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

Special Issue “Pediatric Eye Disease: Screening, Causes and Treatment”

Clinical manifestations and courses of eye diseases in children are profoundly variable, from minor irritations, pain, infections, inflammations, ocular misalignment, refractive errors and visual impairment, to permanent blindness [...]

Prevention of myopia shift and myopia onset using 0.01% atropine in premyopic children - a prospective, randomized, double-masked, and crossover trial

This study aims to evaluate the efficacy of 0.01% atropine eye drops in preventing myopia shift and myopia onset in premyopic children. A prospective, randomized, double-masked, placebo-controlled, and crossover trial was conducted over 13 months. Sixty premyopic children aged 6-12 years with cycloplegic spherical equivalent refraction (SER) >  - 0.75 D and ≤  + 0.50 D in both eyes were assigned in a 1:1 ratio to receive one drop of 0.01% atropine or placebo once nightly for 6 months (period 1), followed by a 1-month recovery period. Then, the 0.01% atropine group was crossed over to the placebo group, and the latter was crossed over to the 0.01% atropine group for another 6 months (period 2). The primary outcomes were changes in SER and axial length (AL), and the secondary outcomes were the proportion of myopia onset (SER ≤  - 0.75D) and fast myopic shift (change in SER ≤  - 0.25D) in the two periods. Generalized estimating equation (GEE) model performed a statistically significant treatment effect of 0.01% atropine compared with placebo (p_SER = 0.02, p_AL < 0.001), with a mean SER and AL difference of 0.20D (- 0.15 ± 0.26D vs. - 0.34 ± 0.34D) and 0.11 mm (0.17 ± 0.11 mm vs. 0.28 ± 0.14 mm) in period 1, and 0.17D (- 0.18 ± 0.24D vs. - 0.34 ± 0.31D) and 0.10 mm (0.15 ± 0.15 mm vs. 0.24 ± 0.11 mm) in period 2. The GEE model showed that the proportion of myopia onset (p = 0.004) and fast myopic shift (p = 0.009) was significantly lower in the 0.01% atropine group than that in the placebo group. The period effect was not statistically significant (all p > 0.05). A total of 0.01% atropine significantly prevented myopic shift, axial elongation, and myopia onset in premyopic schoolchildren in central Mainland China.

CONCLUSION

Within the limits of only two consecutive 6-month observation period, 0.01% atropine eye drops effectively prevented myopic shift, axial elongation, and myopia onset in premyopic children.

TRIAL REGISTRATION

This trial was registered in the Chinese Clinical Trial Registry (Registration number: ChiCTR2000034760). Registered 18 July 2020.

WHAT IS KNOWN

• Minimal studies on interventions for pre-myopia, despite the International Myopia Institute stating that preventing myopia is an "even more valuable target" for science and practice than reducing progression after onset.

WHAT IS NEW

• A total of 0.01% atropine eye drops may safely and effectively reduce the proportion of myopia onset and fast myopic shift in premyopic schoolchildren.

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 and prevention: From lifestyle to low-concentration atropine. The 2022 Josh Wallman Memorial Lecture

The purpose of this study was to explore the findings from the Hong Kong Children Eye Study and the Low Concentration Atropine for Myopia Progression (LAMP-1) Study. The incidence of myopia among schoolchildren in Hong Kong more than doubled during the COVID-19 pandemic, with outdoor time decreased significantly and screen time increased. The change in lifestyle during the COVID-19 pandemic aggravated myopia development. Low-concentration atropine (0.05%, 0.025% and 0.01%) is effective in reducing myopia progression with a concentration-related response. This concentration-dependent response was maintained throughout a 3-year follow-up period, and all low concentrations were well tolerated. An age-dependent effect was observed in each treatment group with 0.05%, 0.025% and 0.01% atropine. Younger age was associated with a poor treatment response to low-concentration atropine. Additionally, low-concentration atropine induced choroidal thickening along a concentration-dependent response throughout the treatment period. During the third year, continued atropine treatment achieved a better effect across all concentrations compared with the washout regimen. Stopping treatment at an older age and receiving lower concentration were associated with a smaller rebound effect. However, differences in the rebound effect were clinically small across all the three concentrations studied.

Myopia progression after cessation of low-dose atropine eyedrops treatment: A two-year randomized, double-masked, placebo-controlled, cross-over trial

PURPOSE

The purpose of the study was to evaluate myopia progression and axial elongation after stopping 0.01% atropine eye drops through a 2-year cross-over study.

METHODS

This study was a randomized, double-masked, placebo-controlled, cross-over trial in mainland China. 220 children aged 6-12 years with spherical equivalent range of -1.00 D to -6.00 D in both eyes were enrolled in Phase 1 for 1 year. Children who had completed the first year's follow-up continued in the second phase. In Phase 2, the placebo group was crossed over to the 0.01% atropine group (referred to as the 'placebo-atropine group'), and the 0.01% atropine group was crossed over to the placebo group (referred to as the 'atropine-placebo group'). All children underwent the examination of cycloplegic refraction and axial length at a 6-month interval. Only data from right eyes were included in analysis.

RESULTS

One hundred thirty-three subjects completed 2 years of follow-up. In the first year, the mean myopia progression in atropine-placebo group was 0.21 ± 0.08 D slower than that in placebo-atropine group. After cross-over treatment, the mean myopia progression in atropine-placebo group was 0.22 ± 0.07D faster than that in placebo-atropine group in the second year. Over 2 years, the mean myopia progression was -1.26 ± 0.66D and -1.25 ± 0.70D in the atropine-placebo and placebo-atropine groups (p = 0.954).

CONCLUSIONS

The difference in myopia progression between atropine-placebo group and placebo-atropine group in Phase 1 was similar to Phase 2 during the cross-over treatment. Through our cross-over trial, the results suggest that there is no rebound effect after using 0.01% atropine eye drops to prevent progression of myopia.

