Effectiveness study of atropine for progressive myopia in Europeans

Efficacy and Safety of 0.03% Atropine Eye Drops in Controlling Myopia Progression: A One-Year Prospective Clinical Study

Objective: To investigate the efficacy and safety of one-year treatment with 0.03% atropine eye drops for slowing myopia progression among children aged 6-12 years. Methods: Healthy Caucasian children aged 6-12 years with cycloplegic spherical equivalent (SE) from -1.0 D to -5.0 D and astigmatism and anisometropia ≤1.5 D were included. Changes in mean axial length (AL) and objective SE as well as changes in intraocular pressure (IOP), central corneal thickness (CCT), anterior chamber depth (ACD) and lens thickness (LT) were assessed in the 0.03% atropine eye drops group and the control group from baseline through the 1-year follow-up. The proportion of participants showing myopia progression of <0.5 D from baseline in each group and any potential side effects in 0.03% atropine group were evaluated. Results: The study involved 31 patients in the 0.03% atropine eye drops group and 41 in the control group. Administration of 0.03% atropine for 1 year resulted in a mean change in SE of -0.34 (0.44) D/year, significantly lower than the -0.60 (0.50) D/year observed in the control group (p = 0.024). The change in AL was 0.19 (0.17) mm in the 0.03% atropine group, compared to 0.31 (0.20) mm in the control group (p = 0.015). There were no significant differences in changes of IOP, CCT and LT between the groups (all p ≥ 0.05). The 0.03% atropine group had a significantly greater increase in ACD compared to the control group (p = 0.015). In total, 64.5% of patients in the 0.03% atropine group showed progression <0.5 D/year, in contrast to 39.0% in the control group (p = 0.032). Adverse events were reported in 13 (35.0%) out of 37 patients in the treatment group, leading to discontinuation of the eye drops in six (16.0%) cases. None of the adverse events were severe. Conclusions: Despite a higher incidence of adverse events, 0.03% atropine eye drops effectively slowed the progression of myopia over 1-year.

Models of myopia: the effect of accommodation, lenses and atropine

BACKGROUND

Two quantitative models for myopia have been proposed and used for myopic intervention, one derived from feedback theory, and the other from physiological and mechanical considerations. This paper shows that they both predict the same results indicating that they are valid and reliable. These models are the only ones that can make predictions about the effect of atropine and lenses on myopia, explain multiple observations heretofore unexplained and offer possible interventions.

OBJECTIVE

Using their predictive power we test the models by calculating and comparing the effect of accommodation, lenses or atropine. The models offer a rationale that makes atropine equivalent to a positive lens for purposes of refractive development.

METHODS

This report includes thought experiments, actual experiments and trials, as well as an analysis of clinical data and integrates and tests results from all of them for far-reaching conclusions.

RESULTS

Both models accurately predict the same myopia progression caused by near work. These models are simple but powerful enough to suggest what treatments are indicated. Interventions for prevention and control of myopia are evaluated analytically, in particular atropine and optical treatments, such as positive lenses and under correction.

CONCLUSION

Optical treatments have enormous potential; atropine is of questionable value since there are ways to get the same or superior effect with lenses of power calculated as described here.

Atropine: Updates on myopia pharmacotherapy

The prevalence of myopia has rapidly increased over the last 30 years, with the World Health Organization estimating a worldwide incidence of 23%, projected to increase to 50% by 2050. The myopia epidemic has prompted a reincarnation in efforts to overcome this challenge. The exploration of atropine use in myopia was a result due to a lack of treatment in effect. This study aimed at reviewing the role of atropine in the management of myopia worldwide based on currently available findings. A literature search was conducted using PubMed/MEDLINE and Google Scholar for studies published up to April 2022 inclusive. Articles with high or medium clinical relevance were selected for this review. Multiple studies have demonstrated the relevance and efficacy rates of different concentrations of atropine, despite still insufficiently explained the exact site and mechanism of action of atropine in slowing myopia progression. Currently available findings highlight that topical atropine opened a new page in pharmacotherapy of myopia and have shown a high therapeutic effect on myopia progression in Asian and European child population, irrespective of ethnicity. There is potential for myopia control with fewer side effects using lower concentrations but still exists a room for improvement, underscoring the requirement of modified atropine topical preparations with increased bioavailability, potentially with nanoparticle formulations, to enable the effective management of myopia.

Efficacy and Safety of Low-Dose Atropine on Myopia Prevention in Premyopic Children: Systematic Review and Meta-Analysis

Background: Early-onset myopia increases the risk of irreversible high myopia. Methods: This study systematically evaluated the efficacy and safety of low-dose atropine for myopia control in children with premyopia through meta-analysis using random-effects models. Effect sizes were calculated using risk ratios (RRs) with 95% confidence intervals (CIs). Comprehensive searches of PubMed, EMBASE, Cochrane CENTRAL, and ClinicalTrials.gov were conducted until 20 December 2023, without language restrictions. Results: Four studies involving 644 children with premyopia aged 4-12 years were identified, with atropine concentrations ranging from 0.01% to 0.05%. The analysis focused on myopia incidence and atropine-related adverse events. Lower myopia incidence (RR, 0.62; 95% CI, 0.40-0.97 D/y; p = 0.03) and reduction in rapid myopia shift (≥0.5 D/1y) (RR, 0.50; 95% CI, 0.26-0.96 D/y; p < 0.01) were observed in the 12-24-month period. Spherical equivalent and axial length exhibited attenuated progression in the atropine group. No major adverse events were detected in either group, whereas the incidence of photophobia and allergic conjunctivitis did not vary in the 12-24-month period. Conclusions: Our meta-analysis supports atropine's efficacy and safety for delaying myopia incidence and controlling progression in children with premyopia. However, further investigation is warranted due to limited studies.

