A 3-year follow-up study of atropine treatment for progressive myopia in Europeans

Five-year results of atropine 0.01% efficacy in the myopia control in a European population

AIMS

To evaluate the efficacy and safety of 0.01% atropine eye-drops in controlling myopia progression over 5 years.

METHODS

Experimental, analytical, prospective, randomised and longitudinal study, in 361 right eyes from 361 children randomised into the control group (177 eyes without treatment) and treatment group (184 eyes with 0.01% atropine eye-drops). Children assigned to the treatment group used 0.01% atropine once a day every night and the control group's children did not use any treatment or placebo. All the subjects completed an eye examination every 6 months for the 5 years of follow-up. The examination included subjective and objective refraction with cycloplegia, axial length (AL), keratometry and anterior chamber depth (ACD) to evaluate the efficacy of the treatment. It also included the anterior and posterior pole examination to evaluate the safety of the treatment.

RESULTS

The SE increased -0.63±0.42D in children after 5 years of treatment with 0.01% atropine, while in the control group the increase was -0.92±0.56D. AL increased 0.26±0.28 mm in the treatment group compared with 0.49±0.34 mm in the control group. Atropine 0.01% showed an efficacy of 31.5% and 46.9% in the control of the SE and AL increase, respectively. ACD and keratometry did not have significant changes between groups.

CONCLUSIONS

Atropine 0.01% is effective in slowing myopia progression in a European population. There were no side effects after 5 years of 0.01% atropine.

One-year efficacy of myopia control by the defocus distributed multipoint lens: a multicentric randomised controlled trial

AIMS

To report the 1-year results of the efficacy of a defocus distributed multipoint (DDM) lens in controlling myopia progression in a multicentre, randomised controlled trial.

METHODS

Overall, 168 children aged 6-13 years were recruited and randomly assigned to wear a DDM lens (n=84) or single-vision (SV) lens (n=84) in three centres. Cycloplegic autorefraction (spherical equivalent refraction (SER)) and axial length (AL) were measured. Linear mixed model analysis was performed to compare between-group SER and AL changes. Logistic regression analysis was used to analyse the between-group difference in rapid myopia progression (SER increase≥0.75 D per year or AL growth≥0.40 mm per year).

RESULTS

After 1 year, mean changes in SER were significantly lower in the DDM group (-0.47±0.37 D) than in the SV group (-0.71±0.42 D) (p<0.001). Similarly, mean changes in AL were significantly lower in the DDM group (0.21±0.17 mm) than in the SV group (0.34±0.16 mm) (p<0.001). After adjusting for age, sex, daily wearing time and parental myopia, rapid myopia progression risk was higher in the SV group than in the DDM group (OR=3.51, 95% CI: 1.77 to 6.99), especially for children who wore a lens for >12 hours per day, boys and younger children (6-9 years) with ORs (95% CIs) of 10.82 (3.22 to 36.37), 5.34 (1.93 to 14.78) and 8.73 (2.6 to 29.33), respectively.

CONCLUSIONS

After 1 year, DDM lenses effectively retarded myopia progression in children. Longer daily wearing time of DDM lens improved the efficacy of myopia control. Future long-term studies are needed for validation.

TRIAL REGISTRATION NUMBER

NCT05340699.

Myopia progression following 0.01% atropine cessation in Australian children: Findings from the Western Australia - Atropine for the Treatment of Myopia (WA-ATOM) study

BACKGROUND

A rebound in myopia progression following cessation of atropine eyedrops has been reported, yet there is limited data on the effects of stopping 0.01% atropine compared to placebo control. This study tested the hypothesis that there is minimal rebound myopia progression after cessation of 0.01% atropine eyedrops, compared to a placebo.

METHODS

Children with myopia (n = 153) were randomised to receive 0.01% atropine eyedrops or a placebo (2:1 ratio) daily at bedtime during the 2-year treatment phase of the study. In the third year (wash-out phase), all participants ceased eyedrop instillation. Participants underwent an eye examination every 6 months, including measurements of spherical equivalent (SphE) after cycloplegia and axial length (AL). Changes in the SphE and AL during the wash-out phase and throughout the 3 years of the study (treatment + wash-out phase) were compared between the treatment and control groups.

