AAO Releases Updated PPP Guidelines for Adult Eye Exams

The AAO's updated PPP for adult medical eye evaluations maintains many of the same protocols and care intervals as 2021 guidelines but features several distinctions, including the addition of a new subsection for uncorrected refractive error. Click image to enlarge. The preferred practice pattern (PPP) guidance documents from the American Academy of Ophthalmology (AAO) often set the stage for protocols used in eye care, or at least provide evidence-based fodder for discussion. The 2026 update to the AAO’s Comprehensive Adult Medical Eye Evaluation guidelines, published earlier this week, aims to refine screening and follow‑up recommendations, clarify diagnostic pathways and align care with contemporary standards to improve patient outcomes. Compared to the 2021 PPP, the 2026 revision maintains core care intervals and framework while providing several noteworthy revisions to disease risk factors, updates to AMD management and diagnostics and greater emphasis on uncorrected refractive error and high myopia. Read on for the key changes you need to know.What Stayed the SameFor asymptomatic adults without risk factors, recommended exam intervals remain identical to those delineated in 2021 (under 40: every five to 10 years; 40 to 54: every two to four years; 55 to 64: every one to three years; ≥65: every one to two years). Also unchanged is exam timing for patients with diabetes: those with type 1 diabetes should receive annual examinations beginning five years after diagnosis, while patients with type 2 diabetes should be examined at diagnosis and once yearly thereafter (clarified in 2026 as “at least yearly”). The new guidelines also maintain that anti-VEGF is the first-line treatment for neovascular AMD, initiated at diagnosis. Glaucoma You can access Review of Optometry’s full index of guideline documents here. One of the most prominent updates in the 2026 PPP is an expansion of risk factors for various ocular diseases, including open-angle glaucoma, which now include type 2 diabetes, lower systemic blood pressure and lower ocular perfusion pressure, myopia, lower corneal hysteresis, optic disc hemorrhage, a larger cup-to-disc ratio, higher visual field pattern standard deviation, older age, family history of glaucoma, Black race, Latino or Hispanic ethnicity, elevated intraocular pressure and thin central corneal thickness. Given these new additions, the AAO recommends that clinicians update intake to capture diabetes status, myopia and family history, as well as train technicians to document disc hemorrhages and suspicious cup-to-disc ratios. They also suggest that clinicians consider obtaining corneal hysteresis data if available/applicable.DiabetesWhile the AAO made no changes to yearly screening recommendations, the 2026 update removes the note that “gestational diabetes mellitus does not require pregnancy exam.” Instead, it encourages clinicians to defer to diabetic retinopathy PPPs when managing these patients. The new document also reports on the rising prevalence of diabetes in the US, noting that “approximately one third of Americans are at risk of developing diabetes mellitus during their lifetime.” The AAO emphasizes how social determinants of health (income, housing, and education) contribute to these climbing rates and states that various demographic factors, including race and ethnicity, “also remain strong predictors of mortality risk among adults with diabetes.” AMDGuidelines on AMD treatment have also shifted from 2021, now incorporating two approved therapies for geographic atrophy—pegcetacoplan (Syfovre, Apellis) and avacincaptad pegol (Izervay, Astellas). The AAO notes that these therapies slow GA growth, though no BCVA benefit was shown in clinical trials. It also advises that clinicians monitor patients on these drugs for exudative conversion. The AAO also reaffirmed the benefit of the AREDS2 supplement for patients with AMD, which forgoes beta-carotene and adds lutein/zeaxanthin. Moreover, the 2026 PPP emphasizes the protective association of a Mediterranean diet.Another notable change pertains to smoking counseling; the 2026 update explicitly states that “smoking cessation should be encouraged”—a minor distinction from 2021 guidelines, which identified smoking as a risk factor for AMD/cataract.Primary Angle-closure DiseaseWhile the 2021 guidelines outlined risk factors of age, female sex, hyperopia and Inuit/Asian ancestry, the 2026 update adds biometric risks to this list, including narrow angle width, shallow anterior chamber depth, shorter axial length, increased lens thickness and lens vault/plateau iris. Moreover, it notes that