# The Ocular and Gut Microbiome Axis in Understanding Glaucoma: A Systematic Review

## TL;DR

This review explores how changes in the eye and gut microbiomes may contribute to glaucoma, a leading cause of blindness.

## Contribution

The study identifies distinct microbiota patterns in glaucoma patients and links them to disease progression and treatment effects.

## Key findings

- Glaucoma patients show altered ocular microbiota with increased Gram-negative bacteria and lipopolysaccharide synthesis.
- Gut microbiota in glaucoma patients show reduced Corynebacterium and increased Firmicutes and Proteobacteria.
- Dysbiosis is more severe in glaucoma patients with dry eye disease and is linked to pro-inflammatory microbial activity.

## Abstract

Background: Glaucoma is a neurodegenerative disease and the second leading cause of irreversible blindness in developed countries. It is characterized by progressive loss of retinal ganglion cells (RGCs) and optic nerve axons, leading to permanent vision impairment. Although elevated intraocular pressure (IOP) is the main recognized risk factor, recent evidence suggests that ocular and gut microbiota may play a significant role in the onset and progression of glaucoma. Objectives: This study aimed to characterize ocular and gut microbiota alterations in patients with different types of glaucoma. Methods: Five searches were conducted between June and September 2025 using selected keywords. A total of 121 articles were identified, of which 14 met the inclusion criteria following the PRISMA 2020 guidelines. Results: Findings indicate a Mendelian genetic predisposition influencing microbiota composition associated with glaucoma development. Patients treated with benzalkonium chloride (BAK) showed increased Gram-negative and Alphaproteobacteria on the ocular surface, along with enhanced lipopolysaccharide synthesis. Compared with controls, glaucoma patients exhibited reduced Corynebacterium mastiditis and Actinobacteria and increased Firmicutes, Proteobacteria, and Verrucomicrobiota. Dysbiosis was more pronounced in patients with concurrent dry eye disease, characterized by higher Gram-negative taxa and pro-inflammatory microbial activity. Conclusions: Significant differences in ocular and gut microbiota were observed between glaucoma patients and controls, as well as among glaucoma subtypes such as pseudoexfoliation and primary open-angle glaucoma. Age-related dysbiosis and epigenetic factors appear to contribute to disease development. Microbiota profiling may offer new opportunities for improved prediction, management, and treatment of glaucoma.