Is visual performance affected when combining atropine 0.01% with DIMS spectacle lenses?

Paper title: Safety of DIMS Spectacle Lenses and Atropine as Combination Therapy for Myopia Progression

Authors: Hakan Kaymak (1,2), Ann-Isabel Mattern (1), Birte Graff (1,2), Kai Neller (1,2), Achim Langenbucher (2), Berthold Seitz (3), Hartmut Schwahn (1)

1. Internationale Innovative Ophthalmochirurgie (I. I.O.), Düsseldorf, Deutschland
2. Institut für Experimentelle Ophthalmologie, Universität des Saarlandes, Homburg/Saar, Deutschland
3. Klinik für Augenheilkunde, Universitätsklinikum des Saarlandes UKS Homburg/Saar, Deutschland

Date: Oct 2022

Reference: Kaymak H, Mattern AI, Graff B, Neller K, Langenbucher A, Seitz B, Schwahn H. Safety of DIMS Spectacle Lenses and Atropine as Combination Therapy for Myopia Progression. Klin Monbl Augenheilkd. 2022 Oct;239(10):1197-1205. [Link to open access paper]

This study investigated the effect of combining low-dose 0.01% atropine with DIMS technology spectacle lenses with regards visual functions essential to children's road safety. This study was undertaken as:

1. Previous studies have explored the results of using atropine combined with other myopia control methods, such as orthokeratology,^1,2 to enhance the overall control effect.
2. DIMS spectacle lenses have been shown to be well tolerated^3,4 but atropine side effects of mydriasis could influence visual performance.

The visual functions of 12 adults aged 24 to 45yrs with refractive corrections ranging from an average of +1.13 to -8.13D were tested. The participants were administered 0.01% atropine and wore DIMS spectacle lenses matching their correction. Due to the manufacturing range of DIMS lenses, if a subject was hyperopic, they wore contact lenses to correct their refractive error and the DIMS lenses contained no additional correction.

To assess the effect of atropine on pupil sizes, the scotopic and photopic pupil sizes were measured using Topcon MYAH before the instillation of atropine. After installation, the pupil sizes were measured again at 60-minute, 4-hour and 8-hour intervals. Measures of distance visual acuity, contrast sensitivity, mesopic vision and glare sensitivity were taken before and after atropine instillation. The findings were as follows.

• Distance visual acuity: when looking through the centre of the DIMS lens, atropine caused a non-significant 0.06logMAR (3 letters) drop in acuity. Under glare conditions in combination with atropine, this reduced by a further 0.09logMAR (almost 1 line)
• The acuity looking through the edge of the DIMS lens was reduced by a significant 0.24logMAR, even with no glare or atropine. Glare and atropine had a minimal additional effect. 
• Contrast sensitivity was minimally affected by looking through the DIMS area compared to the central zone, and adding atropine made minimal or small differences.
• Binocular glare sensitivity testing showed no impact of glare or atropine on identification of high contrast targets, with only very low contrast targets affected to a small degree.

This study indicates that combining DIMS spectacle lenses with 0.01% atropine should have minimal impact on visual function, including in situations where glare is experienced.

When looking through the DIMS treatment area of the lens, the visual acuity may be reduced, but this does not seem to be worsened significantly by glare or atropine 0.01%. The authors describe this information as important for road safety, particularly as some of the tests used are those for German driver license requirements. While children aren't driving, and these tests were done in adults, these results indicate that children's visual functions should be minimally impacted by combining atropine 0.01% with DIMS spectacle lenses under a variety of viewing conditions.

1. This study cohort were adults, rather than children who would be the typical group targeted for myopia control treatment(s). A previous study found a smaller reduction in visual acuity when viewing through the DIMS treatment area.³ This may suggest children adapt quicker than adults and notice any visual disturbance from the defocus less than adults. A similar study with child participants could confirm this.
2. The atropine concentration used in the study was a low-dose concentration of 0.01%. While this appears to be the main concentration being utilized in combination treatments, stronger concentrations may potentially have a greater impact on visual functions.

Title: Safety of DIMS Spectacle Lenses and Atropine as Combination Therapy for Myopia Progression

Authors: Hakan Kaymak, Ann-Isabel Mattern, Birte Graff, Kai Neller, Achim Langenbucher, Berthold Seitz, Hartmut Schwahn

Purpose: The aim of this study was to evaluate traffic safety of Defocus Incorporated Multiple Segments (DIMS) spectacle lenses in combination therapy with atropine.

Methods: 12 young adults (age: 24-45; 30,1 ± 5,7 years) were recruited to evaluate corrected distance visual acuity (CDVA), contrast sensitivity (CS; FrACT), glare sensitivity (Mesotest) under the influence of DIMS spectacle correction alone and combination therapy with 0,01% atropine.

Results: When looking through the central area of the DIMS lens, far vision does not decrease due to the influence of atropine; influence of glare and atropine leads to a reduction of CDVA by 0.10 logMAR.When forced to look through the DIMS area, far vision is reduced by 0.09 logMAR due to the influence of atropine in the absence of glare; in the presence of glare, no further loss of visual acuity can be observed under the influence of atropine. Contrast vision with DIMS glasses is not altered by the effects of atropine. Concerning glare sensitivity, DIMS lenses did not show any visual impairment that would be relevant to vision and road safety. Additional atropinization does not affect glare sensitivity.

Conclusions: DIMS spectacle lenses are safe for participation in road traffic and do not relevantly impair traffic safety, neither alone nor under the acute influence of 0,01% atropine.

[Link to open access paper]