RESULTS

During the 1-year wash-out phase, SphE and AL progressed by -0.41D (95% CI = -0.33 to -0.22) and +0.20 mm (95% CI = -0.46 to -0.36) in the treatment group compared to -0.28D (95% CI = 0.11 to 0.16) and +0.13 mm (95% CI = 0.18 to 0.21) in the control group. Progression in the treatment group was significantly faster than in the control group (p = 0.016 for SphE and <0.001 for AL). Over the 3-year study period, the cumulative myopia progression was similar between the atropine and the control groups.

CONCLUSIONS

These findings showed evidence of rapid myopia progression following cessation of 0.01% atropine. Further investigations are warranted to ascertain the long-term effects of atropine eyedrops.

Myopia progression after cessation of atropine in children: a systematic review and meta-analysis

Purpose: To comprehensively assess rebound effects by comparing myopia progression during atropine treatment and after discontinuation. Methods: A systematic search of PubMed, EMBASE, Cochrane CENTRAL, and ClinicalTrials.gov was conducted up to 20 September 2023, using the keywords "myopia," "rebound," and "discontinue." Language restrictions were not applied, and reference lists were scrutinized for relevant studies. Our study selection criteria focused on randomized control trials and interventional studies involving children with myopia, specifically those treated with atropine or combination therapies for a minimum of 6 months, followed by a cessation period of at least 1 month. The analysis centered on reporting annual rates of myopia progression, considering changes in spherical equivalent (SE) or axial length (AL). Data extraction was performed by three independent reviewers, and heterogeneity was assessed using I2 statistics. A random-effects model was applied, and effect sizes were determined through weighted mean differences with 95% confidence intervals Our primary outcome was the evaluation of rebound effects on spherical equivalent or axial length. Subgroup analyses were conducted based on cessation and treatment durations, dosage levels, age, and baseline SE to provide a nuanced understanding of the data. Results: The analysis included 13 studies involving 2060 children. Rebound effects on SE were significantly higher at 6 months (WMD, 0.926 D/y; 95%CI, 0.288-1.563 D/y; p = .004) compared to 12 months (WMD, 0.268 D/y; 95%CI, 0.077-0.460 D/y; p = .006) after discontinuation of atropine. AL showed similar trends, with higher rebound effects at 6 months (WMD, 0.328 mm/y; 95%CI, 0.165-0.492 mm/y; p < .001) compared to 12 months (WMD, 0.121 mm/y; 95%CI, 0.02-0.217 mm/y; p = .014). Sensitivity analyses confirmed consistent results. Shorter treatment durations, younger age, and higher baseline SE levels were associated with more pronounced rebound effects. Transitioning or stepwise cessation still caused rebound effects but combining optical therapy with atropine seemed to prevent the rebound effects. Conclusion: Our meta-analysis highlights the temporal and dose-dependent rebound effects after discontinuing atropine. Individuals with shorter treatment durations, younger age, and higher baseline SE tend to experience more significant rebound effects. Further research on the rebound effect is warranted. Systematic Review Registration: [https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=463093], identifier [registration number].

Myopia management algorithm. Annexe to the article titled Update and guidance on management of myopia. European Society of Ophthalmology in cooperation with International Myopia Institute

Myopia is becoming increasingly common in young generations all over the world, and it is predicted to become the most common cause of blindness and visual impairment in later life in the near future. Because myopia can cause serious complications and vision loss, it is critical to create and prescribe effective myopia treatment solutions that can help prevent or delay the onset and progression of myopia. The scientific understanding of myopia's causes, genetic background, environmental conditions, and various management techniques, including therapies to prevent or postpone its development and slow its progression, is rapidly expanding. However, some significant information gaps exist on this subject, making it difficult to develop an effective intervention plan. As with the creation of this present algorithm, a compromise is to work on best practices and reach consensus among a wide number of specialists. The quick rise in information regarding myopia management may be difficult for the busy eye care provider, but it necessitates a continuing need to evaluate new research and implement it into daily practice. To assist eye care providers in developing these strategies, an algorithm has been proposed that covers all aspects of myopia mitigation and management. The algorithm aims to provide practical assistance in choosing and developing an effective myopia management strategy tailored to the individual child. It incorporates the latest research findings and covers a wide range of modalities, from primary, secondary, and tertiary myopia prevention to interventions that reduce the progression of myopia.

