Comprehensive Review of Physical Activity and Age-Related Macular Degeneration (AMD)

Comprehensive Review of Physical Activity and Age-Related Macular Degeneration: Risk, Progression, and Recommended Protocols

1. Introduction: The Intersection of Ocular Health and Systemic Physiology

Age-Related Macular Degeneration (AMD) stands as a predominant cause of irreversible visual impairment in the developed world, presenting a burgeoning public health crisis as global demographics shift toward an aging population. The disease pathology, characterized by the progressive degeneration of the macula—the central portion of the retina responsible for high-acuity vision—manifests primarily in two forms: non-neovascular (dry) AMD, defined by the accumulation of extracellular deposits known as drusen and atrophy of the retinal pigment epithelium (RPE); and neovascular (wet) AMD, marked by pathological choroidal neovascularization (CNV) and vascular leakage. Current projections estimate that the number of individuals affected by AMD globally will rise to 288 million by the year 2040, imposing a profound burden on healthcare systems and individual quality of life.¹

While therapeutic advancements, particularly anti-vascular endothelial growth factor (anti-VEGF) agents, have transformed the management of neovascular AMD, these treatments are palliative rather than curative, addressing late-stage complications without halting the underlying degenerative processes. Furthermore, for the vast majority of patients diagnosed with early or intermediate dry AMD, no effective medical treatments exist to prevent progression to advanced stages, aside from specific antioxidant formulations (AREDS) which offer only modest risk reduction. This therapeutic lacuna necessitates a paradigm shift toward identifying modifiable lifestyle factors that can influence disease trajectory.

Among modifiable behaviors, Physical Activity (PA) has emerged as a critical, yet historically underutilized, intervention target. Unlike pharmaceutical approaches that target specific molecular pathways, physical activity exerts pleiotropic effects on systemic physiology—modulating inflammation, oxidative stress, vascular endothelial function, and neurotrophic factor expression—all of which are implicated in AMD pathogenesis. Recent epidemiological evidence, ranging from large-scale longitudinal cohorts to Mendelian randomization studies, suggests a robust inverse relationship between physical activity and AMD risk. However, the literature reveals complex nuances regarding the intensity of exercise required, the differential impact on disease onset versus progression, and the modifying roles of genetics and gender.

This report provides an exhaustive synthesis of the current evidence base linking physical activity to AMD. It critically evaluates epidemiological data on incidence and progression, dissects the biological mechanisms conferring retinal protection, analyzes the profound impact of fear of falling (FoF) on patient mobility, and delineates evidence-based protocols for clinical intervention. By integrating findings from diverse global cohorts—including the National Runners’ Health Study, the Blue Mountains Eye Study, and the E3 Consortium—this review aims to provide a definitive reference for leveraging physical activity in the management of macular degeneration.

2. Epidemiological Evidence: Physical Activity and the Incidence of AMD

The epidemiological landscape regarding physical activity and AMD incidence is vast, characterized by varying methodologies and population demographics. A synthesis of these studies reveals a consistent signal: physical activity is a potent protective factor, though its efficacy is influenced by intensity, dose, and specific demographic variables.

2.1 Vigorous Activity and Dose-Response: The National Runners’ Health Study

One of the most compelling datasets elucidating the relationship between exercise intensity and AMD risk comes from the National Runners’ Health Study. This prospective analysis of 29,532 men and 12,176 women, followed for an average of 7.7 years, provides a unique window into the effects of vigorous physical activity—specifically running—on ocular health.¹

The study established a significant, inverse dose-response relationship between the volume of running and the incidence of clinically diagnosed AMD. This association persisted even after rigorous adjustment for potential confounders, including body mass index (BMI), cardiorespiratory fitness, and cigarette smoking history. The data indicates that the protective benefits of exercise are not merely a proxy for a generally healthy lifestyle but are driven by the specific metabolic and physiological adaptations associated with vigorous activity.