patients with primary angle-closure disease have a higher risk of blindness than those with primary open-angle glaucoma. The AAO urges clinicians to reinforce gonioscopy for at-risk patients, standardize LPI referral criteria and add biometric recognition to training.Uncorrected Refractive Error While this concern was addressed implicitly within refraction processes in 2021, the AAO has now dedicated a subsection to uncorrected refractive error, highlighting its high prevalence, asymptomatic tendency and negative effects on quality of life. In the 2026 PPP document, they cite findings from a 2021-2022 cross-sectional study reporting uncorrected refractive error as the leading cause of vision impairment at two Michigan clinics serving low-income communities. The AAO notes that this common condition “can be detected on comprehensive medical evaluation by history and visual acuity testing with pinhole,” adding that “refraction can be undertaken at that time or upon referral to an appropriate clinician.” It also suggests building low-cost eyewear referral options into clinics.High MyopiaUpdated guidance on high myopia incorporates new global projections that estimate by 2050, “half of the world population will be myopic and 10% will be highly myopic.” By that year, the AAO also reports “visual impairment due to myopic macular degeneration will grow from 10.0 million to 55.7 million people worldwide.” Given the rising prevalence of high myopia and documented risk of myopic maculopathy and retinal detachment among these patients, revisions to clinical guidelines include requiring annual dilated fundus examinations for certain individuals, particularly those with a refractive error of ≤-6.00D or axial length >26mm. In pathologic myopia, the AAO also suggests considering OCT/OCT-A baselines.Other Notable ChangesThe AAO expanded the list of systemic disease indicators from 2021 (AIDS, syphilis, toxoplasmosis; HCQ/tamoxifen/phenothiazines toxicities) to now include trauma, sleep apnea, congenital abnormalities and steroid exposure. The 2026 guidelines also specify HIV and add optic nerve red flags like idiopathic intracranial hypertension and malignancy.Regarding examination components and testing, the updated PPP now specifies recording pinhole visual acuity when reduced and emphasizes dilation for posterior segment evaluation. Additionally, it expands upon specialized clinical tests and diagnostics, now including fundus autofluorescence, widefield photography, in-office point-of-care tests (MMP-9, osmolarity, adenovirus) and biometry (explicitly for IOL calculations).A small change was made to history-taking practices; the 2026 update moved “sexual activity” to the social history section, which had previously been recorded on a separate line.The 2026 document also relays more recent estimates of blindness and visual impairment prevalence in the US. Based on 2015 data, the 2021 PPP cited that the prevalence of vision loss in the US was around 1.02 million, while 3.22 million people were visually impaired. The 2026 update reflects newer data from 2017/2019, estimating that roughly 1.08 million are blind, while 7.08 million have visual acuity loss. It also highlights the increasing global prevalence of AMD, especially amid an aging population, “leading to an estimated 196 million patients with AMD in 2020 and a projected 288 million by 2040.”The AAO also touched on the growing economic burden of vision loss and ocular disorders. In 2012, costs among people younger than 40 were estimated at $27.5 billion, split fairly evenly between direct and indirect costs ($14.5 billion vs. $13 billion). By 2017, a broader, all-ages estimate put the national burden at $134.2 billion, with a larger share from direct medical and vision-related expenses ($98.7 billion) than indirect costs ($35.5 billion), indicating a shift toward higher overall—and more direct—spending.Bottom LineIn short, the 2026 PPP keeps the framework but raises the bar on risk identification, AMD management and diagnostic rigor—adding uncorrected refractive error and high myopia as priorities. Eyecare clinicians should begin implementing these new recommendations in their practices to deliver more precise, equitable and up-to-date care to their patients.Click here for the journal source. Wallace DW, Flaxel CJ, Gedde SJ, et al. Comprehensive adult medical eye evaluation preferred practice pattern. Ophthalmology. February 11, 2026. [Epub ahead of print].  This article was developed by the editorial staff in conjunction with experts in the field. In the process, AI may have been among the editorial tools used to meet the goals of human editors, who approved all content.