Glaucoma is the leading cause of irreversible blindness worldwide. Experts project it will affect over 110 million people by 2040. For decades, every treatment: eye drops, lasers, surgery, has worked by lowering eye pressure. That remains the standard of care. But a critical gap exists: many patients continue to lose vision even when their eye pressure is well controlled.
This gap has driven one of the most exciting areas of glaucoma research today: neuroprotection. Specifically, the question of whether niacinamide, a form of vitamin B3, can protect the optic nerve independent of eye pressure.
I published an editorial on this question in the Journal of Current Glaucoma Practice in 2022, titled “Niacinamide and Neuroprotection: The Glaucoma Holy Grail” (Bhartiya S. PMID 36793265). This article is a patient-facing explanation of what the science shows, what it does not yet show, and what it means for your care.
What Is Niacinamide and Why Does It Matter for Glaucoma?
Niacinamide, also called nicotinamide or NAM, is the amide form of vitamin B3. It is widely available as an over-the-counter supplement, well known in skincare, and generally considered safe at moderate doses.
Its relevance to glaucoma lies in a molecule called NAD+ – nicotinamide adenine dinucleotide. NAD+ is a coenzyme found in every cell in your body. It is essential for energy production, DNA repair, and cell survival. Retinal ganglion cells, the nerve cells that form the optic nerve and are destroyed in glaucoma, are among the most metabolically demanding cells in the body. They depend heavily on NAD+ to function and survive.
Here is the problem: in glaucoma patients, NAD+ levels in retinal ganglion cells are depleted. Studies have documented lower serum nicotinamide levels in glaucoma patients compared to controls. As NAD+ falls, retinal ganglion cells become metabolically stressed, vulnerable, and eventually die. This damage is irreversible.
Niacinamide is a direct precursor to NAD+. Supplementing with niacinamide raises NAD+ levels, which may protect retinal ganglion cells from this metabolic collapse.
What the Research Shows
The evidence comes from multiple directions and is building rapidly.
In animal models, the results have been striking. At the lower dose tested — equivalent to approximately 2.7 grams per day for a 60-kilogram human — niacinamide protected retinal ganglion cells from glaucomatous damage without any change in eye pressure. The protective effect was attributed entirely to neuroprotection. At higher doses, there was an additional reduction in eye pressure elevation, making the action two-pronged. In one mouse model of inherited glaucoma, 93% of eyes at the highest tested dose showed no detectable glaucoma.
In human clinical studies, early results are encouraging. A phase 2 randomised controlled trial in the United States found that oral supplementation with 3 grams per day of nicotinamide, combined with calcium pyruvate, improved visual field test locations compared to placebo over 9 weeks. A 12-week crossover trial in Australia of 57 patients found improved inner retinal function as measured by electroretinography.
In 2025, the American Glaucoma Society and the American Academy of Ophthalmology jointly published a position statement acknowledging that niacinamide holds promise as a potential neuroprotective agent in glaucoma, based on both laboratory and human studies. My 2022 editorial has been cited in subsequent international peer-reviewed reviews of this evidence, contributing to the growing body of literature that informed this field-wide acknowledgment.
Multiple large clinical trials are currently underway globally, in the United States, United Kingdom, Sweden, Australia, Hong Kong, China, Korea, and Italy, with a combined target enrolment of over 1,300 participants. Results are expected progressively from 2026 onwards.
Why This Is Different from Previous Neuroprotection Attempts
Glaucoma neuroprotection has been attempted before, and failed. Memantine, brimonidine, and various antioxidants were all studied without convincing clinical evidence of benefit in humans.
Niacinamide is different for three reasons.
First, it targets a specific, documented metabolic deficit. NAD+ depletion in glaucomatous retinal ganglion cells is not theoretical. It has been measured. Niacinamide addresses a known pathway, not a hypothetical one.
Second, it is already being studied in multiple well-designed randomised controlled trials simultaneously. The field has moved from preclinical promise to serious clinical investigation.
Third, it is safe, accessible, and inexpensive. Unlike gene therapy or novel pharmaceuticals, niacinamide is a widely available supplement. The safety data at doses used in glaucoma research, generally 1.5 to 3 grams per day, is reassuring, with low rates of adverse effects when used appropriately.
What This Means for You as a Patient
If you have glaucoma, or are a glaucoma suspect, you may have read about niacinamide online and wondered whether you should start taking it. Here is my honest, evidence-based answer.
Niacinamide is not currently approved as a treatment for glaucoma. It is not a replacement for your eye drops, laser treatment, or surgery. Eye pressure control remains the only proven, guideline-recommended treatment for glaucoma progression.
However, the evidence for niacinamide as a complementary neuroprotective strategy is more substantive than for any previous neuroprotection candidate in glaucoma. It is being studied seriously by major academic centres and now has an international joint position statement from the AGS and AAO.
If you are considering niacinamide, the following applies. Do not start without speaking to your ophthalmologist. Doses used in glaucoma research are higher than typical supplement doses, generally 1.5 to 3 grams per day, and carry a small risk of liver toxicity, particularly at the higher end. The AGS and AAO recommend periodic liver function testing if doses under 3 grams per day are being considered, and advise against doses of 3 grams or more outside of clinical trials.
Do not stop your prescribed drops. Niacinamide does not lower eye pressure at standard doses. It works through a completely different mechanism. It is additive at best, not substitutive.