Oral administration of caffeine metabolite 7-methylxanthine is associated with slowed myopia progression in Danish children

PURPOSE

Myopia is associated with an increased risk of permanent vision loss. The caffeine metabolite 7-methylxanthine (7-MX), licensed in Denmark since 2009 as a treatment to reduce the rate of childhood myopia progression, is the only orally administered therapy available. The purpose of the current study was to assess the rate of myopia progression in children taking 7-MX.

METHODS

Longitudinal cycloplegic refraction and axial length data for 711 myopic children from Denmark treated with varying doses of oral 7-MX (0-1200 mg per day) were analysed using linear mixed models.

RESULTS

The median age at baseline was 11.1 years (range 7.0 -15.0 years). Children were followed for an average of 3.6 years (range 0.9-9.1 years) and the average myopia progression was 1.34 dioptres (D) (range -6.50 to +0.75 D). Treatment with 7-MX was associated with a reduced rate of myopia progression (p<0.001) and axial elongation (p<0.002). Modelling suggested that, on average, an 11-year-old child taking 1000 mg 7-MX daily would develop -1.43 D of myopia over the next 6 years, compared with -2.27 D if untreated. Axial length in this child would increase by 0.84 mm over 6 years when taking a daily dose of 1000 mg of 7-MX, compared with 1.01 mm if untreated. No adverse effects of 7-MX therapy were reported.

CONCLUSIONS

Oral intake of 7-MX was associated with reduced myopia progression and reduced axial elongation in this sample of myopic children from Denmark. Randomised controlled trials are needed to determine whether the association is causal.

Compounded 0.01% Atropine-What's in the Bottle?

OBJECTIVE

To describe the labeling, packaging practices, and characteristics of compounded 0.01% ophthalmic atropine.

METHODS

A convenience sample of parents of children who had previously been prescribed low-concentration atropine for myopia management were randomized to obtain 0.01% atropine ophthalmic solution from one of nine compounding pharmacies. The products were analyzed for various important quality attributes. The main outcomes were labeling practices, concentration of atropine and degradant product tropic acid, pH, osmolarity, viscosity, and excipients in 0.01% atropine samples obtained from nine US compounding pharmacies.

RESULTS

Twenty-four samples from nine pharmacies were analyzed. The median bottle size was 10 mL (range 3.5-15 mL), and eight of nine pharmacies used clear plastic bottles. Storage recommendations varied and were evenly split between refrigeration (33%), room temperature (33%), and cool, dark, dry location (33%). Beyond use dates ranged from 7 to 175 days (median, 91 days). Median pH of samples was 7.1 (range, 5.5-7.8). Median measured concentration relative to the prescribed concentration was 93.3% (70.4%-104.1%). One quarter of samples were under the 90% minimum target concentration of 0.01%.

CONCLUSIONS

An inconsistent and wide variety of formulation and labeling practices exist for compounding 0.01% atropine prescribed to slow pediatric myopia progression.

The Effectiveness and Tolerability of Atropine Eye Drops for Myopia Control in Non-Asian Regions

Myopia is the most common ocular disorder worldwide with an increasing prevalence over the past few decades. It is a refractive error associated with excessive growth of the eyeball. Individuals with myopia, especially high myopia, are prone to develop sight-threatening complications. Currently, atropine is the only drug that is used to slow myopia progression in clinical practice. However, there are still areas of uncertainty such as treatment strategy, optimal concentration when considering risk–benefit ratio and active treatment period. Since the prevalence of myopia is much higher in Asian countries, most of the research on myopia control has been conducted in Asia. Data on the efficacy and tolerability to atropine eye drops in the non-Asian population remains limited. In this review, we summarize the results of published clinical trials on the effectiveness and tolerability of atropine eye drops for myopia control in non-Asian regions. The efficacy was evaluated by the mean change in spherical equivalent (SE) or axial length (AL). The tolerability of atropine eye drops was analyzed based on patients complains and adverse events. The results of this review suggest that 0.01% atropine eye drops are effective in non-Asian regions achieving less side effects compared to 0.5% concentration.

Myopia control in Mendelian forms of myopia

PURPOSE

To study the effectiveness of high-dose atropine for reducing eye growth in Mendelian myopia in children and mice.