Low-Dose Atropine Induces Changes in Ocular Biometrics in Myopic Children: Exploring Temporal Changes by Linear Mixed Models and Contribution to Treatment Effect by Mediation Analyses

This study aimed to investigate changes in non-cycloplegic ocular biometrics during the initial six months of treatment with a 0.1% atropine loading dose and 0.01% atropine compared with a placebo and analyze their contribution to the treatment effect on cycloplegic spherical equivalent (SE) progression. The study was based on a randomized, double-masked, placebo-controlled, multicenter trial evaluating a 0.1% atropine six-month loading dose and 0.01% atropine in reducing myopic progression in Danish children. The treatment phase was 24 months, and the washout phase was 12 months. Parameters measured included changes in axial length (AL), anterior chamber depth (ACD), lens thickness (LT), vitreous chamber depth (VCD), and choroidal thickness (ChT), while cycloplegic SE and lens power were calculated. Longitudinal changes and contributions to treatment effects were analyzed using constrained linear mixed models and mediation analyses, respectively. After six months, AL was 0.13 mm shorter (95% confidence interval [CI], -0.18 to -0.07 [adjusted p < 0.001]) and 0.06 mm shorter (95% CI, -0.11 to -0.01 [adjusted p = 0.060]) with a 0.1% atropine loading dose and 0.01% atropine, respectively, compared to the placebo group. Similar concentration-dependent changes were found with ACD, LT, VCD, ChT, and cycloplegic SE. Although the treatment effects trended toward concentration-dependent responses, only the treatment effect mediated by AL at three months differed significantly between 0.01% atropine and a 0.1% atropine loading dose (adjusted p = 0.023). Several ocular biometrics, including AL, ACD, and LT, changed dose-dependently during low-dose atropine treatment. Moreover, the treatment effect of atropine on SE progression was mediated by a subset of ocular biometrics, mainly AL, with trends toward concentration dependency and distributional shifts over time.

Interventions for myopia control in children: a living systematic review and network meta-analysis

BACKGROUND

Myopia is a common refractive error, where elongation of the eyeball causes distant objects to appear blurred. The increasing prevalence of myopia is a growing global public health problem, in terms of rates of uncorrected refractive error and significantly, an increased risk of visual impairment due to myopia-related ocular morbidity. Since myopia is usually detected in children before 10 years of age and can progress rapidly, interventions to slow its progression need to be delivered in childhood.

OBJECTIVES

To assess the comparative efficacy of optical, pharmacological and environmental interventions for slowing myopia progression in children using network meta-analysis (NMA). To generate a relative ranking of myopia control interventions according to their efficacy. To produce a brief economic commentary, summarising the economic evaluations assessing myopia control interventions in children. To maintain the currency of the evidence using a living systematic review approach.  SEARCH METHODS: We searched CENTRAL (which contains the Cochrane Eyes and Vision Trials Register), MEDLINE; Embase; and three trials registers. The search date was 26 February 2022.  SELECTION CRITERIA: We included randomised controlled trials (RCTs) of optical, pharmacological and environmental interventions for slowing myopia progression in children aged 18 years or younger. Critical outcomes were progression of myopia (defined as the difference in the change in spherical equivalent refraction (SER, dioptres (D)) and axial length (mm) in the intervention and control groups at one year or longer) and difference in the change in SER and axial length following cessation of treatment ('rebound').  DATA COLLECTION AND ANALYSIS: We followed standard Cochrane methods. We assessed bias using RoB 2 for parallel RCTs. We rated the certainty of evidence using the GRADE approach for the outcomes: change in SER and axial length at one and two years. Most comparisons were with inactive controls.

MAIN RESULTS

We included 64 studies that randomised 11,617 children, aged 4 to 18 years. Studies were mostly conducted in China or other Asian countries (39 studies, 60.9%) and North America (13 studies, 20.3%). Fifty-seven studies (89%) compared myopia control interventions (multifocal spectacles, peripheral plus spectacles (PPSL), undercorrected single vision spectacles (SVLs), multifocal soft contact lenses (MFSCL), orthokeratology, rigid gas-permeable contact lenses (RGP); or pharmacological interventions (including high- (HDA), moderate- (MDA) and low-dose (LDA) atropine, pirenzipine or 7-methylxanthine) against an inactive control. Study duration was 12 to 36 months. The overall certainty of the evidence ranged from very low to moderate. Since the networks in the NMA were poorly connected, most estimates versus control were as, or more, imprecise than the corresponding direct estimates. Consequently, we mostly report estimates based on direct (pairwise) comparisons below. At one year, in 38 studies (6525 participants analysed), the median change in SER for controls was -0.65 D. The following interventions may reduce SER progression compared to controls: HDA (mean difference (MD) 0.90 D, 95% confidence interval (CI) 0.62 to 1.18), MDA (MD 0.65 D, 95% CI 0.27 to 1.03), LDA (MD 0.38 D, 95% CI 0.10 to 0.66), pirenzipine (MD 0.32 D, 95% CI 0.15 to 0.49), MFSCL (MD 0.26 D, 95% CI 0.17 to 0.35), PPSLs (MD 0.51 D, 95% CI 0.19 to 0.82), and multifocal spectacles (MD 0.14 D, 95% CI 0.08 to 0.21). By contrast, there was little or no evidence that RGP (MD 0.02 D, 95% CI -0.05 to 0.10), 7-methylxanthine (MD 0.07 D, 95% CI -0.09 to 0.24) or undercorrected SVLs (MD -0.15 D, 95% CI -0.29 to 0.00) reduce progression.  At two years, in 26 studies (4949 participants), the median change in SER for controls was -1.02 D. The following interventions may reduce SER progression compared to controls: HDA (MD 1.26 D, 95% CI 1.17 to 1.36), MDA (MD 0.45 D, 95% CI 0.08 to 0.83), LDA (MD 0.24 D, 95% CI 0.17 to 0.31), pirenzipine (MD 0.41 D, 95% CI 0.13 to 0.69), MFSCL (MD 0.30 D, 95% CI 0.19 to 0.41), and multifocal spectacles  (MD 0.19 D, 95% CI 0.08 to 0.30). PPSLs (MD 0.34 D, 95% CI -0.08 to 0.76) may also reduce progression, but the results were inconsistent. For RGP, one study found a benefit and another found no difference with control. We found no difference in SER change for undercorrected SVLs (MD 0.02 D, 95% CI -0.05 to 0.09). At one year, in 36 studies (6263 participants), the median change in axial length for controls was 0.31 mm. The following interventions may reduce axial elongation compared to controls: HDA (MD -0.33 mm, 95% CI -0.35 to 0.30), MDA (MD -0.28 mm, 95% CI -0.38 to -0.17), LDA (MD -0.13 mm, 95% CI -0.21 to -0.05), orthokeratology (MD -0.19 mm, 95% CI -0.23 to -0.15), MFSCL (MD -0.11 mm, 95% CI -0.13 to -0.09), pirenzipine (MD -0.10 mm, 95% CI -0.18 to -0.02), PPSLs (MD -0.13 mm, 95% CI -0.24 to -0.03), and multifocal spectacles (MD -0.06 mm, 95% CI -0.09 to -0.04). We found little or no evidence that RGP (MD 0.02 mm, 95% CI -0.05 to 0.10), 7-methylxanthine (MD 0.03 mm, 95% CI -0.10 to 0.03) or undercorrected SVLs (MD 0.05 mm, 95% CI -0.01 to 0.11) reduce axial length. At two years, in 21 studies (4169 participants), the median change in axial length for controls was 0.56 mm. The following interventions may reduce axial elongation compared to controls: HDA (MD -0.47mm, 95% CI -0.61 to -0.34), MDA (MD -0.33 mm, 95% CI -0.46 to -0.20), orthokeratology (MD -0.28 mm, (95% CI -0.38 to -0.19), LDA (MD -0.16 mm, 95% CI -0.20 to  -0.12), MFSCL (MD -0.15 mm, 95% CI -0.19 to -0.12), and multifocal spectacles (MD -0.07 mm, 95% CI -0.12 to -0.03). PPSL may reduce progression (MD -0.20 mm, 95% CI -0.45 to 0.05) but results were inconsistent. We found little or no evidence that undercorrected SVLs (MD -0.01 mm, 95% CI -0.06 to 0.03) or RGP (MD 0.03 mm, 95% CI -0.05 to 0.12) reduce axial length. There was inconclusive evidence on whether treatment cessation increases myopia progression. Adverse events and treatment adherence were not consistently reported, and only one study reported quality of life. No studies reported environmental interventions reporting progression in children with myopia, and no economic evaluations assessed interventions for myopia control in children.