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].

Incidence of Adverse Events Induced by Atropine in Myopic Children: A Meta-Analysis

A large number of studies have evaluated the efficacy of low-dose atropine in preventing or slowing myopic progression. However, it is challenging to evaluate the ocular safety from these studies. We aimed to evaluate the incidence of adverse events induced by atropine in children with myopia. We performed a systematic literature search in several databases for studies published until November 2022. The incidence of adverse events induced by atropine was pooled by a common-effect (fixed-effect) or random-effects model. Subgroup analyses were conducted according to drug doses, types of adverse events, and ethnicity. A total of 31 articles were ultimately included in the study. The overall incidence of adverse events for atropine was 5.9%, and the incidence of severe adverse events was 0.0%. The most commonly reported adverse events were photophobia (9.1%) and blurred near vision (2.9%). Other adverse events including eye irritation/discomfort, allergic reactions, headache, stye/chalazion, glare, and dizziness occurred in less than 1% of the patients. The incidence of atropine-induced adverse events varied depending on the drug doses. A lower dose of atropine was associated with a lower incidence of adverse events. There was no significant difference in the incidence of adverse events for low-dose atropine between Asian and White children. Our study suggests photophobia and blurred near vision are the most frequently reported adverse events induced by atropine. Low-dose atropine is safer than moderate- and high-dose atropine. Our study could provide a safe reference for ophthalmologists to prescribe atropine for myopic children.

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.

[Progression of Myopia - which Preventive Measures Can be Recommended?]

The prevalence of myopia shows a worldwide increase with large regional differences. Especially high myopia enhances the risk of irreversible vision loss due to myopic maculopathy or other secondary effects. Reducing the prevalence and progression of myopia in schoolchildren is therefore a main goal in ophthalmology. Spending at least two hours a day outdoors is the easiest way to reduce myopia progression. Another modifiable factor is to reduce continuous near work with distances of less than 30 cm. Low-dose atropine eye drops administered once daily over two or more years have been shown to reduce myopia progression. Optical interventions which have been effective are multifocal contact lenses or orthokeratology contact lenses, but these have the risk of microbial keratitis. Whereas neither under- nor overcorrection of myopia have been proven effective, new so-called multisegment glasses have reduced myopia progression. Most of the studies concerning atropine and optic interventions have been performed in groups of Asian children, which are known to have more severe myopia progression, although actually there are many studies being conducted on Caucasian children. Still, there is also a lack of studies contrasting pharmacologic against optic interventions and comparing these with a combination of methods. The decision to start optic or pharmacologic measures can therefore only be an individual decision and is mainly based on age, refraction and progression in the past, while environmental factors should be assessed first.

Myopie(progression) – welche präventiven Ansätze sind sinnvoll?

Weltweit nimmt die Anzahl myoper Menschen stark zu, und damit wird zukünftig auch die Zahl der Patienten mit Folgeerkrankungen wie myoper Makulopathie und Netzhautablösungen steigen. Daher sind präventive Ansätze in den Fokus gerückt, die die Progression der Myopie im Kindes- und Jugendalter reduzieren sollen. Neben der Modifikation von Umweltfaktoren sind pharmakologische und optische Methoden möglich.

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.

Temporal and spatial characterization of myopia in China

Purpose

The aim of this study was to characterize the temporal and spatial distribution of myopia among students aged 7-18 years, by analyzing the aggregation area and providing the basis for the prevention and control of myopia in China.

Methods

A database for the spatial analysis of myopia in China during 1995-2014 was established using ArcGIS10.0 software as a platform for data management and presentation. A spatial autocorrelation analysis of myopia was undertaken, and a temporal and spatial scan analysis was performed using SaTScan9.5 software.

Results

Our data demonstrated that the prevalence of myopia in China in 1995, 2000, 2005, 2010, and 2014 was 35.9, 41.5, 48.7, 57.3, and 57.1%, respectively, thus indicating a gradual upward trend. The prevalence of myopia was analyzed in various provinces (municipalities and autonomous regions), and the highest was found in Jiangsu Province, with an average Moran's I index of 0.244295 in China (P ≤ 0.05). According to the local Moran's I autocorrelation analysis, there was a spatial aggregation of myopia prevalence among students in the entire country, with Shandong, Jiangsu, Anhui, and Shanghai being classified as high-high aggregation areas, while Hainan and Guangxi were classified as low-low aggregation areas. In addition, the Getis-Ord General G results of the global hotspot analysis showed a countrywide myopia prevalence index of 0.035020 and a Z score of 1.7959 (P = 0.07251). Because the myopia prevalence correlation difference was not statistically significant, there were no "positive hotspots" or "negative hotspots." The local hotspot analysis shows that Shandong and Jiangsu belong to high-value aggregation areas, while Hainan and Guizhou belong to low-value aggregation areas. Further analysis using time-space scanning showed 15 aggregation regions in five stages, with four aggregation regions having statistically significant differences (P ≤ 0.05). However, the aggregation range has changed over time. Overall, from 1995 to 2014, the aggregation areas for the myopia prevalence in Chinese students have shifted from the northwest, north, and northeast regions to the southeast regions.

Conclusion

Our data demonstrate that, from 1995 to 2014, the prevalence of myopia increased in students aged 7-18 years in China. In addition, the prevalence of myopia is randomly distributed in various provinces (municipalities and autonomous regions) and exhibits spatial aggregation. Also, the gathering area is gradually shifting to the southeast, with the existence of high-risk areas. It is, therefore, necessary to focus on this area and undertake targeted prevention and control measures.