METHODS

We studied the effect of high-dose atropine in children with progressive myopia with and without a monogenetic cause. Children were matched for age and axial length (AL) in their first year of treatment. We considered annual AL progression rate as the outcome and compared rates with percentile charts of an untreated general population. We treated C57BL/6J mice featuring the myopic phenotype of Donnai-Barrow syndrome by selective inactivation of Lrp2 knock out (KO) and control mice (CTRL) daily with 1% atropine in the left eye and saline in the right eye, from postnatal days 30-56. Ocular biometry was measured using spectral-domain optical coherence tomography. Retinal dopamine (DA) and 3,4-dihydroxyphenylacetic acid (DOPAC) were measured using high-performance liquid chromatography.

RESULTS

Children with a Mendelian form of myopia had average baseline spherical equivalent (SE) -7.6 ± 2.5D and AL 25.8 ± 0.3 mm; children with non-Mendelian myopia had average SE -7.3 ± 2.9 D and AL 25.6 ± 0.9 mm. During atropine treatment, the annual AL progression rate was 0.37 ± 0.08 and 0.39 ± 0.05 mm in the Mendelian myopes and non-Mendelian myopes, respectively. Compared with progression rates of untreated general population (0.47 mm/year), atropine reduced AL progression with 27% in Mendelian myopes and 23% in non-Mendelian myopes. Atropine significantly reduced AL growth in both KO and CTRL mice (male, KO: -40 ± 15; CTRL: -42 ± 10; female, KO: -53 ± 15; CTRL: -62 ± 3 μm). The DA and DOPAC levels 2 and 24 h after atropine treatment were slightly, albeit non-significantly, elevated.

CONCLUSIONS

High-dose atropine had the same effect on AL in high myopic children with and without a known monogenetic cause. In mice featuring a severe form of Mendelian myopia, atropine reduced AL progression. This suggests that atropine can reduce myopia progression even in the presence of a strong monogenic driver.

A comparison of myopia control in European children and adolescents with defocus incorporated multiple segments (DIMS) spectacles, atropine, and combined DIMS/atropine

PURPOSE

To evaluate the efficacy of a myopia control spectacle lens (DIMS) at slowing the progression of myopia in a population of European children in comparison with 0.01% atropine and combined DIMS and atropine.

METHODS

The study was a non-randomised experimenter-masked prospective controlled observational study of individuals aged 6-18 years with progressing myopia but no ocular pathology. Participants were allocated, according to patient/parent choice, to receive 0.01% atropine eyedrops, DIMS (Hoya® MiyoSmart®) spectacles, combined atropine+DIMS or single vision spectacle lenses (control group). The key outcome variables, cycloplegic autorefraction spherical equivalent refraction (SER) and axial length (AL), were measured at baseline and after three, six, and 12 months.

RESULTS

Of the 146 participants (mean age 10.3y ±3.2), 53 received atropine, 30 DIMS spectacles, 31 atropine+DIMS, and 32 single vision control spectacles. Generalized linear mixed model analysis revealed for SER, whilst controlling for age and SER at baseline, at each stage all treatment groups had significantly reduced progression compared with the control group (p<0.016). For AL, whilst controlling for baseline age and AL, at 6 and 12 months all treatment groups had significantly less progression than the control group (p<0.005). For SER only, in pairwise comparisons at 12 months the atropine+DIMS group had significantly reduced progression compared with the DIMS only and Atropine only groups (p<0.001).

CONCLUSION

In a European population, DIMS and atropine are effective at reducing myopia progression and axial elongation in progressing myopia and are most successful at reducing myopia progression when used in combination.

Myopia Control with Low-Dose Atropine in European Children: Six-Month Results from a Randomized, Double-Masked, Placebo-Controlled, Multicenter Study