AUTHORS' CONCLUSIONS

Studies mostly compared pharmacological and optical treatments to slow the progression of myopia with an inactive comparator. Effects at one year provided evidence that these interventions may slow refractive change and reduce axial elongation, although results were often heterogeneous. A smaller body of evidence is available at two or three years, and uncertainty remains about the sustained effect of these interventions. Longer-term and better-quality studies comparing myopia control interventions used alone or in combination are needed, and improved methods for monitoring and reporting adverse effects.

Effect of Low-Concentration Atropine Eyedrops vs Placebo on Myopia Incidence in Children: The LAMP2 Randomized Clinical Trial

Importance

Early onset of myopia is associated with high myopia later in life, and myopia is irreversible once developed.

Objective

To evaluate the efficacy of low-concentration atropine eyedrops at 0.05% and 0.01% concentration for delaying the onset of myopia.

Design, Setting, and Participants

This randomized, placebo-controlled, double-masked trial conducted at the Chinese University of Hong Kong Eye Centre enrolled 474 nonmyopic children aged 4 through 9 years with cycloplegic spherical equivalent between +1.00 D to 0.00 D and astigmatism less than -1.00 D. The first recruited participant started treatment on July 11, 2017, and the last participant was enrolled on June 4, 2020; the date of the final follow-up session was June 4, 2022.

Interventions

Participants were assigned at random to the 0.05% atropine (n = 160), 0.01% atropine (n = 159), and placebo (n = 155) groups and had eyedrops applied once nightly in both eyes over 2 years.

Main Outcomes and Measures

The primary outcomes were the 2-year cumulative incidence rate of myopia (cycloplegic spherical equivalent of at least -0.50 D in either eye) and the percentage of participants with fast myopic shift (spherical equivalent myopic shift of at least 1.00 D).

Results

Of the 474 randomized patients (mean age, 6.8 years; 50% female), 353 (74.5%) completed the trial. The 2-year cumulative incidence of myopia in the 0.05% atropine, 0.01% atropine, and placebo groups were 28.4% (33/116), 45.9% (56/122), and 53.0% (61/115), respectively, and the percentages of participants with fast myopic shift at 2 years were 25.0%, 45.1%, and 53.9%. Compared with the placebo group, the 0.05% atropine group had significantly lower 2-year cumulative myopia incidence (difference, 24.6% [95% CI, 12.0%-36.4%]) and percentage of patients with fast myopic shift (difference, 28.9% [95% CI, 16.5%-40.5%]). Compared with the 0.01% atropine group, the 0.05% atropine group had significantly lower 2-year cumulative myopia incidence (difference, 17.5% [95% CI, 5.2%-29.2%]) and percentage of patients with fast myopic shift (difference, 20.1% [95% CI, 8.0%-31.6%]). The 0.01% atropine and placebo groups were not significantly different in 2-year cumulative myopia incidence or percentage of patients with fast myopic shift. Photophobia was the most common adverse event and was reported by 12.9% of participants in the 0.05% atropine group, 18.9% in the 0.01% atropine group, and 12.2% in the placebo group in the second year.

Conclusions and Relevance

Among children aged 4 to 9 years without myopia, nightly use of 0.05% atropine eyedrops compared with placebo resulted in a significantly lower incidence of myopia and lower percentage of participants with fast myopic shift at 2 years. There was no significant difference between 0.01% atropine and placebo. Further research is needed to replicate the findings, to understand whether this represents a delay or prevention of myopia, and to assess longer-term safety.

Trial Registration

Chinese Clinical Trial Registry: ChiCTR-IPR-15006883.

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.

Myopic tilted disc: Mechanism, clinical significance, and public health implication

Myopic tilted disc is a common structural change of myopic eyes. With advancing ocular imaging technology, the associated structural changes of the eye, particularly the optic nerve head, have been extensively studied. These structural changes may increase patients' susceptibility to axonal damage and the risk of developing serious optic neuropathies including glaucoma. They also lead to diagnostic difficulties of disease suspects and treatment dilemmas of patients, which implicate clinical practice and subsequently the health care system. In the context of the mounting prevalence of myopia worldwide and its implications to irreversible visual impairment and blindness, it is essential to gain a thorough understanding of the structural changes of myopia. Myopic tilted disc has been extensively investigated by different study groups. However, generalizing the knowledge could be difficult because of the variable definitions of myopic tilted disc utilized in these studies and the complexities of the changes. The current review aimed to clarify the concepts and discuss various aspects of myopic tilted disc, including the definitions, association with other myopia-related changes, mechanism of tilted disc development, structural and functional changes, and clinical implications.

Reproducibility of Mesopic and Photopic Pupil Sizes in Myopic Children Using a Dedicated Pupillometer with Human-Assisted or Automated Reading

This study aimed to investigate the reproducibility of pupil size measurements over time and between reading methods when comparing human-assisted reading to automated reading. Pupillary data were analyzed on a subset of myopic children enrolled in a multicenter randomized clinical trial on myopia control with low-dose atropine. Pupil size measurements were obtained prior to randomization at two time points (screening and baseline visits) using a dedicated pupillometer under mesopic and photopic conditions. A customized algorithm was built to perform automated readings, allowing comparisons between human-assisted and automated readings. Reproducibility analyses followed the principles of Bland and Altman and included the calculation of the mean difference between measurements and limits of agreement (LOA). We included 43 children. Mean (standard deviation) age was 9.8 (1.7) years and 25 (58%) children were girls. Using human-assisted readings, reproducibility over time showed mesopic mean difference of 0.02 mm with LOA from -0.87 mm to 0.91 mm, whereas photopic mean difference was -0.01 mm with LOA from -0.25 mm to 0.23 mm. Reproducibility between human-assisted and automated readings was also higher under photopic conditions, with mean difference of 0.03 mm and LOA from -0.03 mm to 0.10 mm at screening and mean difference of 0.03 mm and LOA from -0.06 mm to 0.12 mm at baseline. Using a dedicated pupillometer, we found that examinations performed under photopic conditions demonstrated higher reproducibility over time and between reading methods. We speculate whether mesopic measurements are sufficiently reproducible to be monitored over time. Furthermore, photopic measurements may be of greater relevance when evaluating the side effects of atropine treatment, such as photophobia.