Quantitative Risk Reductions:

• Linear Decrement: The relative risk for developing AMD decreased by approximately 10% for every 1 kilometer per day (km/d) increment in average running distance.¹
• Threshold Effects: The study identified distinct risk strata based on daily running distance, using those running less than 2 km/d as the reference group:
• 2–4 km/d: Individuals in this category exhibited a 19% lower adjusted risk of incident AMD.
• >4 km/d: Runners exceeding this threshold demonstrated a 42% to 54% lower adjusted risk.
• ≥8 km/d: The highest volume group showed the most profound protection, with a 54% to 59% reduction in risk, depending on whether BMI was included in the adjustment model.¹

The Convex Nature of Protection:

The statistical analysis revealed the relationship to be "convex," implying that the steepest gains in risk reduction are achieved during the initial increases in activity. Specifically, the transition from running <2 km/d to 2 km/d yielded a statistically significant 36% risk reduction ($P=0.04$). Further increasing distance from the 2–4 km/d range to >4 km/d yielded additional significant benefits ($P=0.03$). This suggests that while elite levels of exercise offer maximum protection, substantial public health benefits can be realized by moving sedentary individuals into moderate vigorous activity brackets.1

Independence from Cardiorespiratory Fitness:

A critical insight from this cohort was the distinction between exercise performance and exercise volume. While 10-km race times (a proxy for cardiorespiratory fitness) were moderately correlated with running distance, fitness itself was not independently associated with AMD risk when adjusted for distance run. This implies that the total energy expenditure and the cumulative physiological stimulus of the activity, rather than the athlete's speed or conditioning level, are the primary drivers of retinal protection.1

2.2 Longitudinal Cohorts and Age-Specific Nuances

While the runners' cohort emphasizes vigorous activity, general population studies provide essential context regarding age, gender, and the severity of disease prevented.

The Blue Mountains Eye Study (BMES):

In this 15-year prospective Australian study, the relationship between physical activity and AMD was found to be heavily influenced by age and adjustment for systemic comorbidities. Among adults aged 75 years and older, those in the highest tertile of physical activity were 79% less likely to develop incident late AMD compared to the lowest tertile in age-adjusted models (OR 0.21; 95% CI 0.05–0.95).1

However, the robustness of this association wavered under multivariate adjustment. When potential mediators such as BMI, smoking status, fish consumption, and white cell count (a marker of systemic inflammation) were included in the model, the association lost statistical significance (OR 0.26; 95% CI 0.06–1.28).¹ This loss of significance is scientifically illuminating; it suggests that physical activity does not act on the retina in isolation. Instead, its protective effects are likely mediated through these very pathways—by reducing systemic inflammation, managing weight, and correlating with better dietary habits. Therefore, while the direct statistical link weakened, the practical implication remains that physical activity is a regulator of the risk factors that drive AMD. Notably, this study found no significant association between physical activity and the incidence of early AMD, nor did it find protection for individuals under the age of 75.¹

The Melbourne Collaborative Cohort Study:

This study introduced a gender-dimorphic perspective to the evidence base. Analyzing data from over 20,000 participants, researchers found no significant association between total recreational physical activity and AMD risk for the cohort as a whole. However, when stratified by sex and intensity, a specific protective effect emerged for women. Frequent vigorous exercise (defined as ≥3 times/week) was associated with a 22% decrease in the odds of intermediate AMD in women (OR 0.78; 95% CI 0.64–0.96).1 No such association was found in men.

This finding aligns with other data, such as the Tromsø Study, which also observed female-specific protection. The reasons for this gender disparity remain speculative but may involve interactions between exercise-induced metabolic changes and post-menopausal hormonal profiles, or differences in the baseline inflammatory status between aging men and women.¹

2.3 Causal Inference: The Role of Mendelian Randomization

A persistent challenge in observational epidemiology is establishing causality. Does physical activity prevent AMD, or does the visual impairment from early, undiagnosed AMD lead to reduced physical activity (reverse causality)? To address this, Zhou et al. (2025) utilized Mendelian randomization (MR), a method that uses genetic variants associated with physical activity as instrumental variables to infer causality, thereby bypassing confounding and reverse causation issues.¹

Key Findings from MR Analysis:

• Causal Link Confirmed: The study provided strong genetic evidence that moderate-to-vigorous physical activity (MVPA) is causally associated with a reduced risk of AMD. The odds ratio derived from the genetic analysis was 0.77 (95% CI 0.66–0.89), indicating a substantial protective effect.¹
• Sedentary Behavior: Interestingly, the study found no causal link between genetically determined sedentary behaviors (such as sitting at work or commuting) and AMD risk. However, leisure screen time showed a non-significant trend toward increased risk.