The equations of ametropia: Predicting myopia

Why myopia develops, why it is reaching epidemic proportions and what is its cause are questions that puzzle many people. There is an answer to these questions and it is a simple one. This paper makes the connection between ametropic and in particular myopic development and theory to come with a summary of what we know about myopia and its governing equation. Key experiments, involving myopia and the effect of lenses in humans and animals have been done with unmistakable results. The observed effect of lenses implies a feedback mechanism. Feedback theory explains those results with mathematical precision. Disruption of emmetropization, is the mechanism behind ametropia and particularly myopia. Feedback theory for emmetropization was derived by observation of the input and output of the emmetropization feedback system in many patients. We show that it has the same equation as it is derived here independently from simple homeostasis principles. Classical observations and recent clinical studies have shown the association of many variables with myopia. They include near work, atropine, lenses, blur and outdoors versus indoors activities. We propose that human refractive development is controlled by homeostasis and based on that alone we derive the equation for the calculation of refraction for any patient and the effect of lenses. We provide software to calculate the refraction of any individual at any time. The editor of this journal makes the following statement: "This manuscript is intended for scientific discussion rather than clinical application. The present work does not intend to promote clinical under correction or no correction of myopia. Instead, clinicians should follow current clinical myopia management guidelines."

Photorefraction Screening Plus Atropine Treatment for Myopia is Cost-Effective: A Proof-of-Concept Markov Analysis

Purpose

The prevalence of myopia is increasing globally, putting individuals at risk of myopia-associated visual impairment. Low-dose atropine eye drops have been found to safely reduce the risk of progression from myopia to higher levels of myopia and pathological states. In New Zealand, school children have an eye check at age 11. In this study, we aimed to estimate the cost-effectiveness of introducing photorefractive screening for myopia at age 11 in the New Zealand context, with atropine 0.01% eye drops treatment for those screening positive.

Patients and Methods

A Markov cohort simulation was used to model the impact of screening plus atropine compared to usual care across a lifetime horizon and societal perspective with a 3% discount rate. Cost-effectiveness was determined by the incremental cost-effectiveness ratio (ICER), with utility measured in quality-adjusted life-years (QALYs). Multivariate sensitivity analyses were carried out to investigate factors influencing cost-effectiveness.

Results

The ICER for screening plus atropine was NZ$1590 (95% CI 1390, 1791) per QALY gained, with 7 cases of lifetime blindness prevented per 100,000 children screened.

Conclusion

Screening for myopia with photorefraction at age 11 and atropine 0.01% eye drop treatment of children screening positive is likely to be cost-effective. These results suggest that a real-world trial and cost-effectiveness analysis would be worth considering in New Zealand.

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.

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.

Early onset X-linked female limited high myopia in three multigenerational families caused by novel mutations in the ARR3 gene

This study describes the clinical spectrum and genetic background of high myopia caused by mutations in the ARR3 gene. We performed an observational case series of three multigenerational families with high myopia (SER≤-6D), from the departments of Clinical Genetics and Ophthalmology of a tertiary Dutch hospital. Whole-exome sequencing (WES) with a vision-related gene panel was performed, followed by a full open exome sequencing. We identified three Caucasian families with high myopia caused by three different pathogenic variants in the ARR3 gene (c.214C>T, p.Arg72*; c.767+1G>A; p.?; c.848delG, p.(Gly283fs)). Myopia was characterized by a high severity (<-8D), an early onset (<6 years), progressive nature, and a moderate to bad atropine treatment response. Remarkably, a female limited inheritance pattern was present in all three families accordant with previous reports. The frequency of a pathogenic variant in the ARR3 gene in our diagnostic WES cohort was 5%. To conclude, we identified three families with early onset, therapy-resistant, high myopia with a female-limited inheritance pattern, caused by a mutation in the ARR3 gene. The singular mode of inheritance might be explained by metabolic interference due to X-inactivation. Identification of this type of high myopia will improve prompt myopia treatment, monitoring, and genetic counseling.

A multicenter Spanish study of atropine 0.01% in childhood myopia progression

To evaluate the efficacy and safety of atropine 0.01% eye drops for myopia control in a multicentric pediatric Spanish cohort. An interventional, prospective, multicenter study was designed. Children aged between 6 and 14 years, with myopia between - 2.00 D to - 6.00 D, astigmatism < 1.50 D and documented previous annual progression greater than - 0.5 D (cycloplegic spherical equivalent, SE) were included. Once nightly atropine 0.01% eye drops in each eye were prescribed to all participants for 12 months. Age, gender, ethnicity and iris color were registered. All patients underwent the same follow-up protocol in every center: baseline visit, telephone consultation 2 weeks later and office controls at 4, 8 and 12 months. At each visit, best-corrected visual acuity, and cycloplegic autorefraction were assessed. Axial length (AL), anterior chamber depth and pupil diameter were measured on an IOL Master (Carl Zeiss Meditec, Inc, Dublin, CA). Adverse effects were registered in a specific questionnaire. Mean changes in cycloplegic SE and AL in the 12 months follow-up were analyzed. SE progression during treatment was compared with the SE progression in the year before enrollment for each patient. Correlation between SE and AL, and annual progression distribution were evaluated. Progression risk factors were analyzed by multivariate logistic regression analyses. Of the 105 recruited children, 92 completed the treatment. Mean SE and AL changes were - 0.44 ± 0.41 D and 0.27 ± 0.20 mm respectively. Mean SE progression was lower than the year before treatment (- 0.44 ± 0.41 D versus - 1.01 ± 0.38 D; p < 0.0001). An inverse correlation between SE progression and AL progression (r: - 0.42; p < 0.0001) was found. Fifty-seven patients (62%) had a SE progression less than - 0.50 D. No risk factors associated with progression could be identified in multivariate analyses. Mean pupil diameter increment at 12-months visit was 0.74 ± 1.76 mm. The adverse effects were mild and infrequent, and decreased over the time. Atropine 0.01% is effective and safe for myopia progression control in a multicentric Spanish children cohort. We believe this efficacy might be extensible to the myopic pediatric population from Western countries with similar social and demographic features. More studies about myopia progression risk factors among atropine treated patients are needed.