The effect and safety of low-dose atropine in myopia control have not been studied in randomized, placebo-controlled trials outside Asia. We investigated the efficacy and safety of 0.1% atropine loading dose and 0.01% atropine compared with a placebo in a European population. Investigator-initiated, randomized, double-masked, placebo-controlled, equal-allocation, multicenter study comparing 0.1% atropine loading dose (six months) followed by 0.01% atropine (18 months), 0.01% atropine (24 months), and placebo (24 months). Participants were monitored for a 12-months washout period. Outcome measures were axial length (AL), cycloplegic spherical equivalent (SE), photopic and mesopic pupil size, accommodation amplitude, visual acuity, intraocular pressure (IOP), and adverse reactions and events. We randomized 97 participants (mean [standard deviation] age, 9.4 [1.7] years; 55 girls (57%) and 42 boys (43%)). After six months, AL was 0.13 mm shorter (95% confidence interval [CI], -0.18 to -0.07 [adjusted p < 0.001]) with 0.1% atropine loading dose and 0.06 mm shorter (95% CI, -0.11 to -0.01 [adjusted p = 0.06]) with 0.01% atropine than in the placebo group. We observed similar dose-dependent changes in SE, pupil size, accommodation amplitude, and adverse reactions. No significant differences in visual acuity or IOP were found between groups, and no serious adverse reactions were reported. We found a dose-dependent effect of low-dose atropine in European children without adverse reactions requiring photochromatic or progressive spectacles. Our results are comparable to those observed in East Asia, indicating that results on myopia control with low-dose atropine are generalizable across populations with different racial backgrounds.

[Recommendations for Progressive Myopia in Childhood and Adolescence. Statement of the DOG, BVA and the Bielschowsky Society for Strabismus Research and Neuroophthalmology - Status June 2022]

Since the last and at the same time first statement of the German ophthalmological societies on the possibilities of reducing myopia progression in childhood and adolescence, many new details and aspects have emerged in clinical research. This second statement updates the previous document and specifies the recommendations on visual and reading behavior as well as on pharmacological and optical therapy options, which have been both refined and newly developed in the meantime.

[Recommendations for progressive myopia in childhood and adolescence. Statement of the DOG, BVA and the Bielschowsky Society for Strabismus Research and Neuroophthalmology : Status June 2022]

Since the last and at the same time first statement of the German ophthalmological societies on the possibilities of reducing myopia progression in childhood and adolescence, many new details and aspects have emerged in clinical research. This second statement updates the previous document and specifies the recommendations on visual and reading behavior as well as on pharmacological and optical therapy options, which have been both refined and newly developed in the meantime.

Retrospective Analysis of a Clinical Algorithm for Managing Childhood Myopia Progression

SIGNIFICANCE

As the myopia epidemic unfolds, there is growing urgency to identify and implement effective interventions to slow myopia progression. This investigation evaluated the effectiveness of an evidence-based myopia treatment algorithm in a clinical setting among 342 consecutive children.

PURPOSE

This study aimed to evaluate effectiveness of a clinical treatment algorithm for myopia progression in children.

METHODS

A retrospective cohort analysis was performed using data from myopic children treated for at least 1 year with a defined treatment algorithm incorporating orthokeratology, multifocal lenses, and atropine. The main outcome measures were the percentage of children experiencing ≤0.25 D of myopic cycloplegic spherical equivalent autorefraction (CSER) progression and ≤0.10 mm of axial elongation at 1, 2, and 3 years. The secondary outcome measures were the cumulative absolute reduction of axial elongation values derived from age- and ethnicity-matched virtual control data at 1, 2, and 3 years.

RESULTS

Mean annual CSER change values (excluding orthokeratology) were -0.30, -0.20, and -0.13 D at 1, 2, and 3 years, respectively, with 59, 56, and 60% of patients demonstrating ≤0.25 D of change over the prior year. Mean annual axial elongation values were 0.13, 0.12, and 0.09 mm at 1, 2, and 3 years, respectively, with 52, 46, and 65% of patients demonstrating ≤0.10 mm of change over the prior year. The cumulative absolute reduction of axial elongation values were 0.11, 0.20, and 0.29 mm for 1, 2, and 3 years, respectively.

CONCLUSIONS

The treatment algorithm demonstrated effective control of CSER and axial length in a diverse group of progressive myopic children, supporting its use for the clinical management of childhood myopia.

Efficacy and Safety of Consecutive Use of 1% and 0.01% Atropine for Myopia Control in Chinese Children: The Atropine for Children and Adolescent Myopia Progression Study

INTRODUCTION

The purpose of this study was to investigate the efficacy and safety of consecutive use of 1% and 0.01% atropine compared with 0.01% atropine alone over 1 year.