Effect of atropine 0.01% on myopia control in children aged 6-13 years during the 2022 lockdown in Shanghai

Purpose

To compare the myopic progression in children treated with 0. 01% atropine and those who discontinued atropine during the 2022-home quarantine in Shanghai.

Methods

In this retrospective study, children aged 6-13 years with follow-up visits before (between January 2022 and February 2022) and after the lockdown (between July 2022 and August 2022) were included. Cycloplegic refraction and axial length (AL) were measured at both visits. The atropine group had continuous medication during the lockdown while the control group discontinued. The 0.01% atropine eyedrops were administered daily before bedtime. The types of spectacle lens were recorded: single vision (SV) spectacles or defocus incorporated multiple segments lenses (DIMS).

Results

In total, 41 children (81 eyes) in the atropine group and 32 children (64 eyes) in the control group were enrolled. No significant difference was found in the demographic characteristics, spherical diopter, spherical equivalent (SE), AL, and follow-up time between the two groups before the lockdown in 2022 (all p > 0.1). After the home confinement, a greater myopia progression was observed in the control group (-0.46 ± 0.42 D) compared to atropine group (-0.26 ± 0.37 D; p = 0.0023). Axial elongation was also longer in the control group than that in children sustained with atropine (0.21 ± 0.17 vs. 0.13 ± 0.15 mm, p = 0.0035). Moreover, there was no significant change of spherical diopter and SE during lockdown in the atropine + DIMS combined subgroup (0.03 ± 0.033 D for spherical diopter, p = 0.7261 and 0.08 ± 0.27 D for SE, p = 0.2042, respectively). However, significant myopic shift was observed in the atropine + SV subgroup during the quarantine time (-0.31 ± 0.39 D for SE and 0.15 ± 0.16 mm for AL, both p < 0.001).

Conclusion

Children treated with 0.01% atropine had slower myopia progression during the lockdown period in Shanghai compared with children discontinued. Moreover, the effect of atropine on myopic prevention can be strengthened with DIMS lenses.

The impact of the first peak of the COVID-19 pandemic on childhood myopia control practice patterns among ophthalmologists-an international pediatric ophthalmology and strabismus council global perspective

BACKGROUND

The prevalence of myopia keeps increasing during the COVID-19 pandemic. We aimed to map the worldwide treatment preferences of ophthalmologists managing myopia control during the first wave of the pandemic.

METHODS

An online questionnaire inquiring about pharmacological and optical treatment patterns during the first half of 2020 was sent to pediatric ophthalmology as well as general ophthalmology memberships worldwide. The results among pediatric ophthalmologists were compared to a previous study we performed before the pandemic.

RESULTS

A total of 2269 respondents from 94 countries were included. Most respondents were pediatric ophthalmologists (64.6%), followed by ophthalmologists from other subspecialties (32.3%). The preferred modality for all geographical regions was a combination therapy of pharmacological and optical treatments. When evaluated independently, the pharmacological treatment was more popular than the optical treatment in most regions other than East Asia (P < 0.001). Compared to a pre-pandemic questionnaire, the participation of pediatric ophthalmologists affiliated with non-university hospitals increased. Additionally, the prevalence of respondents utilizing either any type of pharmacological treatment and those that using only evidence-based treatments increased globally. Although a decline in the use of optical treatment was evident worldwide, the use of evidence-based optical treatments increased.

CONCLUSION

Ophthalmologists around the world preferred a combination therapy of pharmacological and optical treatments. More pediatric ophthalmologists treated myopia progression and preferred a better evidence-based approach to control myopia. These trends reflect a positive response and more awareness of the rising prevalence of myopia due to the increased burden of myopia imposed by the COVID-19 pandemic.

Topical Review: Studies on Management of Myopia Progression from 2019 to 2021

SIGNIFICANCE

Myopia is a common eye condition that increases the risk of sight-threatening complications. Each additional diopter increases the chance of complications. The purpose of this review was to make an overview of myopia control treatment options for children with myopia progression.In this nonsystematic review, we searched PubMed and Cochrane databases for English-language studies published from 2019 to September 2021. Emphasis was given to selection of randomized controlled trials. Nineteen randomized controlled trials and two retrospective studies were included. Topical atropine and orthokeratology remain the most used treatments, whereas lenses with novel designs are emerging treatments. Overall myopia progression in the treatment groups for low-dose atropine and orthokeratology was lower than in the control groups, and their efficacy was reported in several randomized controlled trials and confirmed by various systematic reviews and meta-analysis. The findings of myopia progression and axial elongation for the MiSight, defocus incorporated multiple segment spectacle lens, highly aspherical lenslets, and diffusion optics technology spectacle lens were comparable. Public health interventions to optimize environmental influences may also be important strategies to control myopia. Optimal choice of management of myopia depends on treatment availability, acceptability to child and parents, and specific patient features such as age, baseline myopia, and lifestyle. Eye care providers need to understand the advantages and disadvantages of each therapy to best counsel parents of children with myopia.

Effectiveness of myopia control interventions: A systematic review of 12 randomized control trials published between 2019 and 2021

Purpose

This study aims to investigate the effectiveness of interventions to control myopia progression. In this systematic review, the primary outcomes were mean differences (MD) between treatment and control groups in myopia progression (D) and axial length (AL) elongation (mm).

Results

The following interventions were found to be effective (p < 0.001): highly aspherical lenslets (HAL, 0.80 D, 95% CI, 0.77-0.83; -0.35 mm, 95% CI -0.36 to -0.34), MiSight contact lenses (0.66 D, 95% CI, 0.63-0.69; -0.28 mm, 95% CI -0.29 to -0.27), low dose atropine 0.05% (0.54 D, 95% CI, 0.38-0.70; -0.21 mm, 95% CI-0.28 to -0.14), Biofinity +2.50 D (0.45 D, 95% CI, 0.29, 0.61; -0.24 mm, 95% CI -0.33 to -0.15), defocus incorporated multiple segments [DIMS] (0.44 D, 95% CI, 0.42-0.46; -0.34 mm, 95% CI -0.35 to -0.33) and ortho-k lenses (-0.24 mm, 95% CI -0.33 to -01.5).

Conclusion

Low-dose atropine 0.01% was not effective in reducing AL progression in two studies. Treatment efficacy with low-dose atropine of 0.05% showed good efficacy. Spectacles (HAL and DIMS) and contact lenses (MiSight and Biofinity) may confer a comparable treatment benefit compared to atropine, to slow myopia progression.