A Meta-Analysis Assessing Change in Pupillary Diameter, Accommodative Amplitude, and Efficacy of Atropine for Myopia Control

PURPOSE

To determine the effect of atropine on pupillary diameter, accommodative amplitude as well as myopia progression.

METHODS

Medical databases and Cochrane Library were systematically searched for studies from 1980 until June 2020. The primary and secondary outcomes were: a) change in pupillary diameter (PD) and accommodative amplitude (AA) and b) annualized mean change in spherical equivalent and axial length with various concentrations of atropine compared to control.

RESULTS

Thirteen trials (6 RCTs, 7 observational studies) that studied 9 atropine concentrations (0.01-1.0%) were included. The relation between atropine and change in PD and AA was nonlinear; at < 0.10% atropine, the slope of the curve was steep but the change in PD (+0.7 mm; 95% CI: +0.1 to +1.4) and AA (-1.6D; 95% CI: -3.9 to +0.7) was smaller whereas at ≥0.10% atropine, the slope plateaued but change in PD (+3.2 mm, 95% CI: +2.8 to +3.5) and AA (-10.7D; 95% CI: -12.2 to -9.2) was high.Reduction in myopia progression with atropine at <0.10% and ≥0.10% as compared to controls was 0.37D (95% CI: 0.16 to 0.58) versus 0.75D (95% CI: 0.17 to 1.33) for spherical equivalent and -0.10 mm (95% CI: -0.24 to 0.05) versus -0.23 mm (95% CI: -0.34 to -0.13) for axial length.

CONCLUSIONS

A nonlinear dose-response relationship exists between atropine and PD and AA. Further work is warranted to determine the concentration that provides maximal efficacy with tolerable side effects.

Is 0.01% Atropine an Effective and Safe Treatment for Myopic Children? A Systemic Review and Meta-Analysis

Several conflicting results regarding the efficacy of 0.01% atropine in slowing axial elongation remain in doubt. To solve this issue and evaluate the safety of 0.01% atropine, we conducted a systematic review and meta-analysis with the latest evidence. The review included a total of 1178 participants (myopic children). The efficacy outcomes were the mean annual progression in standardized equivalent refraction (SER) and axial length (AL). The safety outcomes included mean annual change in accommodative amplitude, photopic and mesopic pupil diameter. The results demonstrated that 0.01% atropine significantly retarded SER progression compared with the controls (weighted mean difference [WMD], 0.28 diopter (D) per year; 95% confidence interval (CI) = 0.17, 0.38; p < 0.01), and axial elongation (WMD, −0.06 mm; 95% CI = −0.09, −0.03; p < 0.01) during the 1-year period. Patients receiving 0.01% atropine showed no significant changes in accommodative amplitude (WMD, −0.45 D; 95% CI = −1.80, 0.90; p = 0.51) but showed dilated photopic pupil diameter (WMD, 0.35 mm; 95% CI = 0.02, 0.68; p = 0.04) and mesopic pupil diameter (WMD, 0.20 mm; 95% CI = 0.08, 0.32; p < 0.01). In the subgroup analysis of SER progression, myopic children with lower baseline refraction (>−3 D) and older age (>10-year-old) obtained better responses with 0.01% atropine treatment. Furthermore, the European and multi-ethnicity groups showed greater effect than the Asian groups. In conclusion, 0.01% atropine had favorable efficacy and adequate safety for childhood myopia over a 1-year period.

Myopia management in the Netherlands

PURPOSE

A trend that myopia is becoming gradually more common is shown in studies worldwide. Highest frequencies have been found in East Asian urban populations (96.5%) but also a study in Europe shows that nearly half of the 25-29 year olds has myopia. With the increase in prevalence, high myopia, i.e. a spherical equivalent of -6 or more and an axial length of 26 mm or more is also on the rise. High myopia particularly carries a significant risk of ocular pathology related to the long axial length. This highlights the need for myopia management in children with progressive myopia, in particular progression to high myopia.

RECENT FINDINGS

During the last decade, many intervention studies for myopia progression have emerged. Although lifestyle adjustments are effective, pharmacological and optical interventions have shown the highest efficacy on reduction of eye growth. High concentration atropine (0.5%-1.0%) shows the most reduction in axial length progression, but has drawbacks of light sensitivity and loss of accommodation. Nevertheless, when these side effects are mitigated by multifocal photochromatic glasses, the long-term adherence to high dose atropine is high. Lower concentrations of atropine are less effective, but have less side effects. Studies on optical interventions have reported reduction of progression for Ortho-K and multifocal contact lenses, but are in need for replication in larger studies with longer duration.

SUMMARY

The field of myopia management is rapidly evolving, and a position on the best approach for daily clinics is desirable. Over the last 10 years, our team of clinical researchers has developed a strategy which involves decision-making based on age, axial length, position on the axial length growth chart, progression rate, risk of high myopia, risk profile based on lifestyle and familial risk, side effects, and individual preference. This personalised approach ensures the most optimal long-term myopia control, and helps fight against visual impairment and blindness in the next generations of elderly.