This genetic evidence is pivotal. It confirms that the associations observed in longitudinal cohorts are not merely artifacts of healthier people having better vision, but that increasing physical activity creates biological conditions that actively suppress the development of macular degeneration.¹

2.4 The Beijing Eye Study: Cultural and Regional Variations

In contrast to the strong associations found in Western populations, the Beijing Eye Study reported only a marginally significant association between physical activity and AMD prevalence ($p=0.04$).¹ This association was notably weaker than that found for diabetic retinopathy ($p=0.009$).

This discrepancy highlights the potential influence of genetic background, environmental exposures, and cultural lifestyle differences on disease etiology. For instance, the types of physical activity common in this cohort (e.g., walking, Tai Chi) may differ in intensity from the vigorous running or gym-based exercises often measured in Western studies. Additionally, the baseline prevalence of metabolic risk factors in the Beijing cohort may alter the relative importance of physical activity as a protective mechanism.¹

2.5 Meta-Analytic Synthesis

Aggregating these diverse findings, a comprehensive meta-analysis by McGuinness et al. (2017) synthesized data from nine studies involving over 38,000 participants. This analysis concluded that physical activity is associated with lower odds of both early AMD (OR 0.92) and late AMD (OR 0.59).¹ The stronger protective effect for late-stage disease (41% risk reduction) versus early-stage disease (8% risk reduction) suggests that physical activity may be particularly effective in preventing the catastrophic progression to neovascularization or geographic atrophy, potentially by maintaining choroidal perfusion and limiting chronic inflammation.

3. Disease Progression: Does Activity Halt the Slide?

A critical clinical question is whether physical activity can slow the worsening of AMD once the disease process has begun. The evidence here suggests a nuanced distinction between preventing incidence (the onset of early disease) and preventing progression (the transition from early to late disease).

The E3 Consortium Multi-Cohort Analysis:

This massive study, pooling longitudinal data from 14,630 adults across seven European and Australian cohorts, utilized Markov multistate models to rigorously track transitions between disease states.1 The results revealed a "threshold effect" for protection:

• Incidence of Early AMD: High levels of physical activity were significantly protective against the transition from "No AMD" to "Early AMD." Individuals with low-to-moderate activity had a 1.19-fold increased risk (HR 1.19; $P=0.04$) of developing early signs of the disease compared to highly active individuals.¹
• Progression to Late AMD: However, physical activity levels were not significantly associated with the transition from "Early AMD" to "Late AMD".¹

Study or Cohort Name	Population Description	Sample Size	Physical Activity Metric	Key Findings	Risk Reduction or Odds Ratio	Disease Stage Impact
Meta-analysis by McGuinness et al. (2017)	Synthesis of nine prospective and cross-sectional studies	Over 38,000	General physical activity	Demonstrated a stronger protective effect for late-stage disease compared to early-stage disease.	Early AMD: OR 0.92 (8% reduction); Late AMD: OR 0.59 (41% reduction)	Early and Late AMD
National Runners’ Health Study	Prospective analysis of men and women	29,532 men and 12,176 women	Daily running distance ( $km/d$ )	Significant inverse dose-response relationship; protection is likely driven by metabolic adaptations to vigorous activity.	10% reduction per $km/d$ ; 42% to 54% reduction for $>4$ $km/d$ ; 54% to 59% reduction for $\ge 8$ $km/d$	Incident AMD (onset)
Mendelian Randomization Analysis (Zhou et al. 2025)	Genetic analysis using instrumental variables	Not in source	Moderate-to-vigorous physical activity (MVPA)	Confirmed a causal link between MVPA and reduced AMD risk; no causal link was found for sedentary behavior.	OR 0.77 (23% risk reduction)	AMD risk (causality)
Blue Mountains Eye Study (BMES)	Adults aged 75 years and older in Australia	Not in source	Tertiles of physical activity	Highest activity tertile was significantly less likely to develop late AMD, though association weakened after multivariate adjustment.	OR 0.21 (79% less likely) in age-adjusted models	Late AMD (No association with early AMD)
Melbourne Collaborative Cohort Study	Participants stratified by sex and intensity	Over 20,000	Frequent vigorous exercise ( $\ge 3$ times/week)	Gender-specific protective effect found specifically in women.	OR 0.78 (22% decrease in odds for women)	Intermediate AMD
E3 Consortium Multi-Cohort Analysis	Pooled data from seven European and Australian cohorts	14,630 adults	Physical activity levels (Markov multistate models)	Protective against the transition from No AMD to Early AMD; no significant effect on the transition from Early to Late AMD.	Low-to-moderate activity: 1.19-fold increased risk (HR 1.19) compared to high activity	Transition to Early AMD only
NHANES Study	US adults cross-sectional study	Not in source	MVPA measured via visual acuity control	Participants with late AMD engaged in significantly less activity, primarily attributed to vision loss.	50% less MVPA compared to those without AMD	Late AMD
Beijing Eye Study	Regional population in China	Not in source	Physical activity (e.g., walking, Tai Chi)	Only a marginally significant association was observed, which is weaker than findings in Western cohorts.	$p=0.04$ (marginally significant)	AMD prevalence

