Complex Atropine Cases

Choosing the right treatment for an individual child can be one of the most complex aspects of myopia management. With atropine eye drops, there are multiple factors that should be considered before commencing treatment. Here are three complex atropine cases, to get you thinking about the things to consider when prescribing topical atropine. In each case names and certain details have been changed to respect patient privacy.

Tom was a 13 year old male who presented with a history of progressing myopia and type 1 diabetes. His last recorded refraction from 12 months ago showed R&L-2.00DS. He reported never wearing his glasses as he disliked the appearance of them, and denied any difficulties in the classroom however his mother suggested otherwise. Medications included a continuous insulin pump and control of the diabetes was reported as very good. There was no known congenital syndromes and no cardiac complications, and no retinal complications of diabetes.

Tom was particularly keen on contact lenses, which seemed appropriate given his reluctance to wear glasses. His parents on the other hand had heard of Atropine, and their treating preference was the drops.

After discussion with Tom and his parents, including highlighting the current lack of evidence for an additive benefit to combining MFCL and Atropine at that time (it was 2016!), the consensus was for dual therapy - Tom commenced wearing MiSight contact lenses 6 days a week, and Atropine 0.01% nightly. This made his parents comfortable, and Tom over the moon.

The importance of good CL hygiene, especially in a low immune situation such as diabetes was discussed, and also the risk of under-correction increasing myopia progression - Tom agreed to wear his new updated spectacles on the 7^th day. The optometrist called the treating paediatrician to discuss the current medications that Tom was on, his diabetic control and any concerns the paediatrician may have with adding topical ophthalmic atropine. The paediatrician approved, Tom's acuity with MiSight + atropine 0.01% nightly was excellent, and there were no reported side effects of the atropine.

After two years of a stable refraction and excellent tolerance of CL wear, the atropine was quickly tapered to every 2 days and then every three days (each for 7 doses) and then ceased. Tom elected to continue wearing the contact lenses. Tom has been followed every six months since and has still exhibited no myopia progression and excellent tolerance of his MiSight contact lenses.

The clinical pearl from Tom's case? Atropine can cause systemic side effects, and in a child with an autoimmune disease such as Type 1 Diabetes ensuring that the atropine will not be a contraindication with other medications is important. Insulin specifically does not interact with Atropine, however communication with the paediatrician was positive for the patient and parents and crucial to good prescribing.

Another key factor is considering contact lens safety, with reference to a patient's autoimmune profile. Given Tom's diabetes was well controlled, he was a motivated wearer and wearing daily disposable contact lenses, this risk is well managed. Reinforcing hygiene measures and ensuring patient and parent understanding of signs of contact lens complications and what to do are important for any contact lens patient; arguably even more so in a case like this.

Mary was 13 year old of Caucasian ethnicity, with a history of myopia progression from R&L -0.50 a year prior to R&L -2.00 presently. She had been referred by a colleague optometrist for atropine treatment, as she had refused contact lens options for myopia control. Mary had two highly intelligent professional parents, one with myopia - despite their prior discussions with the referring optometrist, we started again with discussing all of the options. We also discussed Mary's medical history - while a generally healthy child with no allergies, she had recently commenced the antidepressant medication Escitalopram (proprietary name Lexapro).

Escitalopram is a selective serotonin reuptake inhibitor (SSRI) which is known to dilate the pupils. As such, it could be considered a contraindication for atropine use as it could potentiate the side effects of atropine. This could be especially important in children with lighter irides, who may show greater mydriatic response to such agents. As a blue eyed child, atropine didn't seem the best choice for Mary's myopia management.

Instead, we revisited contact lens options. Mary was given both a soft contact lens and an OrthoK lens to touch and feel, and reassured that we could give her the time and space to learn how to handle them. After some home discussion time and three contact lens teaches, Mary started wearing CooperVision MiSight contact lenses and then later moved to OrthoK.

Mary moved to OrthoK wear because she and her parents were most intrigued by this option when it was first described and hence they set it as her treatment goal. While Mary tolerated MiSight well, another potential side effect of SSRIs is dry eye, which could additionally make OrthoK a better choice for Mary.

The clinical pearls from Mary's case? The potential combination of her antidepressant medication and atropine could have led to significant atropine side effects. In addition, her medication could also cause dry eye, being an important consideration in contact lens fitting. Mary's medication meant that atropine wasn't the best first choice for myopia management.

Six months later Mary is successfully wearing her OrthoK lenses, has no dry eye symptoms or ocular surface signs and her myopia appears stable.

James was a 5 year old boy with an emmetropic mother and a highly myopic father of around -8.00D. At such a tender age, James was already R&L -1.00D and once his parents understood James' likelihood of progression to high myopia and the risks associated with it, they were extremely motivated for myopia management. In fact, James' father hadn't been educated to the risks of high myopia until his son's appointment - he responded by instituting annual eye exams for himself including a full retinal examination.

Having done their online research, James' parents were interested in atropine treatment. His medical history, though, revealed that James was born with a small ventricular septal defect (hole in the heart) which was being monitored by a paediatrician and cardiologist. The potential for systemic absorption of topical atropine drops was highlighted as a concern - atropine can increase heart rate and alter conduction so could be considered contraindicated in children with cardiac defects or disease. Instead we discussed firstly trying an optical intervention - full time wear of progressive spectacle lenses. James hadn't worn a full time correction before, and his binocular vision status suited this intervention. We decided to hold off on atropine prescribing and evaluate the influence of full time optical correction first. It was also decided that any future atropine prescribing would be done in co-management with a paediatric ophthalmologist, while also communicating with James' paediatrician and cardiologist, as required.

Does a single drop on the eye have effects on the whole body? Click this link to read a review article on the topic, which covers the whole spectrum of eye medications.

The clinical pearls from James' case? Firstly to investigate health history and secondly to proceed carefully, by doing the simple things first - ensuring full time wear of his full correction was an important first step to evaluating James' response and subsequent myopia progression. Given his early onset and family history, James is at risk of progression to high myopia, so future atropine or combination treatments may be required.

• Atropine – wonder or weak treatment?
• When to prescribe Atropine for myopia control
• Complex Atropine Cases
• Complications in atropine compounding
• The Latest and Greatest Research on Atropine

• Which atropine dosage should I prescribe for myopia control?

• Atropine eye drops and ocular allergy - what's the cause?

1. Atropine, engaging with science and responsible practice with Professor Karla Zadnik from Ohio State University, USA.

2. More on atropine 0.01% treatment for myopia management with Professor Mark Bullimore from the University of Houston, Texas USA.

3. Atropine 0.01% for myopia management with Professor James Loughman from Technological University Dublin, and the Centre for Eye Research Ireland.