The cause of myopia development and progression: Theory, evidence, and treatment

I review the key findings and our current knowledge of the cause of myopia, making the connections among the reliable observations on myopia development and theory to arrive at a summary of what we know about myopia, the proposed prevailing theory, and applicable action. Myopia is reaching epidemic proportions. It is estimated that half of the world's population will be myopic by 2050 unless new strategies to fight myopia are developed. Our high-level mathematical description of myopia is translated into clinical applications involving effective treatment and prevention. A regulating mechanism controlling the refraction of the eye is intimately related to myopia. The approach at hand is to review our knowledge about emmetropization, connecting myopia and emmetropization feedback theory to unveil the cause of myopia. Many observations discussed here test the validity of feedback theory positively. The cause of human myopia fits perfectly with the idea that emmetropization, in particular its feedback theory implementation, is the controlling mechanism behind myopia. They include near work, atropine, lenses, defocus, and outdoor versus indoor activities. The key findings in myopia research point the same way: myopia is the result of corrective lenses interfering with emmetropization. We have enough knowledge to answer the question of whether myopia can be reversed or prevented. There is no need to have mathematical skills to apply theory to real cases. It is enough to know the predictions of the feedback theory of emmetropization.

A retrospective analysis of the therapeutic effects of 0.01% atropine on axial length growth in children in a real-life clinical setting

BACKGROUND

Several randomized controlled studies have demonstrated the beneficial effects of 0.01% atropine eye drops on myopia progression in children. However, treatment effects may be different in a routine clinical setting. We performed a retrospective analysis of our clinical data from children to investigate the effect of 0.01% atropine eye drops on myopia progression in a routine clinical setting.

METHODS

Atropine-treated children were asked to instill one drop of 0.01% atropine in each eye every evening at 5 days a week. Myopic children who did not undergo atropine treatment served as controls. Objective refraction and ocular biometry of 80 atropine-treated and 103 untreated children at initial visit and 1 year later were retrospectively analyzed.

RESULTS

Myopic refractions in the treated and untreated children at initial visit ranged from -0.625 to -15.25 D (-4.21 ± 2.90 D) and from -0.125 to -9.375 D (-2.92 ± 1.77 D), respectively. Ages at initial visit ranged from 3.2 to 15.5 years (10.1 ± 2.7 years) in the treated and from 3.4 to 15.5 years (11.2 ± 3.0 years) in untreated children. Two-factor ANOVA for age and atropine effects on axial length growth confirmed that axial length growth rates declined with age (p<0.0001) and revealed a significant inhibitory effect of atropine on axial length growth (p<0.0015). The atropine effect on axial length growth averaged to 0.08 mm (28%) inhibition per year. Effects on refraction were not statistically significant.

CONCLUSION

The observed atropine effects were not very distinctive: Statistical analysis confirmed that atropine reduced axial length growth, but to an extent of minor clinical relevance. It was also shown that beneficial effects of 0.01% atropine may not be obvious in each single case, which should be communicated with parents and resident ophthalmologists.

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.

Effectiveness of topical cycloplegics as anterior segment analgesics: systematic review and meta-analysis

OBJECTIVE

Topical cycloplegic agents often are used in ophthalmology in the context of management of ocular inflammation. Preliminary searches of the literature provided little evidence to support their use in relieving pain or reducing inflammation. The goal of this study was to evaluate the current literature for any evidence regarding the effectiveness of cycloplegics for treatment of pain or inflammation in patients with anterior segment injury or inflammation through a systematic review and meta-analysis.

METHODS

Using multiple keywords relating to cycloplegics and inflammatory and infectious eye conditions, a search was conducted on multiple scientific databases for relevant articles. A 2-level screening approach was used and articles that were relevant to the topic were included in the systematic review. Data from these articles, if applicable, were extracted for meta-analyses. Statistical assessments involved computation of I²statistics, Z-value, and χ² statistics.

RESULTS

We screened 5753 articles for relevance. Seven were included in the systematic review and 5 were included in the meta-analysis. There was considerable heterogeneity between the included studies. Statistical analysis revealed significant reductions in pain using homatropine and cyclopentolate after 2 days. Nonsignificant changes in the anterior chamber cells and flare were seen using cyclopentolate and atropine at different follow-up times.

CONCLUSIONS

Little published evidence exists in the literature to guide the use of cycloplegics on relieving pain and treating inflammation. Therefore, higher-quality randomized controlled trials with longer follow-up times are needed to fully understand the role that cycloplegics play in reducing pain in inflammatory conditions.

Efficacy and safety of atropine to control myopia progression: a systematic review and meta-analysis

Background

The effect and safety of atropine on delaying the progression of myopia has been extensively studied, but its optimal dose is still unclear. Therefore, the purpose of this meta-analysis is to systematically evaluate the safety and effectiveness of atropine in controlling the progression of myopia, and to explore the relationship between the dose of atropine and the effectiveness of controlling the progression of myopia.

Methods

This work was done through the data searched from PubMed, MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials. The Cochrane Handbook was also used to evaluate the quality of the included studies. In addition, a meta-analysis was performed using Revman5.3 software.

Results

A total of 10 randomized controlled trials (RCTs) were included. Myopia progression was mitigated greater in the atropine treatment group than that in the control group, with MD = − 0.80, 95% CI (− 0.94, − 0.66) during the whole observation period. There was a statistical difference among 0.05, 0.5, and 1.0% atropine (P = 0.004). In addition, less axial elongation was shown, with MD = − 0.26, 95% CI (− 0.33, − 0.18) during the whole observation period.

Conclusion

The effectiveness of atropine in controlling the progression of myopia was dose related. A 0.05% atropine was likely to be the optimal dose.

