## 2 Factors Affecting the IOP Response to Exercise
### Cognitive Requirements  
In many settings, physical and cognitive demands occur simultaneously, such as in occupational environments, military operations, and team sports. These activities require individuals to not only perform physically challenging tasks but also to engage in complex cognitive processes like decision making, strategic thinking, and problem solving [64,65]. The combined demands of physical and mental exertion can result in an additive or even synergistic effect on IOP. For example, studies have shown that increasing mental demands during physical tasks, such as cycling or basketball free-throw shooting, causes a significant rise in IOP [66,67]. These findings suggest that cognitive stress during exercise may exacerbate the IOP response, which could be particularly concerning for individuals with or at risk of glaucoma.  
If reducing IOP is a therapeutic goal, mental stress should be minimized during physical activity. This highlights the importance of investigating the role of psychological factors in glaucoma prevention and management. Mental stress has been shown to trigger a range of physiological changes, including elevated IOP, which could undermine the benefits of exercise that typically help to lower IOP [68]. For individuals with glaucoma, stress reduction becomes a critical aspect of managing the condition and preventing its progression. Physical activities promoting benefits for physical status and mental well-being should be considered (e.g., yoga, Tai Chi, Pilates, etc.). These practices have been shown to improve both physical and mental health, promoting relaxation, reducing stress, and enhancing overall quality of life [69]. Recent studies have also suggested its potential benefits on the management of glaucoma [70, 71, 72]. A recent meta-analysis [68] found that various relaxation techniques (i.e., meditation, yoga, autogenic relaxation exercises, etc.) cause significant IOP reductions in the long term.  
One of the major challenges in managing chronic conditions like glaucoma is ensuring long-term adherence to exercise regimens. In the context of exercise prescription, especially for individuals with chronic conditions, maintaining adherence is a key factor in achieving therapeutic benefits. Exercise adherence enables glaucoma patients to meet their physical activity guidelines, which is associated with a lower risk of developing glaucoma [13,19]. Evidence from sports science and psychology has consistently shown that the enjoyment and pleasure derived from physical activity are critical determinants of adherence to exercise programs [73,74]. If an exercise routine is perceived as enjoyable, individuals are more likely to stick with it, which is essential for improving long-term health outcomes. This is especially important for glaucoma patients, who may need to adopt exercise as a regular part of their lifestyle to manage IOP and reduce disease progression. Eye care providers and fitness professionals can work together to recommend activities that are both beneficial for IOP regulation and enjoyable for the individual, ensuring that the patient remains motivated and committed to long-term exercise participation.