Atropine for myopia control – the clinical experience

In 2010 Visique Rose Optometrists in New Zealand launched its myopia control clinic. The aim of this clinic was to provide evidence based treatment options for the correction for myopia. Two years ago Atropine was introduced with help and collaboration of local ophthalmology. All patients within the clinic are reviewed regularly with cycloplegic refraction (as indicated) and IOL master measurement of axial length. As part of this article I have included some tips on creating a clinical protocol for your patients, based on the protocol used within our clinic with respect to Atropine. This is a guide only, and if you would like assistance in developing your own myopia control clinic then feel free to email me: jlallu@visique.co.nz

Atropine for the treatment of childhood myopia has in recent times been more extensively researched through the ATOM trials with the latest update released on August 11,2015. The first paper in a series of three so far was published in 2006. This study was the first randomized, double-masked, placebo-controlled trial designed primarily to study whether topical 1% Atropine can prevent the progression of low and moderate myopia effectively and safely in children between 6 and 12 years of age over two years study duration[1].

Four hundred children were recruited of which three hundred and sixty completed the trial, aged between six and twelve. Refractive errors included spherical equivalents 1.00 to 6.00 diopters and moderate astigmatism (1.50 D or less). The results showed that Atropine 1% did in fact slow the progression of low to moderate myopia in asian children by 77% with no serious adverse events[1], although evaluation of pupillary dilation and impaired accommodation wasn’t undertaken. Also, a rebound effect occurred, where post-treatment eyes progressed more quickly than the untreated controls for the year following Atropine cessation, resulting in the cumulative myopia control effect being 45% over three years[2].

In 2012 the Atropine for the Treatment of Childhood Myopia: Safety and Efficacy of 0.5%, 0.1%, and 0.01% Doses (ATOM 2) study aimed to compare three different concentrations of Atropine with respect to efficacy and side effects. Four hundred children were recruited into the study with 161, 155, and 84 children in the 0.5%, 0.1%, and 0.01% atropine treatment arms, respectively. 0.5% Atropine was the most effective in terms of slowing progression however 0.01% was the most clinically useful due to its lower effect on accommodation, allergic reaction and pupil size. The myopia controlling effect of the 0.01% Atropine was shown to be 59%, when compared to the historical control group in ATOM1[3]. In our clinic we utilise 0.01% Atropine formulated by a compounding pharmacy, as it is not yet commercially available.

The most recent paper, Five-Year Clinical Trial on Atropine for the Treatment of Myopia 2 compared the safety and efficacy of different concentrations of atropine eye drops in controlling myopia progression over 5 years. This study built on the first two years of the ATOM2 study, where the patients were divided into 0.1%, 0.05% and 0.01% Atropine groups, after which all were ceased for a year. Children who showed any progression of 0.5D or more in either eye during the one year of ‘washout’ were then restarted on 0.01% Atropine for another two years. Over the total of 5 years, atropine 0.01% eye drops were most effective in slowing myopia progression with an average of -1.38 ± 0.98D total progression, with the 0.05% group showing average progression of -1.83D and 0.1% showing progression of -1.98D. There was no control group in this study for comparison, but this increased efficacy of 0.01% Atropine was significant, with less visual side effects compared with higher doses of atropine – pupil dilation was measured as only 0.8mm, accommodation reduction was only 2-3D, and no near visual loss was found compared with higher doses[4].

Over the last two years we have been following a number of patients using Atropine 0.01%, of twelve patients followed thus far none have progressed with no patients noticing clinically significant side effects of pupil dilation, affect on near vision through impairment of accommodation or drug sensitivity. This dataset is similar to Dr Shuan Dai’s research where The Eye Doctors (Auckland ophthalmology group) have treated 20 children with 0.01% Atropine. All patients showed >2D of myopia and prior to treatment were progressing 0.5 D or more. The results showed no progression of more than 0.25 D with no side effects. You can read Shuan Dai's comments at this link.

Our myopia control clinic

At Visique Rose Optometrists, we provide patients with an information sheet which describes the concept of Preventative Medicine – taking a proactive approach to patient care through myopia control, which will in turn reduce risk of serious ocular conditions such as myopic macular degeneration, retinal detachment and glaucoma where the risks climb significantly for higher levels of myopia.

What do we tell our patients?

We explain that low dose Atropine drops (0.01%) is a new treatment for myopia control. The commercially available concentration of 1.0% can cause blurred near vision, pupil dilation and significant light sensitivity, and that there are also potential systemic side effects. However recent research has shown that Atropine at lower concentrations has a better safety and tolerance profile.