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

BACKGROUND

Atropine is the most powerful treatment for progressive myopia in childhood. This study explores the 3-year effectiveness of atropine in a clinical setting.

METHODS

In this prospective clinical effectiveness study, children with progressive myopia ≥ 1D/year or myopia ≤ -2.5D were prescribed atropine 0.5%. Examination, including cycloplegic refraction and axial length (AL), was performed at baseline, and follow-up. Outcome measures were spherical equivalent (SER) and AL; annual progression of SER on treatment was compared with that prior to treatment. Adjustments to the dose were made after 1 year in case of low (AL ≥ 0.3 mm/year) or high response (AL < 0.1 mm/year) of AL.

RESULTS

A total of 124 patients were enrolled in the study (median age: 9.5, range: 5-16 years). At baseline, median SER was -5.03D (interquartile range (IQR): 3.08); median AL was 25.14 mm (IQR: 1.30). N = 89 (71.8%) children were persistent to therapy throughout the 3-year follow-up. Median annual progression of SER for these children was -0.25D (IQR: 0.44); of AL 0.11 mm (IQR: 0.18). Of these, N = 32 (36.0%) had insufficient response and were assigned to atropine 1%; N = 26 (29.2%) showed good response and underwent tapering in dose. Rebound of AL progression was not observed. Of the children who ceased therapy, N = 9 were lost to follow-up; N = 9 developed an allergic reaction; and N = 17 (19.1%) stopped due to adverse events.

CONCLUSION

In children with or at risk of developing high myopia, a starting dose of atropine 0.5% was associated with decreased progression in European children during a 3-year treatment regimen. Our study supports high-dose atropine as a treatment option for children at risk of developing high myopia in adulthood.

Pathogenesis and Prevention of Worsening Axial Elongation in Pathological Myopia

PURPOSE

This review discusses the etiology and pathogenesis of myopia, prevention of disease progression and worsening axial elongation, and emerging myopia treatment modalities.

INTRODUCTION

Pediatric myopia is a public health concern that impacts young children worldwide and is associated with numerous future ocular diseases such as cataract, glaucoma, retinal detachment and other chorioretinal abnormalities. While the exact mechanism of myopia of the human eye remains obscure, several studies have reported on the role of environmental and genetic factors in the disease development.

METHODS

A review of literature was conducted. PubMed and Medline were searched for combinations and derivatives of the keywords including, but not limited to, "pediatric myopia", "axial elongation", "scleral remodeling" or "atropine." The PubMed and Medline database search were performed for randomized control trials, systematic reviews and meta-analyses using the same keyword combinations.

RESULTS

Studies have reported that detection of genetic correlations and modification of environmental influences may have a significant impact in myopia progression, axial elongation and future myopic ocular complications. The conventional pharmacotherapy of pediatric myopia addresses the improvement in visual acuity and prevention of amblyopia but does not affect axial elongation or myopia progression. Several studies have published varying treatments, including optical, pharmacological and surgical management, which show great promise for a more precise control of myopia and preservation of ocular health.

DISCUSSION

Understanding the role of factors influencing the onset and progression of pediatric myopia will facilitate the development of successful treatments, reduction of disease burden, arrest of progression and improvement in future of the management of myopia.

Prevalence of Myopia in Newly Enlisted Airmen at Joint Base San Antonio

Purpose

Myopia is the most common type of refractive error and can lead to significant visual impairment. The frequency of myopia has risen considerably, and its worldwide prevalence is expected to continue to increase. Myopia is present in an increasing number of Basic Military Trainees upon entry into the United States Air Force. This study aims to demonstrate the prevalence of myopia in newly enlisted members of the United States Air Force.

Methods

This study is an institutional retrospective analysis of data collected from the United States Air Force candidates entering Basic Military Training from 1 January 2017 to 31 March 2017. A random selection of 767 Air Force Basic Military Trainees were included in the analysis, yielding 1534 total eyes. The primary outcome measure studied is the mean spherical equivalent (MSE) of participants at initial evaluation. A linear regression analysis was performed to identify any associations related to participant demographics.

Results

Of participants analyzed, 45% had myopia (<−0.5 D) and 2% high myopia (<−6.0 D) upon entry into the United States Air Force. Myopia was found to be associated with male gender (p = <0.001).

Conclusion

Myopia is present in a significant proportion of Basic Military Trainees upon entry into the United States Air Force, regardless of age, gender, race, or ethnicity. The prevalence of myopia presented is higher than previous studies, reflecting a continued trend towards increased myopia prevalence worldwide.

Efficacy and Safety of 1% Atropine on Retardation of Moderate Myopia Progression in Chinese School Children

Background: To evaluate the long-term efficacy and safety of topical 1% atropine for retarding moderate myopia. Methods: A randomized, controlled study evaluating atropine and placebo in 660 Chinese children. Patients received drops q1month for 24 months, then q2month for 12 months, followed by no drops for 12 months. Spherical equivalent, axial length, intraocular pressure and atropine-related side effects were examined at 6, 12, 24, 36 and 48 months for all children. Results: Spherical equivalent, myopic progression, axial length augmentation, and progression rate were significantly reduced in the atropine group than those in the placebo group (all P<0.05), indicating that 1% atropine effectively retarded myopia. Moreover, myopic rebound and adverse effects of 1% atropine were eliminated by gradual withdrawal and elimination of 1% atropine. Furthermore, pupil size, near visual acuity, and amplitude of accommodation returned to pretreatment levels after withdrawal of atropine. Conclusion: Topical 1% atropine periodically and alternatively in phase I with gradual reduction in phase II and final withdrawal in phase III may effectively improve atropine efficacy, retard moderate myopia, reduce atropine side effects, minimize myopic rebound, and increase compliance of children simultaneously.

