This may involve oxidative stress due to increased free radicals.

Swimming goggles: Wearing them can cause a temporary and marked increase in intraocular pressure.

In a study of patients newly diagnosed with glaucoma, the group that exercised for 30 minutes daily showed a significant reduction in intraocular pressure compared to the medication group. It has been reported that each 10-minute increase in evening activity reduces the odds of visual field progression in POAG patients by 15%. Increased physical activity has also been associated with a slower rate of thinning of the ganglion cell inner plexiform layer, suggesting that exercise may have neuroprotective effects beyond lowering intraocular pressure.

However, the 6th edition of the EGS states that “there is currently no strong evidence that dietary or lifestyle factors affect glaucoma” ²⁾, and lifestyle modifications are only considered adjunctive. It is important to consult with your primary care physician regarding the type, intensity, and timing of exercise, and to make decisions based on individual medical conditions.

Q Should glaucoma patients avoid yoga?

A

It is not necessary to avoid all yoga, but poses where the head is lower than the heart, such as “downward dog,” “forward bend,” and “headstand,” are recommended to be avoided as they significantly increase intraocular pressure. Caution is especially needed in patients at high risk of progression. Poses that can be performed while sitting or standing are usually not problematic.

4. Diet, Habits, and Intraocular Pressure

Dietary Nitrate and Green Leafy Vegetables

Dietary nitrate, abundant in green leafy vegetables, is converted to nitric oxide in the body. Nitric oxide is thought to protect against glaucoma through vasodilation, increased aqueous humor outflow, and decreased episcleral venous pressure. Large cohort studies (e.g., Nurses’ Health Study) have shown that groups with higher dietary nitrate intake have a 20–30% lower risk of developing POAG.

Omega-3 Fatty Acids

Omega-3 fatty acids (EPA and DHA) regulate systemic microcirculation and ocular blood flow. In a prospective study of patients with pseudoexfoliation glaucoma, oral DHA intake for 6 months resulted in a significant reduction in intraocular pressure. However, a high ratio of omega-6 to omega-3 has also been reported to increase glaucoma risk, so conclusions are not yet definitive.

Vitamins and Supplements

The main findings are summarized below.

Nutrient	Main Findings
Vitamin B3 (Niacinamide)	Prevents mitochondrial dysfunction and provides neuroprotection
Flavonoids	Improvement in mean deviation of visual field
Vitamin A	Suggestive association between intake and glaucoma risk9)

Vitamin B3 (nicotinamide) reduces vulnerability to glaucoma in mouse models, and clinical trials have shown improvement in inner retinal function. However, at present, there is insufficient evidence that specific vitamin supplements reduce the risk of glaucoma. The EGS 6th edition states that evidence supporting the role of alternative therapies or neuroprotective agents in glaucoma management is insufficient²⁾.

Alcohol

Alcohol consumption temporarily lowers intraocular pressure, but chronic intake may increase the risk of open-angle glaucoma by 1.18 times. An umbrella review classified this as “weak evidence”⁹⁾. The certainty of the evidence is very low.

Caffeine

Caffeine intake is not associated with increased intraocular pressure in healthy individuals, but in patients with a history of glaucoma or ocular hypertension, it is associated with a temporary increase of about 2.4 mmHg one hour after consumption. In patients with a family history of glaucoma or genetic predisposition, an association between caffeine intake and glaucoma prevalence has been suggested.

Q Should glaucoma patients avoid coffee?

A

Moderate coffee consumption is generally considered not a major problem. However, in patients with glaucoma or ocular hypertension, a temporary increase in intraocular pressure (about 2.4 mmHg) after caffeine intake has been reported. Especially for those with a family history of glaucoma or inadequate intraocular pressure control, it is advisable to avoid high caffeine intake (more than 2-3 cups of coffee per day).

5. Sleep, Body Position, and Smoking

Sleeping Position and Intraocular Pressure

Intraocular pressure is affected by body position¹⁾. Key findings are as follows:

• Supine position: Compared to sitting, intraocular pressure increases by 1-2 mmHg in healthy individuals and by 4 mmHg in glaucoma patients. The main mechanism is an increase in episcleral venous pressure due to postural change¹⁾
• Side-lying position: Intraocular pressure in the lower eye increases by about 1.5–2 mmHg. In glaucoma patients, if there is a habit of sleeping with the more affected side down, the risk of visual field progression may increase.
• Rubbing the eyes: In a primate model study using telemetry sensors, transient intraocular pressure elevations exceeding an average of 109 mmHg were recorded ³⁾.

Diurnal variation of intraocular pressure

In normal individuals, intraocular pressure fluctuates by about 3–6 mmHg throughout the day ¹⁾. In glaucoma patients, the fluctuation range becomes larger due to reduced aqueous humor outflow ¹⁾. The highest intraocular pressure is often observed in the morning, and the lowest in the evening to nighttime ¹⁾.

Obstructive sleep apnea syndrome

Obstructive sleep apnea syndrome has been reported as a risk factor for glaucoma ⁵⁾. In an umbrella review, it was classified as “suggestive evidence” ⁹⁾. However, this association is not consistently shown in all studies ⁴⁾.