METHODS

A total of 207 participants aged 6-12 years with myopia of - 0.50 to - 6.00 D in both eyes were enrolled in this randomized, controlled, non-masked trial and randomly assigned (1:1) to groups A and B. Group A received 1% atropine weekly and were tapered to 0.01% atropine daily at the 6-month visit, and group B received 0.01% atropine daily for 1 year.

RESULTS

Of the 207 participants, 109 were female (52.7%) and the mean (± standard deviation) age was 8.92 ± 1.61 years. Ninety-one participants (87.5%) in group A and 80 participants (77.7%) in group B completed the 1-year treatment. Group A exhibited less refraction progression (- 0.53 ± 0.49 D vs. - 0.74 ± 0.52 D; P = 0.01) and axial elongation (0.26 ± 0.17 mm vs. 0.36 ± 0.21 mm; P < 0.001) over 1 year compared with group B. The changes in refraction (- 0.82 ± 0.45 D vs. - 0.46 ± 0.35 D; P < 0.001) and axial length (0.29 ± 0.12 mm vs. 0.17 ± 0.11 mm; P < 0.001) during the second 6 months in group A were greater than those in group B, with 72.5% of participants presenting refraction rebound. No serious adverse events were reported.

CONCLUSIONS

The 1-year results preliminarily suggest that consecutive use of 1% and 0.01% atropine confers an overall better effect in slowing myopia progression than 0.01% atropine alone, despite myopia rebound after the concentration switch. Both regimens were well tolerated. The long-term efficacy and rebound after the concentration switch and regimen optimization warrant future studies to determine.

TRIAL REGISTRATION NUMBER

Clinical Trials.gov PRS (Registration No. NCT03949101).

The Role of Atropine in Preventing Myopia Progression: An Update

Several approaches have been investigated for preventing myopia progression in children and teenagers. Among them, topical atropine has shown promising results and it is being adopted in clinical practice more and more frequently. However, the optimal formulation and treatment algorithm are still to be determined. We discuss the pharmacokinetic, pharmacodynamic, clinical, and tolerability profile revealed first by the multicenter, randomized ATOM 1 and 2 trials and, more recently, by the LAMP Study. Results from these trials confirmed the efficacy of low-concentration atropine with a concentration-dependent response. Although atropine at 0.025% and 0.05% concentrations has shown the most encouraging results in large-scale studies, these formulations are not yet commonplace in worldwide clinical practice. Moreover, their rebound effect and the possibility of reaching a stabilization effect have not been fully investigated with real-life studies. Thus, further larger-scale studies should better characterize the clinical efficacy of atropine over longer follow-up periods, in order to define the optimal dosage and treatment regimen.

Effect of 0.01% Atropine on Accommodation in Myopic Teenagers

Purpose: The purpose of the study is to evaluate the effects of 0.01% atropine eye drops on accommodative system parameters among teenagers with low myopia. Methods: Ninety-five myopic teenagers [39 boys (8.69 ± 2.473) and 56 girls (8.54 ± 2.054) aged 5-17 years] with no history of eye disease were enrolled. Biometric and accommodative system parameters were evaluated before and at 1 week, 1 month, 3 months, and 6 months of 0.01% atropine eye drop instillation. Results: Participants without accommodative demand at 6 months demonstrated insignificant changes after the atropine instillation (all p > 0.05). Nevertheless, there were significant differences in accommodative sensitivity, accommodative amplitude, accommodative responsiveness, and negative relative accommodation (NRA) at 3 months compared with baseline after atropine instillation (all p < 0.05). Except spherical equivalent refraction, cornea thickness, intraocular pressure, and axial length were stable after the 0.01% atropine instillation (all p > 0.05). Conclusion: Morphologically, current measurements suggested that 0.01% atropine had favorable reduction of accommodation for childhood low myopia over a half-year period.

Varying Dose of Atropine in Slowing Myopia Progression in Children Over Different Follow-Up Periods by Meta-Analysis

Purpose: To evaluate the efficacy and safety of atropine for slowing myopia progression and to investigate whether the treatment effect remains constant with continuing treatment.

Method: Studies were retrieved from MEDLINE, EMBASE, and the Cochrane Library from their inception to May 2021, and the language was limited to English. Randomized controlled trials (RCTs) and cohort studies involving atropine in at least one intervention and placebo/non-atropine treatment in another as the control were included and subgroup analysis based on low dose (0.01%), moderate dose (0.01%–<0.5%), and high dose (0.5–1.0%) were conducted. The Cochrane Collaboration and Newcastle-Ottawa Scale were used to evaluate the quality of RCTs and cohort studies, respectively.