Efficacy of atropine 0.01% for the treatment of childhood myopia in European patients

PURPOSE

To evaluate the efficacy and safety of atropine 0.01% in slowing myopia progression in European paediatric patients.

METHODS

Retrospective, medical records review study. Medical charts of paediatric patients with a myopia progression > 0.5 D/year treated with atropine 0.01% for at least 1 year were included. Patients receive a complete ophthalmic examination before and 12 months after initiation of atropine treatment. A group of myopic untreated children serves as a control group. The rate of myopia progression at baseline and 12 months after treatment with atropine was evaluated. The rate of myopia progression in treated and untreated patients was also compared. Adverse events were recorded.

RESULTS

Medical records of 52 treated and 50 control subjects were analysed. In the atropine group, the mean rate of myopia progression after 12 months of treatment (-0.54 ± 0.61 D) was significantly slower compared with the baseline progression (-1.20 ± 0.64 D; p < 0.0001) and to the progression in the control group (-1.09 ± 0.64; p < 0.0001). The responders patients were 41/52 (79%), whereas 11/52 patients (21%) showed a progression > 0.50 D despite treatment. The only adverse event was temporary photophobia in five patients (9.6%), severe adverse events were not reported, and none of the patients discontinued the treatment.

CONCLUSION

Low-dose atropine significantly slowed the rate of myopia progression in European paediatric patients with a favourable safety profile.

A Pilot Study on the Efficacy and Safety of 0.01% Atropine in German Schoolchildren with Progressive Myopia

INTRODUCTION

Although the interest is growing in topical low-dose atropine to control myopia in schoolchildren worldwide, its use in children of European ancestry remains controversial and solid evidence is sparse. The Oxford Centre for Evidence Based Medicine (OCEBM) classifies the evidence for this therapy as level I for East Asian populations, but only level IV in non-Asian populations.

METHODS

Fifty-six children, aged a median of 11 years (range 6-17), were analysed after 12 months of topical treatment with 0.01% preservative-free atropine in both eyes at bedtime every day. Efficacy was assessed during treatment every 6 months. In a subset of 20 patients, treatment of the second eye was delayed by 1 day to enable a controlled safety assessment of side effects such as pupil dilation, hypoaccommodation, and near vision reduction.

RESULTS

Prior to treatment, the mean myopic progression was estimated as 1.05 D/year; after 12 months of treatment with 0.01% atropine, it was 0.40 D/year (p < 0.0001). The only consistently measurable side effect was the induction of 1 mm pupil dilatation, which was only noticeable in comparison to the non-treated eye during the safety investigation.

CONCLUSIONS

Topical low-dose atropine appears to be safe and efficacious also in a cohort of European schoolchildren. These data should motivate researchers to conduct more randomised clinical trials.

Short-Term Effect of Low-Dose Atropine and Hyperopic Defocus on Choroidal Thickness and Axial Length in Young Myopic Adults

Purpose

To examine the interaction between a short period of hyperopic defocus and low-dose atropine upon the choroidal thickness and ocular biometrics of healthy myopic subjects.

Methods

Twenty young adult myopic subjects had subfoveal choroidal thickness (ChT) and ocular biometry measurements taken before and 30 and 60 min following the introduction of optical blur (0.00 D and −3.00 D) combined with administration of 0.01% atropine or placebo. Each combination of optical blur and drug was tested on different days in a fixed order.

Results

The choroid exhibited significant thinning after imposing hyperopic defocus combined with placebo (mean change of −11 ± 2 μm, p < 0.001). The combination of hyperopic blur and 0.01% atropine led to a significantly smaller magnitude of subfoveal choroidal thinning (−4 ± 8 μm), compared to placebo and hyperopic defocus (p < 0.01). Eyes treated with 0.01% atropine with no defocus exhibited a significant increase in ChT (+6 ± 2 μm, p < 0.01). Axial length also underwent small but significant changes after treatment with hyperopic blur and placebo and 0.01% atropine alone (both p < 0.01), but of opposite direction to the changes in choroidal thickness. However, the 0.01% atropine/hyperopic blur condition did not lead to a significant change in axial length compared to baseline (p > 0.05).

Conclusion

Low-dose atropine does inhibit the short-term effect of hyperopic blur on choroidal thickness and, when used alone, does cause a slight thickening of the choroid in young healthy myopic adults.

IMI - Clinical Management Guidelines Report

Best practice clinical guidelines for myopia control involve an understanding of the epidemiology of myopia, risk factors, visual environment interventions, and optical and pharmacologic treatments, as well as skills to translate the risks and benefits of a given myopia control treatment into lay language for both the patient and their parent or caregiver. This report details evidence-based best practice management of the pre-, stable, and the progressing myope, including risk factor identification, examination, selection of treatment strategies, and guidelines for ongoing management. Practitioner considerations such as informed consent, prescribing off-label treatment, and guides for patient and parent communication are detailed. The future research directions of myopia interventions and treatments are discussed, along with the provision of clinical references, resources, and recommendations for continuing professional education in this growing area of clinical practice.