The "Metabolic Rescue" Hypothesis:

This finding implies that physical activity is most effective as a primary preventative measure. In the healthy retina, the systemic benefits of exercise—improved lipid profiles, reduced oxidative stress, and enhanced perfusion—may be sufficient to maintain RPE homeostasis and prevent the initial accumulation of drusen. However, once the pathological cascade is established (early AMD), the disease may become driven by local ocular mechanisms (e.g., complement activation, local oxidative stress, RPE senescence) that are less responsive to systemic exercise-induced modulation.

This does not negate the value of exercise for patients with early AMD. Given the systemic comorbidities often associated with AMD (cardiovascular disease, hypertension), physical activity remains crucial for overall health and mortality reduction. Furthermore, while the E3 study did not find statistical significance for late AMD progression, other meta-analyses (like McGuinness et al.) did find strong associations with prevalent late AMD, suggesting that survival bias or differences in study design may account for the discrepancy.

4. Mechanisms of Action: How Exercise Protects the Retina

The protective effects of physical activity on the retina are biologically plausible and are likely mediated through a complex interplay of systemic and local mechanisms. The retina is a high-energy tissue with the greatest metabolic demand per unit weight in the human body, making it uniquely susceptible to oxidative stress and perfusion deficits.

4.1 Systemic Inflammation and C-Reactive Protein (CRP)

Chronic, low-grade systemic inflammation is a central driver of AMD pathogenesis. Elevated levels of C-reactive protein (CRP), a marker of systemic inflammation, are consistently associated with increased AMD risk. Physical activity acts as a potent modulator of this inflammatory state.

Research by Subhi et al. demonstrated that in patients with neovascular AMD, physical activity was independently associated with significantly lower CRP levels ($P=0.009$).¹ Physically active patients exhibited a median CRP of 1.6 mg/L, compared to 2.1 mg/L in inactive patients. Crucially, the study found that the presence of neovascular AMD itself did not contribute to elevated CRP when physical activity was accounted for. This suggests that the "inflammatory profile" often attributed to AMD patients may largely be a consequence of their sedentary lifestyle—driven by visual impairment—rather than the disease pathology itself.¹

Mechanism: Skeletal muscle acts as an endocrine organ. During contraction, muscles release myokines (such as IL-6) which, in the context of exercise, exert anti-inflammatory effects by inhibiting the production of TNF-alpha and stimulating the release of anti-inflammatory cytokines like IL-10 and IL-1ra.

4.2 Oxidative Stress and Mitochondrial Function

The RPE is tasked with phagocytosing shed photoreceptor outer segments, a process that generates significant oxidative stress. Mitochondria in the RPE are essential for generating the ATP required for this high metabolic turnover.