Results: Twelve RCTs and fifteen cohort studies involving 5,069 children aged 5 to 15 years were included. The weighted mean differences in myopia progression between the atropine and control groups were 0.73 diopters (D), 0.67 D, and 0.35 D per year for high-dose, moderate-dose, and low-dose atropine, respectively (χ² = 13.76; P = 0.001, I² = 85.5%). After removing studies that provided extreme findings, atropine demonstrated a significant dose-dependent effect on both refractive change and axial elongation, with higher dosages of atropine resulting in less myopia progression (r = 0.85; P = 0.004) and less axial elongation (r = −0.94; P = 0.005). Low-dose atropine showed less myopia progression (−0.23 D; P = 0.005) and less axial elongation (0.09 mm, P < 0.001) in the second year than in the first year, whereas in high-dose atropine more axial elongation (−0.15 mm, P = 0.003) was observed. The higher dose of atropine was associated with a higher incidence of adverse effects, such as photophobia with an odds ratio (OR) of 163.57, compared with an OR of 6.04 for low-dose atropine and 8.63 for moderate-dose atropine (P = 0.03).

Conclusion: Both the efficacy and adverse effects of atropine are dose-dependent in slowing myopia progression in children. The efficacy of high-dose atropine was reduced after the first year of treatment, whereas low-dose atropine had better efficacy in a longer follow-up period.

Three-Year Clinical Trial of Low-Concentration Atropine for Myopia Progression Study: Continued Versus Washout: Phase 3 Report

PURPOSE

(1) To compare the efficacy of continued and stopping treatment for 0.05%, 0.025%, and 0.01% atropine during the third year. (2) To evaluate the efficacy of continued treatment over 3 years. (3) To investigate the rebound phenomenon and its determinants after cessation of treatment.

DESIGN

A randomized, double-masked extended trial.

PARTICIPANTS

A total of 350 of 438 children aged 4 to 12 years originally recruited into the Low-Concentration Atropine for Myopia Progression (LAMP) study.

METHODS

At the beginning of the third year, children in each group were randomized at a 1:1 ratio to continued treatment and washout subgroups. Cycloplegic spherical equivalent (SE) refraction and axial length (AL) were measured at 4-month intervals.

MAIN OUTCOME MEASURES

Changes in SE and AL between groups.

RESULTS

A total of 326 children completed 3 years of follow-up. During the third year, SE progression and AL elongation were faster in the washout subgroups than in the continued treatment groups across all concentrations: -0.68 ± 0.49 diopters (D) versus -0.28 ± 0.42 D (P < 0.001) and 0.33 ± 0.17 mm versus 0.17 ± 0.14 mm (P < 0.001) for the 0.05%; -0.57 ± 0.38 D versus -0.35 ± 0.37 D (P = 0.004) and 0.29 ± 0.14 mm versus 0.20 ± 0.15 mm (P = 0.001) for the 0.025%; -0.56 ± 0.40 D versus -0.38 ± 0.49 D (P = 0.04) and 0.29 ± 0.15 mm versus 0.24 ± 0.18 mm (P = 0.13) for the 0.01%. Over the 3-year period, SE progressions were -0.73 ± 1.04 D, -1.31 ± 0.92 D, and -1.60 ± 1.32 D (P = 0.001) for the 0.05%, 0.025%, and 0.01% groups in the continued treatment subgroups, respectively, and -1.15 ± 1.13 D, -1.47 ± 0.77 D, and -1.81 ± 1.10 D (P = 0.03), respectively, in the washout subgroup. The respective AL elongations were 0.50 ± 0.40 mm, 0.74 ± 0.41 mm, and 0.89 ± 0.53 mm (P < 0.001) for the continued treatment subgroups and 0.70 ± 0.47 mm, 0.82 ± 0.37 mm, and 0.98 ± 0.48 mm (P = 0.04) for the washout subgroup. The rebound SE progressions during washout were concentration dependent, but their differences were clinically small (P = 0.15). Older age and lower concentration were associated with smaller rebound effects in both SE progression (P < 0.001) and AL elongation (P < 0.001).