Smoking

Smoking is listed as one of the risk factors for glaucoma. It is thought to be involved through increased oxidative stress, impaired retinal microcirculation, and direct toxicity to the optic nerve. In an umbrella review, both current smoking and former smoking were classified as “non-significant” ⁹⁾, but considering the impact on overall health, smoking cessation is recommended.

Prevention and daily care

The following are some tips that glaucoma patients can incorporate into their daily lives:

• Make a habit of moderate aerobic exercise such as walking.
• Aim for a balanced diet (especially green leafy vegetables).
• Avoid excessive caffeine intake and excessive alcohol consumption.
• Avoid yoga poses that put the head down.
• Avoid rubbing the eyes vigorously.
• Quit smoking
• Consider elevating the head during sleep (if necessary)

6. Driving and Travel Safety

Visual field defects and driving risks

The odds of stopping driving double for every 5 dB worsening of visual field loss in the worse eye. Patients with advanced glaucoma have 3.5 times higher odds of being involved in a motor vehicle accident ⁴⁾. Impairment of the useful field of view (UFOV) is the strongest risk factor for motor vehicle accidents ⁴⁾.

In on-road driving tests, glaucoma patients with mild to moderate visual field defects were able to complete the driving course, but were 6 times more likely to require instructor intervention. In simulator studies, glaucoma patients showed significantly more saccades, fixations, and pursuit eye movements, and their gaze patterns did not change when hazards appeared in areas of visual field loss.

Safety considerations for clinic visits

When elderly patients visit the outpatient clinic, always check the following three items:

1. Presence of an accompanying person: including their relationship to the patient
2. Means of transportation: if by car, whether they drive themselves or use a taxi, etc.
3. Walking aids: cane, wheelchair, walker, mobility scooter, etc.

This information should be shared among all staff involved in outpatient care.

Progression of glaucoma itself may make eye drop therapy or oral medication difficult, potentially leading to reduced treatment accuracy for other diseases. Maintaining QoL is one of the most important goals in glaucoma care, and comprehensive life support including securing means of transportation is required ¹⁾. The 6th edition of the EGS also notes that patients are often confused about regional regulations regarding glaucoma and driving, and recommends providing appropriate information ²⁾.

Points to note about driving and visual field defects

As glaucoma progresses and visual field defects become severe, it may become impossible to ensure safety while driving. Based on the results of regular visual field tests, consult with your doctor about whether you can drive. If you are concerned about driving, consider alternative means such as public transportation or taxis early on.

7. Daily Functional Impairment and Low Vision Care

Major Functional Impairments

The goal of glaucoma management is to minimize visual impairment and promote the best possible quality of life (QoL) within a sustainable healthcare system ²⁾. While early to moderate glaucoma has a limited impact on QoL, advanced bilateral visual loss significantly reduces QoL ²⁾.

• Reading difficulty: In glaucoma, reading speed and letter search are reduced, involving central visual function and contrast sensitivity loss in addition to visual field defects ⁶⁾. Difficulties are more pronounced under low-contrast conditions.
• Walking impairment: Walking speed is strongly correlated with the mean deviation (MD) of the worse eye. Fear of falling leads to reduced QoL and increased morbidity.
• Driving ability: For every 5 dB worsening of visual field defect in the worse eye, the odds of driving cessation double (see “Driving and Mobility Safety” section).
• Face recognition difficulty: Contrast sensitivity loss and visual field defects act in combination ⁶⁾. This is an important component of social interaction and significantly affects QoL.

Importance of Contrast Sensitivity

Contrast sensitivity is an important predictor of the ability to perform activities of daily living ⁶⁾. Even in glaucomatous eyes with visual acuity of 20/40 or better, contrast sensitivity is significantly reduced (correlation with visual field MD: r=0.638, P<0.05), and visual acuity alone cannot predict the degree of functional impairment ⁶⁾. Recent studies have shown that macular damage in early glaucoma is more common than previously thought ⁶⁾.

Assessment Scales

Several scales are available to assess the impact of visual function on QoL.

Assessment Scale	Number of Items	Type
NEI-VFQ 25	25 items	Self-report
GSS	10 items	Self-report
GQL-15 / GAL-9	15 questions / 9 questions	Self-report
ADREV	9 tasks	Performance-based
UFOV	—	Performance-based

Self-report scales

Advantages: Easy to administer. Reflects the patient’s subjective perception

Disadvantages: Reporting bias. Disability may be underreported if tasks are avoided

Representative examples: NEI-VFQ, GSS, GQL-15/GAL-9

Direct measurement scales

Advantages: Can be tested under standardized conditions. Less susceptible to reporting bias.

Disadvantages: Difficult to administer and burdensome for subjects. Cannot fully replicate real-world environments.

Representative examples: ADREV, UFOV

Support resources

Low vision centers and local disability support organizations assist visually impaired individuals in independent living.

