Exercise for the prevention and mitigation of eye disease

About 20 years ago, an endocrinologist told me that he had the “perfect drug” for better managing my type 1 diabetes, one that was highly effective, inexpensive, and with few adverse reactions, provided I did not “overdose.” I was half expecting him to write an off-label prescription for psilocybin or an opioid but instead he simply said, “exercise.”

In fact, the benefits of consistent physical activity (PA) have been demonstrated for a host of systemic conditions, including diabetes, hypertension, dyslipidemia, overweight/obesity, obstructive sleep apnea, as well as prevalent mental health disorders such as anxiety and depression.^1-6 As each of these is, in turn, associated with eye disease, it makes sense that PA (Figure 1) and its benefits for ocular health are something that eye doctors should be discussing with our patients. Let’s take a look at some of the evidence for some common ocular diagnoses that have a major public health impact.

Age-related macular degeneration (AMD): The Beaver Dam Eye Study found that incident exudative AMD rates were reduced by 30% among those in the highest quintile of blocks walked per day compared with those in the lowest quintile, after controlling for other risk factors.⁷ Another cohort study, showing body mass index and waist circumference were associated with a doubly high risk of advanced AMD, also found 25% less progression in participants with early or intermediate AMD who engaged in 3 sessions of vigorous PA weekly.⁸ Lending further support to the hypothesis that “vigor is better” is a 7-year analysis of incident AMD in more than 40,000 runners showing a 10% reduction in relative risk with each additional kilometer per day.⁹ Significant precursors to AMD, the presence of drusen greater than 63 microns in diameter, were also found to be reduced by two-thirds in participants self-reporting 7 or more hours per week of PA vs those reporting 0 to 2 hours per week.¹⁰ Perhaps most impressively, given the significance of genetics in the development of AMD, is a UK Biobank/FinnGen genetic analysis of 863,000 individuals showing a 23% risk reduction for any form of AMD with 600 to 3000 metabolic minutes per week (ie, walking 4 miles per hour for 30 minutes 5 days per week at a minimum) after controlling for all known single nucleotide polymorphisms linked to AMD.¹¹

Glaucoma: The risk of incident of glaucoma was reduced by 47% in a 5-year study of more than 9500 Texans participating in the Aerobics Center Longitudinal Study and who engaged in at least 500 MET-minutes weekly (ie, walking 4 mph for 20 minutes, 5 days weekly) compared with those self-reporting less than 500 MET-minutes, after controls for age, race, diabetes, and other established risk factors.¹² Another study found running distance and speed were each linked to a reduced likelihood of glaucoma diagnosis in men; 5% reduction for each kilometer per day and a 51% risk reduction for those running 4.5 to 5.0 kilometers per hour, with no cases of glaucoma reported in those running more than 5 km per hour (11 mph).¹³ Unfortunately, no data for glaucoma subtyping were provided by the investigators of the 2 aforementioned studies, but it is believed that both aerobic exercise and resistance training reduce intraocular pressure by 2 to 4 mm Hg, improve mitochondrial function, and increase the neuro-protective protein BDNF.¹⁴ Notwithstanding these putative benefits, PA involving excessive positional change that places the eyes/head below the level of the heart for extended times (eg, inversion therapy or head-down yoga positions) is contraindicated in glaucoma, as these are linked to significant increases in IOP.¹⁵

Diabetic retinopathy (DR): Multiple studies demonstrate a dose-responsive decrease in the risk of type 2 diabetes with PA, so it makes biologic sense that exercise will, accordingly, reduce rates of diabetes-related microvascular complications, including DR.¹⁶ PA results in better glycemic control once patients have diabetes (hemoglobin A_1c reductions average about 0.7% for all forms of exercise vs a sedentary lifestyle).¹⁷ Moreover, dose-response meta-analyses show that PA is associated with a lower risk of diabetes-related complications even at lower levels, with a 32% decreased relative risk for new or worsening DR for high vs low levels of PA.¹⁸ In addition, higher rates of PA independently decreased the odds of patients needing photocoagulation by as much as 39% over 12 years of follow-up.¹⁹ Maximal PA benefit for DR prevention was found at 26 MET-hours per week (1 hour of moderate PA per day, 5 days per week) in a separate, prospective analysis of adult Japanese participants with type 2 diabetes.²⁰

The benefits of PA against DR are likely not confined to improved blood glucose levels in isolation; PA also improves blood pressure and dyslipidemia,²¹ known contributors to the pathogenesis of DR and other posterior segment diseases more commonly seen in diabetes (ie, hypertensive retinopathy, retinal vascular occlusion, AION). Intense exercise can induce hypoglycemia that is also being increasingly linked to worsening DR, specifically in patients using exogenous insulin or insulin secretagogues (ie, sulfonylurea agents), so we should advise patients on these therapies to carry a rapid-acting carbohydrate when they exercise and, ideally, use a continuous glucose monitoring device (see my previous column, The Low Down on Hypoglycemia in Diabetes).