CONCLUSIONS

During the third year, continued atropine treatment achieved a better effect across all concentrations compared with the washout regimen. 0.05% atropine remained the optimal concentration over 3 years in Chinese children. The differences in rebound effects were clinically small across all 3 studied atropine concentrations. Stopping treatment at an older age and lower concentration are associated with a smaller rebound.

Influence of coronavirus disease 2019 on myopic progression in children treated with low-concentration atropine

Purpose

The outbreak of coronavirus disease 2019 (COVID-19) has caused many children to stay indoors. Increased near work and insufficient outdoor activities are considered important risk factors for myopic progression. This study aimed to compare the changes in myopic progression before and after COVID-19 in children treated with low-concentration atropine.

Methods

The records of 103 eyes of 103 children who were treated with low-concentration atropine eye drops were retrospectively reviewed. We classified children according to the concentration of atropine eye drops and children’s age. The beginning of the pre-COVID-19 period was set from January 2019 to May 2019, and the endpoint was set in March 2020. The beginning of the post-COVID-19 period was set in March 2020, and the endpoint was set from January 2021 to March 2021. We evaluated the questionnaires administered to children’s parents.

Results

A significant myopic progression was observed in the post-COVID-19 period compared to the pre-COVID-19 period in the 0.05% and 0.025% atropine groups (P < 0.001 and P = 0.020, respectively). For children aged 5 to 7 and 8 to 10 years, the axial elongations were significantly faster in the post-COVID-19 period than in the pre-COVID-19 period (P = 0.022 and P = 0.005, respectively). However, the rates of axial elongation and myopic progression were not significantly different between pre- and post-COVID-19 in children aged 11 to 15 years (P = 0.065 and P = 0.792, respectively). The average time spent using computers and smartphones and reading time were significantly increased, and the times of physical and outdoor activity were significantly decreased in the post-COVID-19 period compared to the pre-COVID-19 period.

Conclusions

The rates of myopic progression have increased substantially after the spread of COVID-19 with an increase in the home confinement of children. Therefore, it is necessary to control the environmental risk factors for myopia, even in children undergoing treatment for the inhibition of myopic progression.

Update and guidance on management of myopia. European Society of Ophthalmology in cooperation with International Myopia Institute

The prevalence of myopia is increasing extensively worldwide. The number of people with myopia in 2020 is predicted to be 2.6 billion globally, which is expected to rise up to 4.9 billion by 2050, unless preventive actions and interventions are taken. The number of individuals with high myopia is also increasing substantially and pathological myopia is predicted to become the most common cause of irreversible vision impairment and blindness worldwide and also in Europe. These prevalence estimates indicate the importance of reducing the burden of myopia by means of myopia control interventions to prevent myopia onset and to slow down myopia progression. Due to the urgency of the situation, the European Society of Ophthalmology decided to publish this update of the current information and guidance on management of myopia. The pathogenesis and genetics of myopia are also summarized and epidemiology, risk factors, preventive and treatment options are discussed in details.

Corneal Penetration of Low-Dose Atropine Eye Drops

Major studies demonstrating the inhibition of myopia in children and juveniles by low-dose atropine eye drops provide little information on the manufacturing process and the exact composition of the atropine dilutions. However, corneal penetration might significantly vary depending on preservatives, such as benzalkonium chloride (BAC), and the atropine concentration. Since there is a trade-off between side effects, stability, and optimal effects of atropine on myopia, it is important to gain better knowledge about intraocular atropine concentrations. We performed an ex vivo study to determine corneal penetration for different formulations. Atropine drops (0.01%) of different formulations were obtained from pharmacies and applied to the cornea of freshly enucleated pig eyes. After 10 min, a sample of aqueous humor was taken and atropine concentrations were determined after liquid–liquid extraction followed by high-performance liquid chromatography–tandem mass spectrometry (LC-MS/MS). The variability that originated from variations in applied drop size exceeded the differences between preserved and preservative-free formulations. The atropine concentration in the anterior chamber measured after 10 min was only 3.8 × 10⁻⁸ of its concentration in the applied eye drops, corresponding to 502.4 pM. Obviously, the preservative did not facilitate corneal penetration, at least ex vivo. In the aqueous humor of children’s eyes, similar concentrations, including higher variability, may be expected in the lower therapeutic window of pharmacodynamic action.