• Antioxidant Defense: Exercise upregulates endogenous antioxidant defense systems, including superoxide dismutase (SOD) and glutathione peroxidase (GPx), enhancing the retina's capacity to neutralize reactive oxygen species (ROS).²
• Mitochondrial Health: Physical activity promotes mitochondrial biogenesis and efficiency. In the RPE, efficient mitochondrial function is critical for preventing the accumulation of lipofuscin and other toxic byproducts that constitute drusen. Reductive carboxylation in mitochondria has been suggested as a pathway supporting RPE resilience against oxidative damage.⁴

4.3 Neuroprotection via Brain-Derived Neurotrophic Factor (BDNF)

BDNF is a neurotrophin essential for the survival and maintenance of neurons. The retina, embryologically an extension of the brain, is responsive to neurotrophic support.

• Exercise Induction: Physical activity is a well-established inducer of systemic and central BDNF expression.
• Retinal Protection: Animal models have shown that aerobic exercise increases retinal BDNF protein levels by approximately 20%.⁵ This upregulation has been linked to the protection of retinal structure and function against light-induced degeneration.⁵ Blocking BDNF receptors (TrkB) negates the protective effects of exercise, identifying BDNF signaling as a critical pathway for exercise-induced retinal neuroprotection.⁶

4.4 Choroidal Perfusion

The choroid provides the blood supply to the outer retina and RPE. While some studies on isometric exercise did not show significant differences in choroidal blood flow regulation between AMD patients and controls ⁸, aerobic exercise is generally known to improve endothelial function and vascular reactivity. Maintaining adequate choroidal perfusion is vital for nutrient delivery and waste removal from the RPE, and exercise-induced improvements in cardiovascular health likely translate to better ocular perfusion pressure and vascular health.¹⁰

5. The Reality of Activity in the AMD Population

Despite the clear benefits of physical activity, the AMD population is characterized by significantly reduced activity levels, creating a deleterious cycle of disease, disability, and sedentarism.

5.1 The Discrepancy Between Objective and Self-Reported Activity

Assessing physical activity in visually impaired populations is fraught with measurement error. A study by Zult et al. highlighted a significant discordance between what AMD patients report doing and what they actually do.

• Objective Reality: When measured using accelerometers, healthy controls engaged in 33–34% more moderate-to-vigorous physical activity (MVPA) than AMD patients (both with and without vision loss).¹
• Subjective Illusion: Self-reported questionnaires (GPAQ) failed to detect significant differences between the groups.
• Under-Reporting: Interestingly, while all groups under-reported their activity compared to accelerometers, healthy controls under-reported their MVPA significantly more than AMD patients. This implies that relying on self-reports may mask the true extent of the activity deficit in the AMD population.¹

5.2 Activity Patterns and Fragmentation

It is not just the total volume of activity that suffers, but the pattern of accumulation. Research by the ENGAGE group using accelerometry data has shown that visual field damage is associated with "activity fragmentation"—short bursts of activity followed by rest—rather than sustained movement.¹ This fragmentation is a marker of functional decline, higher fatigability, and poorer physiological reserve.

5.3 The Impact of Vision Loss on Movement

The NHANES study revealed that participants with late AMD engaged in 50% less MVPA compared to those without AMD.¹¹ Importantly, when visual acuity was controlled for in the statistical models, the association between AMD and reduced activity was attenuated. This indicates that it is the loss of vision itself—and the associated difficulties with navigation, balance, and hazard detection—that acts as the primary barrier to activity, rather than the systemic nature of the disease directly draining energy levels.¹¹

6. The Psychological Barrier: Fear of Falling (FoF)

The most significant non-physiological barrier to physical activity in the AMD population is the Fear of Falling (FoF). This psychological phenomenon acts as a potent mediator between visual impairment and sedentary behavior, creating a "vicious cycle" of decline.

6.1 The Vicious Cycle of Inactivity

1. Visual Impairment: AMD reduces depth perception, contrast sensitivity, and visual field integrity. This increases the actual risk of falls by 2- to 8-fold compared to visually normal peers.¹
2. Fear of Falling (FoF): Aware of this risk, patients develop a protective, yet maladaptive, psychological response: a pervasive fear of falling.
3. Activity Restriction: To mitigate anxiety and avoid potential falls, individuals intentionally restrict their movement, avoiding travel outside the home and reducing engagement in daily activities.¹
4. Physical Deconditioning: This self-imposed sedentary behavior leads to muscle atrophy, reduced proprioception, and poorer balance.
5. Increased Fall Risk: Paradoxically, this deconditioning increases the actual risk of falls, reinforcing the fear and perpetuating the cycle.¹

Research indicates that older adults with high FoF are more likely to transition to dependence in daily activities and suffer from social isolation and depression.¹ Addressing FoF is therefore a prerequisite for any successful physical activity intervention in this population. Programs that fail to address the psychological component of mobility restriction are likely to fail.