Studies on the interactions of retinal dopamine with choroidal thickness in the chicken

PURPOSE

Recently, an increasing number of studies relied on the assumption that visually induced changes in choroidal thickness can serve as a proxy to predict future axial eye growth. The retinal signals controlling choroidal thickness are, however, not well defined. We have studied the potential roles of dopamine, released from the retina, in the choroidal response in the chicken.

METHODS

Changes in retinal dopamine release and choroidal thickness changes were induced by intravitreal injections of either atropine (250 µg or 360 nMol), atropine combined with a dopamine antagonist, spiperone (500 µMol), or spiperone alone and were tracked by optical coherence tomography (OCT). To visually stimulate dopamine release, other chicks were exposed to flicker light of 1, 10, or 400 Hz (duty cycle 0.2) and choroidal thickness was tracked. In all experiments, dopamine and 3,4-Dihydroxyphenylacetic acid (DOPAC) were measured in vitreous, retina, and choroid by high-performance liquid chromatography with electrochemical detection (HLPC-ED). The distribution of the rate-limiting enzyme of dopamine synthesis, tyrosine hydroxylase (TH), neuronal nitric oxide synthase (nNOS), vascular endothelial growth factor (VEGF), and alpha2A adrenoreceptors (alpha2A-ADR) was studied in the choroid by immunofluorescence.

RESULTS

The choroid thickened strongly in atropine-injected eyes, less so in atropine + spiperone-injected eyes and became thinner over the day in spiperone alone-, vehicle-, or non-injected eyes. Flickering light at 20 lx, both 1 and 10 Hz, prevented diurnal choroidal thinning, compared to 400 Hz, and stimulated retinal dopamine release. Correlation analysis showed that the higher retinal dopamine levels or release, the thicker became the choroid. TH-, nNOS-, VEGF-, and alpha2A adrenoreceptor-positive nerve fibers were localized in the choroid around lacunae and in the walls of blood vessels with colocalization of TH and nNOS, and TH and VEGF.

CONCLUSIONS

Retinal DOPAC and dopamine levels were positively correlated with choroidal thickness. TH-positive nerve fibers in the choroid were closely associated with peptides known to play a role in myopia development. Findings are in line with the hypothesis that dopamine is related to retinal signals controlling choroidal thickness.

Cost-effectiveness analysis of myopia management: A systematic review

The rising prevalence of myopia is a major global public health concern. Economic evaluation of myopia interventions is critical for maximizing the benefits of treatment and the healthcare system. This systematic review aimed to evaluate the cost-effectiveness of interventions for treating myopia. Five databases were searched - Embase, Emcare, PubMed, Web of Science, and ProQuest - from inception to July 2022 and a total of 2,099 articles were identified. After careful assessments, 6 studies met the eligibility criteria. The primary outcomes of this systematic review were costs, quality-adjusted life years (QALYs), and incremental cost-effectiveness ratio (ICER). The secondary outcomes included utility values and net monetary benefits (NMB). One study determined the cost-effectiveness of photorefractive screening plus treatment with 0.01% atropine, 2 studies examined cost-effectiveness of corneal refractive surgery, and 3 studies evaluated cost-effectiveness of commonly used therapies for pathologic myopia. Corneal refractive surgeries included laser in situ keratomileusis (LASIK), femtosecond laser-assisted in situ keratomileusis (FS-LASIK), photorefractive keratectomy (PRK), and small-incision lenticule extraction (SMILE). Interventions for pathologic myopia included ranibizumab, conbercept, and photodynamic therapy (PDT). At an incremental cost of NZ$ 18 (95% CI 15, 20) (US$ 11) per person, photorefractive screening plus 0.01% atropine resulted in an ICER of NZ$ 1,590/QALY (US$ 1,001/QALY) (95% CI NZ$ 1,390, 1,791) for an incremental QALY of 0.0129 (95% CI 0.0127, 0.0131). The cost of refractive surgery in Europe ranged from €3,075 to €3,123 ([US$4,046 to $4,109 - adjusted to 2021 inflation). QALYs associated with these procedures were 23 (FS-LASIK) and 24 (SMILE and PRK) with utility values of 0.8 and ICERs ranging from approximately €14 (US$17)/QALY to €19 (US$23)/QALY. The ICER of LASIK was US$683/diopter gained (inflation-adjusted). The ICER of ranibizumab and PDT were £8,778 (US$12,032)/QALY and US$322,460/QALY respectively, with conbercept yielding a saving of 541,974 RMB (US$80,163)/QALY, respectively. The use of 0.01% atropine and corneal refractive surgery were cost-effective for treating myopia. Treating pathologic myopia with ranibizumab and conbercept were more cost-effective than PDT. Prevention of myopia progression is more cost-effective than treating pathologic myopia.

Myopia: An ounce of prevention is worth a pound of cure

PURPOSE

Myopia severity has a profound impact on visual impairment in later life. A patient's final level of myopia may be lowered by myopia control, but also by delaying onset. Here, we evaluate the influence of the age of onset on the final recorded level of myopia.

METHODS

Data were extracted from: (1) Three prospective cohort studies of myopia progression in East Asia and the United States where the final recorded level of myopia is presented as a function of the established age of onset. (2) Four retrospective studies of myopia progression in Finland, India, the Netherlands and China and two cross-sectional studies in Argentina and the UK where the age of onset was based on self-report of age at first spectacle prescription. (3) A cohort study of Finnish subjects originally recruited for a clinical trial and followed into adulthood. Subjects were divided into five groups according to age at recruitment that was used as a surrogate for the age of onset.

RESULTS

Final recorded level of myopia was plotted as a function of age of onset for all studies. Among the three East Asian studies, the slopes are between 0.68 and 0.97 D/year, meaning that each later year of onset is associated with between 0.68 and 0.97 less myopia at the final recorded refraction. For six of the seven non-East Asian studies, the slopes are substantially flatter, with slopes between 0.23 and 0.50 D/year. By contrast, the slope for the Finnish study was 0.87 D/year. Increasing age of final recorded refraction tended to be associated with higher levels of myopia.

CONCLUSION

Among East Asians, delaying the onset of myopia by 1 year has the potential to lower the final myopia level by 0.75 D or more-equivalent to 2-3 years of myopia control with existing modalities. The benefit is lower, but meaningful, among non-East Asians.

Low Dose Atropine in Preventing the Progression of Childhood Myopia: A Randomised Controlled Trial

PURPOSE

To study the efficacy of low dose atropine (0.01%) eye drops in preventing myopia progression in children by comparing the mean change in spherical equivalent (diopter) and axial length (mm) over a period of one year to a control group and study its effect on near vision, pupil size, keratometry and pachymetry.

