When to prescribe Atropine for myopia control

Atropine can be the clear front runner for myopia control treatment in some patients, and can be used as both monotherapy and a combination treatment. While it's important to consider the optical correction for myopia - and hence consider an optical treatment which both corrects and controls myopia where possible - for some patients this isn't possible. Here we explore when to use atropine as a first line treatment, an adjunct treatment and how to manage cessation.

Contact lens options likely provide the best option to both correct myopia and control progression as a monotherapy. Some children, though, are simply intolerant to contact lenses, or the parents are not enthusiastic about contacts lenses in young children. Not all countries have access to myopia control specific spectacle and contact lens designs. Other issues such as corneal disease, significant allergy and high astigmatism are important for consideration in selecting the best option for the individual child.

Another thing to consider is cost. Atropine can be significantly cheaper than other treatments - particularly contact lenses - even when the medication is compounded. And as new, formulated products enter the market, this price may go down further.

For children aged 6-10 years with myopia of at least 1D and myopia progression of at least 0.50D per year, the WHO recommends atropine as a potential first line treatment for myopia.¹

Keep in mind this advice from the WHO was published in 2015, and we now know thanks to the Low-Concentration Atropine for Myopia Control (LAMP study) and further analysis of the Atropine for the Treatment of childhood Myopia 2 (ATOM2) that the efficacy of atropine is dose-dependent, and in fact concentrations of 0.025% or 0.05% may be a better place to start, until further research becomes available.^2,3 Commercially prepared formulations of 0.01% are currently being researched, so this could also change the tide on the best concentration with which to start. Read "Atropine - Wonder or Weak Treatment" and "The Latest and Greatest Research on Atropine" for more on the current understanding on the ideal concentration of atropine. Consider starting on a lower dose (such as 0.025%) to best balance side effects and efficacy; and increase from there if needed.

There is interesting evidence that atropine, when combined with orthokeratology, may have compounding effects that improve efficacy compared to either of the two treatments used as monotherapy. Chen et al. recently conducted a retrospective study that showed that the addition of 0.01% atropine used nightly with Ortho-K treatment slowed axial growth considerably to 0.14 ± 0.14 mm over a year, compared to 0.46 ± 0.16 mm in the year prior of Ortho-K treatment alone.⁴ This isn't conclusive data as axial growth ordinarily slows with time anyway, but shows early promise.

Two further studies are investigating combining atropine 0.01% with orthokeratology and centre distance multifocals - only baseline data is currently available (click the links for more) but tolerance to the dual therapy seems good in both studies.

A 'rebound' of accelerated myopia progression after cessation of treatment was indicated in the ATOM2 study.⁵ This study investigated 0.01%, 0.1% and 0.5% concentrations, and found that children on the 0.01% did have a rebound effect over a year of cessation, but less so than for the stronger concentrations. There is limited evidence on rebound for 0.025% and 0.05% however it can be extrapolated that this would be a potential consequence of stopping treatment. The WHO recommendations as described above suggest treatment for two years and then a 'taper' when using and then ceasing atropine drops. There are currently no studies nor guidelines on how to taper, but consider reducing the schedule as you might for steroid treatment.

An example of a tapering schedule might be:

• Every other day for 2-3 months, then
• Once a week for 2-3 months.
• You may even consider additionally reducing concentration (eg. from 0.025% to 0.01%) for 2-3 months, maintaining the same dosage frequency and then reducing, if you feel a longer taper may be required.

The data indicates we should be more concerned about rebounds in children who are younger, previously faster progressors, or those on stronger concentrations. Depending on your level of concern, you would monitor for rebound progression every 3-6 months.

Do you need to stop atropine after two years? The WHO recommendations described above are based on the longest studies available at that time (in 2015), which were two years long; however the ATOM2 Five year study⁵ followed children who underwent treatment for two years, stopped (and demonstrated rebound) and then started again, and tolerance to treatment was good. With close monitoring and clinical care, there's no likely reason you couldn't continue for longer than two years. Perhaps you may choose to stop if or when the child is ready for an effective optical solution like contact lenses, or perhaps you may choose to stop because their myopia appears to be stabilizing. Read our blog When to stop myopia control treatments for more on this topic.

In summary, atropine is an effective and ideal myopia control option for some patients and their families. Remember that an optical correction is still required, and so any atropine treatment is a type of 'combination therapy' with your chosen optical solution. Careful monitoring for side effects, effectiveness and adherence to drop regime is crucial for ongoing success with atropine treatment.

• Atropine – wonder or weak treatment?
• Complex Atropine Cases
• Complications in atropine compounding
• The Latest and Greatest Research on Atropine
• Systemic Side Effects of Atropine Eye Drops

• 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.