7. Recommended Protocols and Interventions

Given the established benefits of physical activity for AMD risk reduction and the significant barriers faced by patients, clinical management must evolve beyond ocular injections and supplements to include prescriptive physical activity. Effective interventions must be holistic, addressing the physiological need for exercise, the safety of the environment, and the psychological barrier of fear.

7.1 The Empowerment-Based Physical Activity Intervention (EPI) Model

A promising, evidence-based protocol identified in the literature is the Empowerment-Based Physical Activity Intervention (EPI), designed specifically for older adults with advanced dry AMD.¹ This mixed-methods approach moves beyond simple exercise prescription to address the root causes of inactivity.

Core Components of the EPI Model:

• Reflective Equilibrium Approach: This philosophy combines "top-down" expertise (researchers designing safety protocols) with "bottom-up" participant power (patients choosing activities that align with their lifestyle goals). This autonomy is crucial for long-term adherence.
• Health Coaching: The protocol includes three individual coaching sessions (Start, Month 4, Month 6) utilizing motivational interviewing techniques. The goal is to build self-efficacy, reframe negative beliefs about capability, and set personalized goals.
• Social Integration: To combat the isolation associated with AMD, the program includes post-exercise social gatherings with refreshments. This facilitates peer support and knowledge exchange.
• Duration: A 6-month structured program is recommended to establish habit formation.

Specific Activities within EPI:

• Group Balance Training: Conducted twice weekly for one hour. The curriculum focuses specifically on strength, movement, and flexibility exercises designed to improve stability and directly target fall risk.
• Adapted Sports: Activities like adapted table tennis are used to promote hand-eye coordination, reaction time, and social engagement without the pressure of high-performance competition.
• Sustainability Transition: In the later stages of the intervention, participants are introduced to municipal drop-in gyms. Researchers educate gym staff on the specific support needs of visually impaired clients, facilitating a smooth transition from a clinical setting to community-based activity.

7.2 Environmental and Safety Interventions

Modifying the physical environment is a first-line strategy to enable safe mobility and reduce the actual risk of falls.

• Occupational Therapist-Led Assessments: Evidence suggests that home safety assessments are significantly more effective when led by occupational therapists (OTs) rather than non-specialists. OTs can expertly identify hazards (e.g., loose rugs, poor lighting) and recommend modifications.¹
• Hazard Modification: Standard protocols include removing trip hazards, improving ambient lighting, installing grab bars, and enhancing contrast on stairs/edges to compensate for reduced contrast sensitivity.
• Limitations: While environmental modification reduces falls, studies suggest it does not necessarily increase physical activity levels on its own. It makes the home safer but does not motivate the patient to move more; thus, it must be paired with behavioral interventions.¹

7.3 Behavioral and Exercise Strategies

• Exercise Programs: The US Preventive Service Task Force (USPSTF) recommends exercise for fall prevention in the elderly with moderate certainty. For AMD patients, programs must be adapted to accommodate visual deficits (e.g., using auditory cues, high-contrast equipment).¹
• The Alexander Technique: While theoretically sound for improving movement quality, trials found this technique was not useful for preventing falls or reducing FoF in visually impaired older adults over a 12-month period, suggesting that more direct strength and balance training is required.¹

7.4 Summary of Clinical Recommendations

Based on the synthesis of epidemiological data and intervention studies, the following clinical protocols are recommended for the management of patients with or at risk of AMD:

Domain	Recommendation	Rationale & Evidence
Assessment	Use objective accelerometry (or validated wearable devices) to assess baseline activity. Do not rely solely on self-reports.	Patients underestimate their inactivity; self-reports fail to capture the significant deficit compared to healthy controls.1
Exercise Type	Prioritize Moderate-to-Vigorous Physical Activity (MVPA).	MVPA (e.g., brisk walking, running) shows the strongest causal link to reduced AMD risk in genetic and longitudinal studies.1
Dosing	Aim for >150 minutes/week of moderate activity. Ideally, encourage 2–4 km/day of walking/running.	Risk reduction is incremental. Even modest amounts (2 km/day) show significant benefit (36% reduction), with greater benefits at higher volumes.1
Fall Prevention	Refer for OT-led home safety assessments combined with balance training.	OT assessments are proven to reduce falls; balance training addresses the physical deficit caused by deconditioning.1
Behavioral Support	Screen for Fear of Falling (FoF) and implement Health Coaching.	FoF is the primary mediator of activity restriction. Addressing it through coaching increases self-efficacy and adherence.1
Sustainability	Integrate patients into community-based adapted sports or municipal gyms with trained staff.	Sustainable activity requires social support and accessible facilities that understand visual impairment needs.1

 

8. Conclusion

The relationship between physical activity and Age-Related Macular Degeneration is characterized by robust evidence supporting protection against disease onset and nuanced evidence regarding disease progression. High levels of physical activity, particularly vigorous exercise, are causally linked to a reduced risk of developing early AMD, likely through the modulation of systemic inflammation (CRP), oxidative stress, and neurotrophic support (BDNF). While PA may not halt the progression to late-stage AMD once the disease is established, it remains a critical intervention for preserving remaining visual function, reducing comorbidity, and maintaining quality of life.

However, the AMD population faces unique and profound barriers to activity, primarily the fear of falling, which leads to a self-perpetuating cycle of inactivity and functional decline. Clinical management of AMD must therefore evolve beyond the prescription of ocular injections and antioxidant supplements to include prescriptive, supported physical activity. Effective interventions must be holistic—integrating environmental safety (OT-led modifications) with empowerment-based behavioral coaching and adapted balance training. By addressing both the physiological need for exercise and the psychological barrier of fear, clinicians can significantly improve the health trajectory of individuals living with macular degeneration.

 

References:

1. zhou-et-al-2025-genetically-determined-physical-activity-levels-sedentary-behaviours-and-their-association-with-the.pdf
2. The Impact of Physical Exercise on Oxidative and Nitrosative Stress: Balancing the Benefits and Risks - MDPI, accessed January 18, 2026, https://www.mdpi.com/2076-3921/13/5/573
3. Oxidative stress: role of physical exercise and antioxidant nutraceuticals in adulthood and aging - PMC - PubMed Central, accessed January 18, 2026, https://pmc.ncbi.nlm.nih.gov/articles/PMC5908316/
4. Reductive carboxylation is a major metabolic pathway in the retinal pigment epithelium | PNAS, accessed January 18, 2026, https://www.pnas.org/doi/10.1073/pnas.1604572113
5. Aerobic Exercise Protects Retinal Function and Structure from Light-Induced Retinal Degeneration - PMC - NIH, accessed January 18, 2026, https://pmc.ncbi.nlm.nih.gov/articles/PMC3921416/
6. Aerobic Exercise Protects Retinal Function and Structure from Light-Induced Retinal Degeneration | Journal of Neuroscience, accessed January 18, 2026, https://www.jneurosci.org/content/34/7/2406.short
7. Enhancing Retinal Resilience: The Neuroprotective Promise of BDNF in Diabetic Retinopathy - MDPI, accessed January 18, 2026, https://www.mdpi.com/2075-1729/15/2/263
8. Effect of isometric exercise on choroidal blood flow in patients with age-related macular degeneration - PubMed, accessed January 18, 2026, https://pubmed.ncbi.nlm.nih.gov/20837789/
9. EFFECT OF ISOMETRIC EXERCISE ON CHOROIDAL BLOOD FLOW IN PATIENTS WITH AGE-RELATED MACULAR DEGENERATION (AMD) - PubMed Central, accessed January 18, 2026, https://pmc.ncbi.nlm.nih.gov/articles/PMC4077432/
10. Exercise for Eyes and Vision - American Academy of Ophthalmology, accessed January 18, 2026, https://www.aao.org/eye-health/glasses-contacts/exercise-eyes-vision-4
11. Age-Related Macular Degeneration Is Associated with Less Physical Activity among US Adults: Cross-Sectional Study | PLOS One - Research journals, accessed January 18, 2026, https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0125394