METHODS

200 eyes of 100 myopic children were randomized into two groups based on a computer-generated random number table. The treatment group was administered 0.01% atropine eye drop once at bedtime and control group was administered a placebo. The follow up was done 3-monthly for 12 months by assessing the mean change in spherical equivalent and mean change in axial length. Other parameters like near vision, pupil size, keratometry and pachymetry were assessed at each follow up.

RESULT

The study was age and sex matched. The mean change in spherical equivalent refraction and axial length was significantly lower in the treatment group (0.31 ± 0.55 D; 0.11 ± 0.22 mm) than the placebo group (0.80 ± 1.65 D; 0.23 ± 0.44 D) (p-value: 0.003). Less steepening of the corneal curvature was observed in the treatment group (0.16 ± 0.28 D vs 0.29 ± 0.3 D; p < 0.001) and the mean change in pachymetry was comparable between the groups (0.00 ± 0.01) (p-value 0.489). No significant change was seen in near vision (96% of the eyes with atropine had no change in near vision; 2% of the eyes had a change of near vision by one line (p-value 0.500); 2% had a change by 3 lines (p-value: 0.07) or pupil size following treatment.

CONCLUSION

The use of 0.01% atropine eye drop reduced the progression of myopia over the study period of one year with no significant changes in near vision, pupil size. No patient reported any systemic and local side effects with administration of 0.01% atropine eye drop.

Low-Concentration Atropine Monotherapy vs. Combined with MiSight 1 Day Contact Lenses for Myopia Management

Objectives: To assess the decrease in myopia progression and rebound effect using topical low-dose atropine compared to a combined treatment with contact lenses for myopic control. Methods: This retrospective review study included 85 children aged 10.34 ± 2.27 (range 6 to 15.5) who were followed over three years. All had a minimum myopia increase of 1.00 D the year prior to treatment. The children were divided into two treatment groups and a control group. One treatment group included 29 children with an average prescription of 4.81 ± 2.12 D (sphere equivalent (SE) range of 1.25−10.87 D), treated with 0.01% atropine for two years (A0.01%). The second group included 26 children with an average prescription of 4.14 ± 1.35 D (SE range of 1.625−6.00 D), treated with MiSight 1 day dual focus contact lenses (DFCL) and 0.01% atropine (A0.01% + DFCL) for two years. The control group included 30 children wearing single-vision spectacles (SV), averaging −5.06 ± 1.77 D (SE) range 2.37−8.87 D). Results: There was an increase in the SE myopia progression in the SV group of 1.19 ± 0.43 D, 1.25 ± 0.52 D, and 1.13 ± 0.36 D in the first, second, and third years, respectively. Myopia progression in the A0.01% group was 0.44 ± 0.21 D (p < 0.01) and 0.51 ± 0.39 D (p < 0.01) in the first and second years, respectively. In the A0.01% + DFCL group, myopia progression was 0.35 ± 0.26 D and 0.44 ± 0.40 D in the first and second years, respectively (p < 0.01). Half a year after the cessation of the atropine treatment, myopia progression (rebound effect) was measured at −0.241 ± 0.35 D and −0.178 ± 0.34 D in the A0.01% and A0.01% + DFCL groups, respectively. Conclusions: Monotherapy low-dose atropine, combined with peripheral blur contact lenses, was clinically effective in decreasing myopia progression. A low rebound effect was found after the therapy cessation. In this retrospective study, combination therapy did not present an advantage over monotherapy.

Compounding of Low-Concentration Atropine for Myopia Control

OBJECTIVES

Low-concentration atropine is commonly prescribed to slow myopia progression in children but is not Food and Drug Administration-approved for that indication and is only available in the United States from compounding pharmacies. The purpose of this study was to ascertain its reported compounding and labeling in the United States.

METHODS

US compounding pharmacies were identified through a survey of eye doctors, social media, conferences, and web search. Twenty-eight pharmacies were identified and contacted through telephone and asked a standard set of questions about their methods to compound and label low-concentration atropine.

RESULTS

Twenty-six pharmacies across 19 states provided responses, with 21 answering all nine items (81%) and a mean of 8.7 of nine responses. The most frequently reported bottle size was 5 mL (interquartile range [IQR]: 3.5-10). For storage, 10 pharmacies (38%) recommended refrigeration and 16 (62%) stated room temperature was sufficient. The median beyond-use date provided was 65 days (IQR: 45-158). For preparation, 12 pharmacies (50%) used commercially available 1% solution, 9 (38%) used powdered atropine, 2 (8%) used both, and 1 (4%) stated their approach was proprietary. For the added excipients, 11 (42%) used artificial tears only, 6 (23%) added 0.9% saline only, 7 (27%) used more than one ingredient, and 2 (8%) were proprietary. Only two pharmacies mentioned adding boric acid and two mentioned "pH-adjusted" saline.

CONCLUSIONS

There were a wide variety of formulation methods in the United States, which may affect atropine stability and potency. Similarly, there are a wide variety of storage and beyond-use recommendations. Further research is needed to assess how these variations may affect the efficacy and safety of low-concentration atropine and of myopia control.

Effect of low-dose atropine eyedrops on pupil metrics: results after half a year of treatment and cessation

Purpose

To evaluate the effect of low-dose atropine eyedrops on pupil metrics.

Methods

This study was based on a randomized, double-masked, placebo-controlled, and cross-over trial in mainland China. In phase 1, subjects received 0.01% atropine or placebo once nightly. After 1 year, the atropine group switched to placebo (atropine-placebo group), and the placebo group switched to atropine (placebo-atropine group). Ocular parameters were measured at the crossover time point (at the 12th month) and the 18th month.

Results

Of 105 subjects who completed the study, 48 and 57 children were allocated into the atropine-placebo and placebo-atropine groups, respectively. After cessation, the photopic pupil diameter (PD) and mesopic PD both decreased (− 0.46 ± 0.47 mm, P < 0.001; − 0.30 ± 0.74 mm, P = 0.008), and the constriction ratio (CR, %) increased (4.39 ± 7.54, P < 0.001) compared with values at the crossover time point of the atropine-placebo group; pupil metrics of the atropine-placebo group had no difference from the values at the crossover time point of the placebo-atropine group. After 6 months of treatment, the photopic PD and the mesopic PD increased (0.54 ± 0.67 mm, P < 0.001; 0.53 ± 0.89 mm, P < 0.001), the CR (%) decreased (− 2.53 ± 8.64, P < 0.001) compared with values at the crossover time point of the placebo-atropine group. There was no significant relationship between pupil metrics and myopia progression during 0.01% atropine treatment.

Conclusion

Pupil metrics and the CR could return to pre-atropine levels after cessation. Pupil metrics had no significant effect on myopia progression during treatment.

Low‐concentration atropine eyedrops for myopia control in a multi‐racial cohort of Australian children: A randomised clinical trial

BACKGROUND

To test the hypothesis that 0.01% atropine eyedrops are a safe and effective myopia-control approach in Australian children.