Do not self-prescribe based on general wellness advice. The evidence base in glaucoma is specific to particular doses, patient profiles, and disease stages. General “niacinamide is good for you” wellness content does not apply here without qualification.
Glaucoma as a Metabolic Disease: The Bigger Picture
The niacinamide story is part of a broader shift in how glaucoma is understood. For most of its history, glaucoma has been framed as a pressure disease. Lower the pressure, save the nerve. That framing is correct, but incomplete.
Glaucoma is increasingly understood as a metabolic optic neuropathy. The optic nerve fails not only because of mechanical pressure but because its cells run out of energy, accumulate metabolic damage, and lose the ability to repair themselves. This metabolic vulnerability accelerates with age. It is worsened by systemic conditions like diabetes, hypertension, and obesity, the same conditions that deplete NAD+ across the body. Read more about GLP-1 agonists and their role in eye health here.
This is why I have published on the intersection of GLP-1 receptor agonists and glaucoma, on allostatic load and glaucoma risk, and on complementary approaches to glaucoma management. The future of glaucoma care is not just about pressure. It is about protecting the optic nerve metabolically, systemically, and long-term.
Smoking cessation may be associated with slower glaucoma progression, because it reduces teh oxidative stress. Long-term cessation may reduce risk closer to non-smokers over time
Niacinamide is the most clinically credible step in that direction so far.
Frequently Asked Questions
Can niacinamide treat glaucoma?
Niacinamide is not currently approved as a glaucoma treatment. It is being studied in multiple clinical trials as a neuroprotective supplement- meaning it may protect retinal ganglion cells from damage independent of eye pressure. It is not a replacement for prescribed glaucoma therapy.
Should I take niacinamide if I have glaucoma?
Only under guidance from your glaucoma specialist. Doses relevant to glaucoma research are higher than typical supplements, generally 1.5 to 3 grams per day, and require monitoring of liver function. Do not start without medical advice and do not stop your eye drops.
Is niacinamide the same as niacin or vitamin B3?
Niacinamide (also called nicotinamide) and niacin (nicotinic acid) are both forms of vitamin B3 but have different properties. Niacin is notorious for causing skin flushing and is not the supplement studied for glaucoma neuroprotection. Niacinamide is better tolerated and is the form studied in glaucoma research.
What is NAD+ and why does it matter in glaucoma?
NAD+ is a coenzyme essential for energy production and cell survival. Retinal ganglion cells — the nerve cells destroyed in glaucoma, depend heavily on NAD+. In glaucoma, NAD+ levels in these cells are depleted, making them vulnerable to damage. Niacinamide is a precursor to NAD+ and may help replenish these levels.
My eye pressure is normal but my glaucoma is still progressing. Could niacinamide help?
This is exactly the patient profile that niacinamide research is addressing: glaucoma that progresses despite adequate pressure control. The evidence suggests that metabolic neuroprotection may be relevant in this group. A specialist review to evaluate the full picture of your disease: optic nerve, visual field trajectory, systemic risk factors, is the right first step.
Is there a glaucoma specialist in Gurgaon who can advise on niacinamide and neuroprotection?
Yes. I discuss neuroprotective strategies including niacinamide as part of holistic glaucoma management at Marengo Asia Hospitals, Sector 56, Gurugram. Book at www.drshibalbhartiya.com or call +91 88826 38735.
The Bottom Line
Niacinamide is the most promising neuroprotective candidate in glaucoma research today. The evidence is not yet sufficient to make it standard of care, but it is sufficient to take seriously. Multiple major clinical trials are underway. A joint AGS-AAO position statement has acknowledged its potential. International reviews cite the work that has come from this research group.
If you have glaucoma that is progressing despite treatment, or if you want to understand all the options available to protect your optic nerve, that conversation deserves a specialist who is aware of the evidence, not just the guidelines.
Read the research
Dr Shibal Bhartiya is a fellowship-trained glaucoma specialist and Mayo Clinic Research Collaborator with over 25 years of experience. She is Clinical Director of Ophthalmology at Marengo Asia Hospitals, Gurugram, and author of “Niacinamide and Neuroprotection: The Glaucoma Holy Grail” (Journal of Current Glaucoma Practice, 2022. PMID 36793265) cited in multiple subsequent international reviews. Her approach focuses on identifying risk before damage is irreversible, simplifying treatment decisions, and protecting vision long-term. Ethical, patient-centred care. Second opinions and teleconsultations/ online reviews welcomed.
She has published peer-reviewed research on glaucoma management, examining how treatment decisions should balance medical evidence, patient preferences, and long-term vision outcomes.
As Editor-in-Chief of Clinical and Experimental Vision and Eye Research and Executive Editor of the Journal of Current Glaucoma Practice (Pubmed Indexed, official journal of the International Society of Glaucoma Surgery), Dr Shibal Bhartiya brings editorial and research depth to every clinical decision. Her 200+ publications, including 90+ PubMed-indexed publications and 28 edited textbooks span glaucoma biology, surgical outcomes, health equity, and emerging diagnostics.
Her work can be accessed on Pubmed, Google Scholar, ResearchGate and ORCID.
Dr Shibal Bhartiya
Glaucoma • Second Opinion • Advanced Care
www.drshibalbhartiya.com
+91 88826 38735
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