So, what specific advice should we be delivering to our patients about PA? The American College of Sports Medicine developed an “Exercise Is Medicine” program that includes its Health Care Providers’ Action Guide (available at exerciseismedicine.org) and offers some valuable recommendations, as follows:

1. Recommend that sedentary patients start slow and build their confidence
2. Recommend primary care physician/cardiology/orthopedic approval and/or a certified exercise training program, and specifically ask about chest pain with and without PA, mobility, and falls, and any safety concerns
3. Recommend an admixture of aerobic, resistance, isometric, and flexibility/balance training (both the Centers for Disease Control and Prevention and World Health Organization advocate that adults ages 18 to 65 set an individualized goal of 150 to 300 minutes of moderate intensity exercise, or 75 to 150 minutes of high intensity exercise per week, including muscle strengthening [resistance] exercise at least 2 days per week [Figure 2]).

For eye care providers, it is imperative to discuss the benefits of balance exercises and a safe environment, especially with those having visual impairment.

References

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2. Salas-Salvadó J, Díaz-López A, Ruiz-Canela M, et al; PREDIMED-Plus investigators. Effect of a lifestyle intervention program with energy-restricted Mediterranean diet and exercise on weight loss and cardiovascular risk factors: one-year results of the PREDIMED-Plus trial. Diabetes Care. 2019;42(5):777-788. doi:10.2337/dc18-0836

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8. Seddon JM, Cote J, Davis N, Rosner B. Progression of age-related macular degeneration: association with body mass index, waist circumference, and waist-hip ratio. Arch Ophthalmol. 2003;121(6):785-792. doi:10.1001/archopht.121.6.785

9. Williams PT. Prospective study of incident age-related macular degeneration in relation to vigorous physical activity during a 7-year follow-up. Invest Ophthalmol Vis Sci. 2009;50(1):101-106. doi:10.1167/iovs.08-2165

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12. Meier NF, Lee DC, Sui X, Blair SN. Physical activity, cardiorespiratory fitness, and incident glaucoma. Med Sci Sports Exerc. 2018;50(11):2253-2258. doi:10.1249/MSS.0000000000001692

13. Williams PT. Relationship of incident glaucoma versus physical activity and fitness in male runners. Med Sci Sports Exerc. 2009;41(8):1566-1572. doi:10.1249/MSS.0b013e31819e420f

14. Sidoti M, Harris A, Coleman-Belin J, et al. The impact of different forms of exercise on intraocular pressure, blood flow, and the risk for primary open angle glaucoma. Eur J Ophthalmol. 2025;35(3):834-843. doi:10.1177/11206721241296027

15. Sawada A, Yamamoto T. Posture-induced intraocular pressure changes in eyes with open-angle glaucoma, primary angle closure with or without glaucoma medications, and control eyes. Invest Ophthalmol Vis Sci. 2012;53(12):7631-7635. doi:10.1167/iovs.12-10454

16. Colberg SR, Sigal RJ, Fernhall B, et al; American College of Sports Medicine; American Diabetes Association. Exercise and type 2 diabetes: the American College of Sports Medicine and the American Diabetes Association: joint position statement. Diabetes Care. 2010;33(12):e147-167. doi:10.2337/dc10-9990

17. Michielsen M, Yagiz J, Hanssens M, et al. The effect of exercise characteristics on HbA1c and other cardiovascular risk factors in adults with type 2 diabetes: a systematic review and meta-analysis of randomised controlled trials. Cardiovasc Diabetol. 2025;25(1):30. doi:10.1186/s12933-025-03048-1

18. Rietz M, Lehr A, Mino E, et al. Physical activity and risk of major diabetes-related complications in individuals with diabetes: a systematic review and meta-analysis of observational studies. Diabetes Care. 2022;45(12):3101-3111. doi:10.2337/dc22-0886

19. Yan X, Han X, Wu C, Shang X, Zhang L, He M. Effect of physical activity on reducing the risk of diabetic retinopathy progression: 10-year prospective findings from the 45 and Up Study. PLoS One. 2021;16(1):e0239214. doi:10.1371/journal.pone.0239214

20. Kuwata H, Okamura S, Hayashino Y, Tsujii S, Ishii H; Diabetes Distress and Care Registry at Tenri Study Group. Higher levels of physical activity are independently associated with a lower incidence of diabetic retinopathy in Japanese patients with type 2 diabetes: a prospective cohort study, Diabetes Distress and Care Registry at Tenri (DDCRT15). PLoS One. 2017;12(3):e0172890. doi:10.1371/journal.pone.0172890

21. Hejazi K, Iraj ZA, Saeidi A, et al. Differential effects of exercise training protocols on blood pressures and lipid profiles in older adults patients with hypertension: a systematic review and meta-analysis. Arch Gerontol Geriatr. 2025;131:105737. doi:10.1016/j.archger.2024.105737