Irrigated agriculture is the dominant water user in Central Asia and is critical for regional food security and livelihoods. Much of the irrigation infrastructure, developed during the Soviet era, enabled large-scale agricultural expansion but contributed to environmental degradation, including the desiccation of the Aral Sea. Since 1991, countries have implemented reforms to improve water governance and efficiency. This review integrates historical policy analysis with Earth observation–based assessments of land use, vegetation dynamics, evapotranspiration, and hydroclimatic trends. Satellite evidence indicates that irrigation demand remains high and has intensified in some regions despite modernization efforts. Meanwhile, climate change—through rising temperatures, reduced snow storage, and increased variability—further pressures water resources. Although emerging technologies such as remote sensing and digital water management offer opportunities for improvement, achieving sustainable irrigation will require stronger institutional reforms, improved basin-scale water accounting, and enhanced transboundary cooperation.