We explain that these drops can affect a child’s accommodation and pupil size upon instillation, and that they may sting. This is the reason why we recommend instilling this medication before bed as when the child wakes up these side effects will have subsided.

When should we follow them up?

We follow our Atropine patients up quarterly for the first year and at the six month visit perform cycloplegic refraction. For year two they are followed up six monthly. Tests performed at visits include: acuities, binocular assessment, retinal assessment and refraction.

Final pearl: As practitioners we are all here to help each other and that it is important to utilise resources like this website. This will help us to make evidence based clinical decisions for the best care of our patients so check back regularly.

jagrut-lallu

About Jagrut

Jagrut Lallu is a New Zealand clinical optometrist involved in contact lens peer leadership and education through national and international professional organisations. He is also a yarn spinner, tan cultivator and accomplished sportsman.

16 thoughts on “Atropine for myopia control – the clinical experience”

  1. Thank you very much Jagrut for sharing your clinical practice regimen for 0.01% atropine.
    Firstly, and sorry if this is a stupid question, is it atropine SULPHATE?
    Secondly, is this suitable for any age myope, including adult, even if say over thirty or forty years of age?
    Finally, is the recommendation for an indefinite course of say >five years?
    Thanks,
    Michael.

    • Hi there Michael,

      Thanks for the questions, yes it is sulphate – the sulphate is part of the formulation of the drug.

      With respect to age of myopia. The research discusses this for the use between younger age groups. Clinically we do see groups of myopes that uncharacteristically progress in their adult years. I think the question of suitability needs to be responded to cautiously. I am about to look at this group in private practice to initiate treatment to assess response. So at the moment would I treat these patients right now – not now. This viewpoint may change with research.

      For the final question – I would review after 2 years use, then stop for a year to review progression every six months. IF progression occurs then reinstate treatment for a further 2 years.

      I hope that answers your questions,

  2. Hi Jagrut

    Well done. Can you elaborate on the side effects the children experienced while using the Atropine? If you consider Myopia control effectiveness, long-term side effects, and visual efficiency what would, in your opinion, be the best Myopia control tool, Atropine, Orthokeratology or bifocal soft contact lenses?

    • Hi Charl,

      Yes I sure can, upon instillation there is a stinging sensation reported by the patient.

      We ask patients to instil the drop at night before bed. If the drop is not instilled before bed, we note a dilation effect and patients do notice some effect on their accommodation. It is for this reason that it is instilled at night so that they do not have observable effects in the morning.

      In response to the second part of your question – I think that all options should be considered but MY personal top two options should be are Atropine and Orthokeratology. We really need to look at all factors as Kate Gifford points out, she has written a blog about outdoor time as an example: http://www.myopiaprofile.com/why-outdoor-time-matters-in-myopia-development/

      I evaluate the options and alternatives for each patient on an individual basis. I also have access to the cooper vision MiSight daily wear dual focus lens, I have only used this lens on near esophoric patients and have had good success with no clinically significant progression on 6 patients since 2010. I selected this group for use with this lens based on Tom Allers twin study and the data seems to be in agreement.

      I hope that answers your questions Charl, thanks for reading the blog.

  3. Hi MD Jagrut Lallu,
    Congratulations for clinical practice atropine 0.01%. I have used in my patients atropine 0.025% since 2010, and almost no side effect is found.
    I begin in children as young as 5 years, If i have 2 years without myopia progress, than i reduce to 0.01% for more 2 years, and if i don´t rise again, i reduce to 0.005%.

    Best Regards,
    Celso Cunha – Brazil

    • Hi Celso,

      Are you looking at doing some research on your methodology. This would greatly benefit the profession. I have not seen any research on this way to prescribe and it would be good to get some research out there.

  4. Awesome Stuff Jagrut.
    An inspiration to every Optometrist who is thinking about Atropine for Myopia Control in their daily practice.
    Thanks

    Tim Eagle
    Optometrist at Visique Shattky on Russell in Hastings, NZ

  5. Hi Jaqrut
    This may seem a silly question, but I am considering using 0.001% atropine for the first time & am just wanting to confirm that this is a daily dose of one drop OU at night time.
    Many thanks

  6. Thanks Jaqrut
    I did mean the 0.01% – typo on that one!
    Are you aware of any studies that use this dosage less often that a daily dose?
    Thanks again.

  7. We are just starting with the protocol, thank you for sharing. I am wondering about washout?
    What is the rationale and your experience on patients starting another 2 years. It would seem very age dependent to me
    thanks Paul

    • Hi Paul, the simple answer is that we don’t know. My rationale is based on the ATOM studies. If we see progression then we reinstigate atropine. Hope that helps You somewhat

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