This review develops and critically grades the 'accommodative aqueous regulation' (AAR) hypothesis — that lifelong ciliary muscle cycling during accommodation conditions trabecular outflow, and that its progressive loss at presbyopia contributes to open-angle glaucoma risk in susceptible eyes, with refractive state (emmetropia, myopia, hyperopia) mapping probabilistically onto glaucoma subtype.
The AAR hypothesis proposes a mechanistic link between three epidemiologic/pharmacologic observations: rising open-angle glaucoma incidence across presbyopic decades, increased glaucoma risk in myopia, and IOP reduction with muscarinic agonists in some normal-tension eyes. The authors explicitly grade the central claim as **untested** — mechanical coupling of ciliary muscle to a mechanosensitive outflow apparatus is supported by existing physiology, but the core hypothesis awaits experimental confirmation.
- The central AAR claim is entirely hypothesis-generating; no new primary data are presented and no clinical trials are reported. - The refractive-state-to-glaucoma-subtype mapping is explicitly probabilistic and cannot be applied to individual eyes. - As a narrative/theoretical review, it is subject to selective citation and cannot establish causality.
This framework is not ready for clinical application — clinicians should not alter glaucoma management based on AAR until the proposed confirmatory experiments are done. However, it highlights presbyopia as a potentially underappreciated temporal risk marker for open-angle glaucoma worth monitoring in susceptible patients.
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