METHODS

Children (6-16 years; 49% Europeans, 18% East Asian, 22% South Asian, and 12% other/mixed ancestry) with documented myopia progression were enrolled into this single-centre randomised, parallel, double-masked, placebo-controlled trial and randomised to receive 0.01% atropine (n = 104) or placebo (n = 49) eyedrops (2:1 ratio) instilled nightly over 24 months (mean index age = 12.2 ± 2.5 and 11.2 ± 2.8 years, respectively). Outcome measures were the changes in spherical equivalent (SE) and axial length (AL) from baseline.

RESULTS

At 12 months, the mean SE and AL change from baseline were -0.31D (95% confidence interval [CI] = -0.39 to -0.22) and 0.16 mm (95%CI = 0.13-0.20) in the atropine group and -0.53D (95%CI = -0.66 to -0.40) and 0.25 mm (95%CI = 0.20-0.30) in the placebo group (group difference p ≤ 0.01). At 24 months, the mean SE and AL change from baseline was -0.64D (95%CI = -0.73 to -0.56) and 0.34 mm (95%CI = 0.30-0.37) in the atropine group, and -0.78D (95%CI = -0.91 to -0.65) and 0.38 mm (95%CI = 0.33-0.43) in the placebo group. Group difference at 24 months was not statistically significant (p = 0.10). At 24 months, the atropine group had reduced accommodative amplitude and pupillary light response compared to the placebo group.

CONCLUSIONS

In Australian children, 0.01% atropine eyedrops were safe, well-tolerated, and had a modest myopia-control effect, although there was an apparent decrease in efficacy between 18 and 24 months, which is likely driven by a higher dropout rate in the placebo group.

Sustained and rebound effect of repeated low‐level red‐light therapy on myopia control: A 2‐year post‐trial follow‐up study

BACKGROUND

To evaluate the long-term efficacy and safety of continued repeated low-level red-light (RLRL) therapy on myopia control over 2 years, and the potential rebound effect after treatment cessation.

METHODS

The Chinese myopic children who originally completed the one-year randomised controlled trial were enrolled. Children continued RLRL-therapy were defined as RLRL-RLRL group, while those who stopped and switched to single-vision spectacle (SVS) in the second year were RLRL-SVS group. Likewise, those who continued to merely wear SVS or received additional RLRL-therapy were SVS-SVS and SVS-RLRL groups, respectively. RLRL-therapy was provided by an at-home desktop light device emitting red-light of 650 nm and was administered for 3 min at a time, twice a day and 5 days per week. Changes in axial length (AL) and cycloplegic spherical equivalence refraction (SER) were measured.

RESULTS

Among the 199 children who were eligible, 138 (69.3%) children attended the examination and 114 (57.3%) were analysed (SVS-SVS: n = 41; SVS-RLRL: n = 10; RLRL-SVS: n = 52; RLRL-RLRL: n = 11). The baseline characteristics were balanced among four groups. In the second year, the mean changes in AL were 0.28 ± 0.14 mm, 0.05 ± 0.24 mm, 0.42 ± 0.20 mm and 0.12 ± 0.16 mm in SVS-SVS, SVS-RLRL, RLRL-SVS and RLRL-RLRL group, respectively (p < 0.001). The respective mean SER changes were -0.54 ± 0.39D, -0.09 ± 0.55D, -0.91 ± 0.48D, and -0.20 ± 0.56D (p < 0.001). Over the 2-year period, axial elongation and SER progression were smallest in RLRL-RLRL group (AL: 0.16 ± 0.37 mm; SER: -0.31 ± 0.79D), followed by SVS-RLRL (AL: 0.44 ± 0.37 mm; SER: -0.96 ± 0.70D), RLRL-SVS (AL: 0.50 ± 0.28 mm; SER: -1.07 ± 0.69D) and SVS-SVS group (AL: 0.64 ± 0.29 mm; SER: -1.24 ± 0.63D). No self-reported adverse events, functional or structural damages were noted.

CONCLUSIONS

Continued RLRL therapy sustained promising efficacy and safety in slowing myopia progression over 2 years. A modest rebound effect was noted after treatment cessation.

Photopic pupil size change in myopic orthokeratology and its influence on axial length elongation

AIM

To explore the photopic pupil size behavior in myopic children undergoing overnight orthokeratology (ortho-k) over 1-year period and its effects on the axial elongation.

METHODS

A total of 202 Chinese myopic children were enrolled in this prospective clinical trial. Ninety-five subjects in ortho-k group and eighty-eight subjects in spectacle group completed the 1-year study. Axial length (AL) was measured before enrollment and every 6mo after the start of ortho-k. The photopic pupil diameter (PPD) was determined using the Pentacam AXL and measured in an examination room with lighting of 300-310 Lx. Stepwise multiple linear regression analysis was used to identify variables contribution to axial elongation.

RESULTS

Compared with spectacle group, the average 1-year axial elongation was significantly slower in the ortho-k group (0.25±0.27 vs 0.44±0.23 mm, P<0.0001). In ortho-k group, PPDs significantly decreased from 4.21±0.62 mm to 3.94±0.53 mm after 1mo of lens wear (P=0.001, Bonferroni correction) and the change lasts for 3-month visit. No significantly change during the other follow-up visits was found (P>0.05, Bonferroni correction). The 4.81 mm PPD may be a possible cutoff point in the ortho-k group. Subjects with PPD below or equal to 4.81 mm tended to have smaller axial elongation compared to subjects with PPD above 4.81 mm after 1-year period (t=-3.09, P=0.003). In ortho-k group, univariate analyses indicated that those with older age, greater degree of myopia, longer AL, smaller baseline PPD (PPD_baseline) experienced a smaller change in AL. In multivariate analyses, older age, greater AL and smaller PPD_baseline were associated with smaller increases in AL. In spectacle group, PPD tended to be stable (P>0.05, Bonferroni correction) and did not affect axial growth.

CONCLUSION

PPDs experience significantly decreases at 1-month and 3-month ortho-k treatment. Children with smaller PPD tend to experience slower axial elongation and may benefit more from ortho-k.

Effect of the combined application of orthokeratology and single-vision spectacles on slowing the progression of high myopia: A systematic review and meta-analysis

PURPOSE

The purpose of the study was to conduct a meta-analysis about the effect of the combined application of orthokeratology and single-vision spectacles on slowing the progression of high myopia.

METHODS

The literature was searched in PubMed, EMBASE, the Cochrane Library, Wang Fang Data, CNKI and sinoMed. The Cochrane Handbook was used to evaluate the quality of the included randomized clinical trials, and the Newcastle-Ottawa Scale was used to evaluate the included case-control or cohort studies. The results were analyzed by Revman 5.3.