• Reading support: Digital readers and tablets for text enlargement and contrast improvement, handheld and desktop magnifiers, video magnifiers (CCTV), text-to-speech software
• Walking and balance: Canes, walkers, non-slip bath mats, bathtub grab bars, bedside rails
• Transportation: Mobility training (guidance on using public transportation), welfare taxis

Maintaining QoL is one of the most important goals in glaucoma care ¹⁾. As glaucoma progresses, eye drops and oral medications may become difficult to administer, and this can also affect the accuracy of treatment for other diseases ¹⁾. To preserve patients’ QoL, it is necessary not only to treat the disease but also to consider the psychological impact of diagnosis and treatment on patients and their families (recommendation level 2C) ¹⁾.

Q What daily life difficulties do glaucoma patients experience?

A

The most frequent complaint is difficulty performing tasks under low or high illumination. Reading difficulty is observed even in moderate glaucoma with normal visual acuity, and is more pronounced with small or low-contrast text. Decreased walking speed and balance problems lead to an increased risk of falls. Driving ability is also significantly affected, with accident risk increasing 3.5 times in advanced cases. These impairments are mainly due to reduced contrast sensitivity and visual field defects.

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8. Latest research and future perspectives

For patients: Please read this

The following content is currently in the research stage or under clinical trial, and is not standard treatment available at general hospitals. It is reference information for professionals regarding future medical developments.

Expansion of SLT as First-Line Treatment

In the 6-year results of the LiGHT trial, 69.8% of the SLT (selective laser trabeculoplasty) group maintained target intraocular pressure without eye drops ⁸⁾. Compared to the eye drop group, the rate of visual field progression was lower (19.6% vs 26.8%, P=0.006), and fewer cases required trabeculectomy (13 eyes vs 32 eyes, P<0.001) ⁸⁾. SLT is particularly useful for patients with adherence issues as a treatment option that does not rely on eye drops.

Sustained-Release Glaucoma Implants

As an alternative to daily eye drops, intracameral implants of bimatoprost and travoprost are being developed. They are expected as an option for patients who have difficulty with eye drops, but long-term efficacy and safety need to be confirmed.

Neuroprotective Effects of Nicotinamide

The neuroprotective effect of nicotinamide (the amide form of vitamin B3) in glaucoma is attracting attention. In a clinical trial by De Moraes et al., the combination of nicotinamide and pyruvate was associated with improvement in pattern standard deviation compared to placebo. A protective effect via prevention of mitochondrial dysfunction is suggested, but the EGS 6th edition does not yet recommend neuroprotective agents ²⁾.

Potential of Telemedicine

The COVID-19 pandemic prompted the introduction of telemedicine into glaucoma care. In a qualitative study by Liu et al. (2023), interviews with 20 glaucoma specialists working in NYC showed that telemedicine utilization during the peak of the pandemic was 29.1%, but dropped sharply to 3.1% a few months later ¹⁰⁾. The main reason was the difficulty of performing intraocular pressure measurements and visual field tests remotely, but optimistic views about future reintroduction due to technological innovations (e.g., home tonometry devices) were also reported ¹⁰⁾.

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Disclaimer

This article is intended to provide information to healthcare professionals and the general public, and does not replace individual diagnosis or treatment. Please consult your ophthalmologist for management of glaucoma. Lifestyle modifications are not a substitute for medication, laser treatment, or surgical treatment.

9. References

1. 日本緑内障学会. 緑内障診療ガイドライン(第5版). 日眼会誌. 2022;126:85-177.

2. European Glaucoma Society. Terminology and Guidelines for Glaucoma, 6th Edition. PubliComm; 2025.

3. Turner DC, Girkin CA, Downs JC. The Magnitude of IOP Elevation Associated with Eye Rubbing. Ophthalmology. 2019;126(1):171-172.

4. American Academy of Ophthalmology. Primary Open-Angle Glaucoma Preferred Practice Pattern. 2020.

5. American Academy of Ophthalmology. Primary Open-Angle Glaucoma Suspect Preferred Practice Pattern. 2020.

6. Kwon M. Impact of Glaucomatous Ganglion Cell Damage on Central Visual Function. Annu Rev Vis Sci. 2024;10(1):425-453. PMID:39292555. PMCID:PMC11529636. doi:10.1146/annurev-vision-110223-123044.

7. Beros AL, Sluyter JD, Hughes AD, et al. Arterial Stiffness and Incident Glaucoma: A Large Population-Based Cohort Study. Am J Ophthalmol. 2024;266:68-76.

8. Gazzard G, Konstantakopoulou E, Garway-Heath D, et al. Laser in Glaucoma and Ocular Hypertension (LiGHT) Trial: Six-Year Results. Ophthalmology. 2023.

9. Shen RY, Zhang Y, Chen LJ, et al. Ocular and Systemic Risk Factors and Biomarkers for Primary Glaucoma: An Umbrella Review. Invest Ophthalmol Vis Sci. 2024.

10. Liu H, Ying S, Kamat S, et al. The Role of Telemedicine in Glaucoma Care Triggered by the SARS-CoV-2 Pandemic: A Qualitative Study. Clin Ophthalmol. 2023;17:2251-2266.