Neuroprotection in Glaucoma: Investigational, Complementary to IOP-Lowering
September 22, 2025

Neuroprotection in Glaucoma: Investigational, Complementary to IOP-Lowering

Tip: Neuroprotection in glaucoma is investigational and may be considered only as an adjunct, never a substitute for IOP-lowering care

Facts: Glaucoma neurodegeneration involves multiple mechanisms, including vascular and mechanical factors, age-related changes, oxidative stress, apoptosis, neuroinflammation, metabolic demand, and mitochondrial dysfunction, all of which contribute to optic nerve damage (1).

A survey of both patients and clinicians within the European Glaucoma Society identified the development of treatments to stop sight loss and restore vision as the foremost research priorities (2). While only a limited number of randomized clinical trials have been completed, emerging evidence suggests promising potential for neuroprotective agents in glaucoma, highlighting the need for larger, well-designed studies to confirm their benefits (3, 4).

Among the candidates, citicoline—administered orally or topically—has shown potential as an adjunctive therapy for improving retinal nerve fiber layer (RNFL) integrity, visual function, and quality of life. It is marketed with varying regulatory statuses in European countries, and several randomized controlled trials are ongoing to assess its long-term impact on visual field preservation and progression (3,5, 6).

Nicotinamide (vitamin B3) has shown neuroprotective effects in preclinical studies and early clinical signals, but it is not approved for glaucoma, and large randomized controlled trials are still underway. Given the potential of drug-induced liver injury, expert consensus recommends that high doses (≥3 grams/day) should only be used within clinical trials with close liver function monitoring (3,7).

Ginkgo biloba has been proposed as an adjunctive therapy, but available evidence is limited to small crossover or retrospective studies, mainly in patients with normal-tension glaucoma, and overall evidence is inconsistent. Safety concerns, particularly the risk of increased bleeding, should also be considered when used alongside other medication (3).


References

  1. Daka Q, et al. Metformin in glaucoma treatment. J Glaucoma. 2024;33(6):387-393.
  2. Azuara-Blanco A, et al. European Glaucoma Society research priorities for glaucoma care. Br J Ophthalmol. 2024;108(8):1088-1093.
  3. European Glaucoma Society. EGS Guidelines, 5th edition. 2025.
  4. Sena DF, Lindsley K. Neuroprotection for treatment of glaucoma in adults. Cochrane Database Syst Rev. 2017;1:CD006539.
  5. Prinz J, et al. Efficacy of citicoline as a supplement in glaucoma patients: A systematic review. PLoS One. 2023;18(9):0291836.
  6. Rossetti L, Iester M, Tranchina L, et al. Can treatment with citicoline eyedrops reduce progression in glaucoma? Results of a randomized placebo-controlled clinical trial. J Glaucoma. 2020;29(7): e57-e64.
  7. Shukla AG, et al. American Glaucoma Society–American Academy of Ophthalmology position statement on nicotinamide use for glaucoma neuroprotection. Ophthalmol Glaucoma. 2025;8(2):112-116.


Contributor: Qëndrëse Daka, MD, PhD, FEBO. Faculty of Medicine University of Prishtina, Kosovo. Glaucoma Ophthalmologist Eye Clinic University Center of Kosovo, Prishtina

Example Image


Tip of the Month Manager: Karin Øyo-Szerenyi
Tip of the Month Editors: Karl Mercieca, Francisco Goñi
Tip of the Month Editors in Chief: Manuele Michelessi, Francesco Oddone