RESULTS

Five studies (2 randomized clinical trials, 2 case-controls, and 1 cohort study) with a total of 360 patients were included in this meta-analysis. The follow-up time was at least 1 year. Combined application of orthokeratology and single-vision spectacles were used in the experimental group. The control group used single-vision spectacles only. The pooled estimates indicated that the standardized mean difference between the 2 groups was -1.46 mm (95% confidence interval: -1.88 to -1.05; P < .05) for axial length elongation and -1.85D (95% confidence interval: -2.40 to -1.31; P < .05) for change in spherical equivalent refraction. No serious adverse events were reported in all studies.

CONCLUSION

The combined application of orthokeratology and single-vision spectacles is more effective than single-vision spectacles only on slowing the progression of high myopia.

The synergistic efficacy and safety of combined low-concentration atropine and orthokeratology for slowing the progression of myopia: A meta-analysis

PURPOSE

To explore the efficacy and safety of combined low-concentration atropine and orthokeratology (OK) for slowing the progression of myopia.

METHODS

We performed a systematic search of English and Chinese databases to collect potentially eligible randomised controlled trials (RCTs), nonrandomised controlled trials (non-RCTs) and retrospective cohort studies (REs) published between the establishment of the database and 1 January 2022. The weighted mean difference (WMD) and 95% confidence interval (CI) were calculated for each outcome.

RESULTS

Fifteen studies were ultimately included in the meta-analysis, which indicated that compared with OK lenses alone, the combination of low-concentration atropine with OK lenses significantly slowed axial growth (WMD = -0.12 mm; 95% CI: -0.13 to -0.11, p < 0.001) and reduced the rate of change of the spherical equivalent refraction (WMD = 0.15 D; 95% CI: 0.06 to 0.24, p < 0.001). Additionally, the combined treatment may cause a slight increase in pupil diameter (WMD = 0.62 mm; 95% CI: 0.42 to 0.81, p < 0.001). No significant difference in the amplitude of accommodation, intraocular pressure, tear film break-up time or corneal endothelial cell density was found between the OK and combination therapy groups.

CONCLUSIONS

The combination therapy of low-concentration atropine and OK lenses had a greater effect in slowing myopia progression during a 6-to-12-month treatment interval and was still effective over a 24-month period. Increased pupil diameter was the major side effect of the combination therapy, with no negative impact on the amplitude of accommodation, intraocular pressure, tear film break-up time or corneal endothelial cell density.

Efficacy of 0.01% atropine for myopia control in a randomized, placebo-controlled trial depends on baseline electroretinal response

This study aimed to evaluate the efficacy of 18-month 0.01% atropine in 61 myopic children (aged 7–10) and the relationship with central retinal response (by multifocal electroretinogram [mfERG]) in a double-masked randomized placebo-controlled clinical trial. Global-flash mfERG was measured at baseline, while cycloplegic spherical equivalent refraction (SER) and axial length (AL) were measured at baseline and at 6-month intervals. Annualized change in SER and AL were compared between atropine and control groups, and the relationships with baseline mfERG were evaluated. Changes in SER (−0.70 ± 0.39D vs. −0.66 ± 0.41D, p = 0.63) and AL (0.32 ± 0.16 mm vs. 0.30 ± 0.22 mm, p = 0.52) were similar in atropine and control groups. Interestingly, in the placebo group, mfERG amplitude was negatively correlated with axial elongation (R_p = −0.44, p = 0.03) as in our previous study. However, in the atropine group, an opposite trend was observed that axial elongation was positively correlated with mfERG amplitude (R_a = 0.37, p = 0.04). Annualized myopia progression demonstrated similar opposite effect between atropine and placebo groups but did not reach statistical significance. An ERG screening protocol may be warranted to identify suitable candidates to reduce the likelihood of an unfavorable treatment response by 0.01% atropine.

Myopia: Mechanisms and Strategies to Slow Down Its Progression

This topical review aimed to update and clarify the behavioral, pharmacological, surgical, and optical strategies that are currently available to prevent and reduce myopia progression. Myopia is the commonest ocular abnormality; reinstated interest is associated with high and increasing prevalence, especially but not, in the Asian population and progressive nature in children. The growing global prevalence seems to be associated with both genetic and environmental factors such as spending more time indoor and using digital devices, particularly during the coronavirus disease 2019 pandemic. Various options have been assessed to prevent or reduce myopia progression in children. In this review, we assess the effects of several types of measures, including spending more time outdoor, optical interventions such as the bifocal/progressive spectacle lenses, soft bifocal/multifocal/extended depth of focus/orthokeratology contact lenses, refractive surgery, and pharmacological treatments. All these options for controlling myopia progression in children have various degrees of efficacy. Atropine, orthokeratology/peripheral defocus contact and spectacle lenses, bifocal or progressive addition spectacles, and increased outdoor activities have been associated with the highest, moderate, and lower efficacies, respectively.

Vision tests on spectacle lenses and contact lenses for optical myopia correction: a pilot study

Objective

Visual performance and short-term tolerability of different designs of myopia correcting options, including therapeutically relevant bifocal contact lenses (CL) and spectacle lenses with ‘defocus incorporated multiple segments (DIMS)’ technology were compared.

Methods and analysis

In myopic volunteering subjects (n=8; spherical equivalent range: −1 to −7 D) visual acuity (VA) using Landolt C and contrast sensitivity (CS) using contrast C were assessed at three different gaze positions (−22° nasal, +22° temporal and 0° central), corresponding to a gaze through the DIMS area or the clear area of the DIMS lens design, respectively, after short-term wear of each of single vision spectacle lenses (SV), DIMS spectacle lenses (DIMS), monofocal soft CL and centre-near multifocal soft CL (MCL). Also, CS was assessed under photopic and mesopic light conditions with and without glare using sinusoidal gratings at 1.5, 3, 6, 12 and 18 cpd.

Results

Mean VA (Landolt C) was −0.12 to –0.10, −0.05 and 0.10 logMAR (SV, DIMS, CL, MCL) at central gaze (0°). At nasal gaze (−22°), VA differed by 0.12, 0.33, 0.05 and 0.01, and at temporal gaze (+22°) by 0.05, 0.26, 0 and −0.08 compared with central gaze values. Mean CS (Contrast C) was 1.74, 1.73, 1.69 and 1.61 logCS (SV, DIMS, CL, MCL) at central gaze at nasal gaze, CS differed by −0.02 to –0.13, −0.01 and −0.01, and at temporal gaze by −0.02 to –0.16, −0.01 and +0.06 compared with central gaze values.

Conclusion

When compared with SV, MCL leads to a general decrease in VA and CS, while DIMS did not differ from SV at straight gaze (0° gaze). With DIMS, VA and CS are decreased to a similar level as with the MCL, but only at nasal and temporal gaze.