Combining atropine and MiSight 1 day: does it work?

Paper title: Low-Concentration Atropine Monotherapy vs. Combined with MiSight 1 Day Contact Lenses for Myopia Management

Authors: Erdinest, Nir (1,2); London, Naomi (3); Lavy, Italy (1); Landau, David (1); Noyman, Dror Ben Ephraim (4); Levinger, Nadav (1,5); Morad, Yair (2,6)

1. Department of Ophthalmology, Hadassah-Hebrew University Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 9574409, Israel.
2. The Myopia Center, Rishon LeZion 4951732, Israel.
3. Naomi Vision Boutique, 5 Even Israel St., Jerusalem 9422805, Israel.
4. Department of Ophthalmology, Rambam Health Care Campus, Haifa 3525408, Israel.
5. Department of Ophthalmology, Enaim Refractive Surgery Center, Jerusalem 9438307, Israel.
6. Department of Ophthalmology, Assaf Harofeh Medical Center, Zerifin 7033001, Israel.

Date: Dec 2022

Reference: Erdinest N, London N, Lavy I, Landau D, Ben Ephraim Noyman D, Levinger N, Morad Y. Low-Concentration Atropine Monotherapy vs. Combined with MiSight 1 Day Contact Lenses for Myopia Management. Vision (Basel). 2022 Dec 12;6(4):73

[Link to open access paper]

Atropine is thought to reduce the rate of axial elongation by influencing growth processes within the sclera and by controlling growth signals within the retina.¹ Atropine appears to have a dose-dependent effect. Since higher concentrations (0.1% to 1%) are effective but bring significant side effects and rebound on treatment cessation,  lower concentrations (0.01-0.05%) have shown the better balance of efficacy and tolerance.²

Spectacle and contact lens designs for myopia control correct myopia while also slowing progression, and atropine has been used in combination with DIMS spectacles, soft multifocal contact lenses and orthokeratology in an attempt to boost myopia control efficacy.

This retrospective study investigated the myopia control and rebound effect of low-dose (0.01%) atropine monotherapy, compared to a combined treatment of atropine and the MiSight 1 day soft contact lens.

The study participants were 85 Caucasian children aged between 6 to 15yrs who presented to a specialist myopia clinic in Israel. They had spherical equivalent refractive error (SER) between -1.25 to -10.87D at baseline and a change of -1D or more in the year prior to the study. The children fell into to one of 2 treatment groups or the single vision spectacle control group. Results were as follows. 

• The A0.01% group (n=29) experienced progression of 0.44 ± 0.21 D and 0.51 ± 0.39 D in the 1^st and 2^nd years of use, respectively. Atropine was tapered to cessation by one less day per week per month, over the course of six months. The progression was 0.24 ± 0.35 D.
• The A0.01% + DFCL group (n=26) showed 0.35 ± 0.26 D and 0.44 ± 0.40 D progression in the 1^st and 2^nd years, respectively. The progression rate 6mths after discontinuing the atropine was 0.18 ± 0.34 D.
• The control group (n=30) wearing single vision spectacles showed 1.19 ± 0.43 D, 1.25 ± 0.52 D and 1.13 ± 0.36 D in the 1^st, 2^nd and 3^rd years, respectively.
• The total progression over 3yrs was 1.196 D (average of 0.34 ± 0.34 D annually), 0.96 D (average 0.324 ± 0.33D annually) and 3.75 D (average of 1.19 ± 0.43D annually) for the A0.01%, A0.01% + DFCL and control groups, respectively.
• Visual acuity was slightly reduced in the A0.01%+DFCL group compared to the single vision group, but was not different to the A0.01% group.

This study was able to demonstrate the efficacy of atropine 0.01% as a monotherapy treatment in this population, which interestingly was similarly effective to the combination of atropine and MiSight 1 day. The lack of axial length data could be a key factor in the apparent similarity of the treatment groups. There did not appear to be a rebound effect on treatment cessation.  

The authors therefore suggested there is little advantage to combining atropine and MiSight 1 day soft contact lenses to boost myopia control efficacy, but this would not be considered definitive until a larger study with matched groups and axial length measures was reported.

• This was a retrospective study using a small cohort of clinical data, and axial length was not measured. Difference between the treatment groups may have been revealed in a larger study utilizing axial length data. 
• Using subjective cycloplegic refraction rather than objective cycloplegic auto-refraction could also have made variation between groups less obvious.
• The two treatment groups were older than the control group. Slower progression in the treatment groups could have confounded potential differences. 

The Low-Concentration Atropine for Myopia Progression (LAMP) study found a dose-dependent effect with atropine,² varying by age group.³ Further studies investigating the combination of varying atropine concentrations alongside other optical treatment methods could suggest targeted management strategies based on age. 

Title: Low-Concentration Atropine Monotherapy vs. Combined with MiSight 1 Day Contact Lenses for Myopia Management

Authors: Erdinest, Nir; London, Naomi; Lavy, Italy; Landau, David; Noyman, Dror Ben Ephraim; Levinger, Nadav; Morad, Yair

Purpose: To assess the decrease in myopia progression and rebound effect using topical low-dose atropine compared to a combined treatment with contact lenses for myopic control

Methods: This retrospective review study included 85 children aged 10.34 ± 2.27 (range 6 to 15.5) who were followed over three years. All had a minimum myopia increase of 1.00 D the year prior to treatment. The children were divided into two treatment groups and a control group. One treatment group included 29 children with an average prescription of 4.81 ± 2.12 D (sphere equivalent (SE) range of 1.25−10.87 D), treated with 0.01% atropine for two years (A0.01%). The second group included 26 children with an average prescription of 4.14 ± 1.35 D (SE range of 1.625−6.00 D), treated with MiSight 1 day dual focus contact lenses (DFCL) and 0.01% atropine (A0.01% + DFCL) for two years. The control group included 30 children wearing single-vision spectacles (SV), averaging −5.06 ± 1.77 D (SE) range 2.37−8.87 D).

Results: There was an increase in the SE myopia progression in the SV group of 1.19 ± 0.43 D, 1.25 ± 0.52 D, and 1.13 ± 0.36 D in the first, second, and third years, respectively. Myopia progression in the A0.01% group was 0.44 ± 0.21 D (p < 0.01) and 0.51 ± 0.39 D (p < 0.01) in the first and second years, respectively. In the A0.01% + DFCL group, myopia progression was 0.35 ± 0.26 D and 0.44 ± 0.40 D in the first and second years, respectively (p < 0.01). Half a year after the cessation of the atropine treatment, myopia progression (rebound effect) was measured at −0.241 ± 0.35 D and −0.178 ± 0.34 D in the A0.01% and A0.01% + DFCL groups, respectively.

Conclusions: Monotherapy low-dose atropine, combined with peripheral blur contact lenses, was clinically effective in decreasing myopia progression. A low rebound effect was found after the therapy cessation. In this retrospective study, combination therapy did not present an advantage over monotherapy.

[Link to open access paper]