IMI - Interventions Myopia Institute: Interventions for Controlling Myopia Onset and Progression Report

Myopia has been predicted to affect approximately 50% of the world's population based on trending myopia prevalence figures. Critical to minimizing the associated adverse visual consequences of complicating ocular pathologies are interventions to prevent or delay the onset of myopia, slow its progression, and to address the problem of mechanical instability of highly myopic eyes. Although treatment approaches are growing in number, evidence of treatment efficacy is variable. This article reviews research behind such interventions under four categories: optical, pharmacological, environmental (behavioral), and surgical. In summarizing the evidence of efficacy, results from randomized controlled trials have been given most weight, although such data are very limited for some treatments. The overall conclusion of this review is that there are multiple avenues for intervention worthy of exploration in all categories, although in the case of optical, pharmacological, and behavioral interventions for preventing or slowing progression of myopia, treatment efficacy at an individual level appears quite variable, with no one treatment being 100% effective in all patients. Further research is critical to understanding the factors underlying such variability and underlying mechanisms, to guide recommendations for combined treatments. There is also room for research into novel treatment options.

IMI - Clinical Myopia Control Trials and Instrumentation Report

The evidence-basis based on existing myopia control trials along with the supporting academic literature were reviewed; this informed recommendations on the outcomes suggested from clinical trials aimed at slowing myopia progression to show the effectiveness of treatments and the impact on patients. These outcomes were classified as primary (refractive error and/or axial length), secondary (patient reported outcomes and treatment compliance), and exploratory (peripheral refraction, accommodative changes, ocular alignment, pupil size, outdoor activity/lighting levels, anterior and posterior segment imaging, and tissue biomechanics). The currently available instrumentation, which the literature has shown to best achieve the primary and secondary outcomes, was reviewed and critiqued. Issues relating to study design and patient selection were also identified. These findings and consensus from the International Myopia Institute members led to final recommendations to inform future instrumentation development and to guide clinical trial protocols.

Practice patterns to decrease myopia progression differ among paediatric ophthalmologists around the world

Introduction

Myopia is a worldwide epidemic. Plethora of treatments are offered to decrease myopia progression. In this study, we compared between different geographical areas worldwide the practice patterns used by paediatric ophthalmologists to decrease the progression of myopia.

Methods

Global responses to a questionnaire were analysed (n=794) for demographic variations. Pharmacological, optical and behavioural categories were defined as effective or ineffective based on the current scientific peer reviewed literature.

Results

Treatment rates varied significantly between geographical regions (mean 57%, range 39%–89%, p<0.001). Nearly all participants who treat myopia used at least one form of effective treatment, regardless of location (98%, p=0.16). Among those prescribing pharmacological treatments, European physicians offered the lowest rate of effective treatment compared with other regions (85% vs mean 97%). Rates of effective optical treatment varied significantly between locations (p<0.001), from 16% (Central-South America) to 56% (Far East). Most treating respondents advocated behavioural modifications (92%), between 87% (North America) and 100% (Central Asia). Nearly all respondents used combinations of treatment modalities (95%)—mostly pharmacological, optical and behavioural combination. However, combination rates varied significantly between regions (p<0.001).

Discussion

The utility of treatment to decrease myopia progression differs significantly across the world both in type, combination and efficacy.

Conclusion

Paediatric ophthalmologists involvement and proficiency in myopia progression treatment varies around the world. This may entail promoting continuous medical education and other incentives to increase the number and proficiency of paediatric ophthalmologist to have a more effective impact to control the myopia epidemic in children.

Short-term effects of low-concentration atropine eye drops on pupil size and accommodation in young adult subjects

PURPOSE

A single eye drop containing 0.01% atropine every evening has previously been found to inhibit myopia progression in young adults. We have tested the short-term effects of very low-dose atropine eye drops on pupil sizes and accommodation in young adult subjects.

METHODS

Fourteen eyes of young adult subjects participated in the clinical observation. A single eye drop was applied with concentrations of either 0.01%, 0.005%, or 0.001% in the evening. Baseline parameters were measured before atropine application. Changes of pupil sizes, under photopic and mesopic conditions, as well as accommodation amplitudes were observed over the next day and analyzed by paired the Wilcoxon signed-rank test.

RESULTS

The pupil was significantly dilated 12 h after instillation of 0.01% atropine eye drops, both under photopic (3.3 ± 0.5 mm vs. 4.9 ± 0.9 mm) and mesopic (4.8 ± 0.7 mm vs. 6.1 ± 0.7 mm) conditions. Pupil sizes recovered over the day but were still significantly larger in the evening, compared to the baseline parameters measured on the day before (3.9 ± 0.5 mm vs. 5.3 ± 0.6 mm). The subjective near point of accommodation was reduced from 8.0 ± 2.4 to 6.6 ± 2.8 dpt in the morning and to 7.0 ± 2.9 dpt in the evening. At 0.005%, the pattern of results remained still similar, although the magnitude of the effects was generally smaller. At 0.001%, pupil sizes were still weakly significantly larger in the morning.

CONCLUSIONS

At a dose of 0.01%, clinically significant short-term effects were detected on pupil size and accommodation for at least 24 h. At the lowest dose of 0.001%, only tiny effects on pupil size were detectable.

Prevention of Progression in Myopia: A Systematic Review

The prevalence of myopia has increased worldwide in recent decades and now is endemic over the entire industrial world. This increase is mainly caused by changes in lifestyle and behavior. In particular, the amount of outdoor activities and near work would display an important role in the pathogenesis of the disease. Several strategies have been reported as effective. Spectacles and contact lenses have shown only slight results in the prevention of myopia and similarly ortokerathology should not be considered as a first-line strategy, given the high risk of infectious keratitis and the relatively low compliance for the patients. Thus, to date, atropine ophthalmic drops seem to be the most effective treatment for slowing the progression of myopia, although the exact mechanism of the effect of treatment is still uncertain. In particular, low-dose atropine (0.01%) was proven to be an effective and safe treatment in the long term due to the lowest rebound effect with negligible side effects.

[Atropine use for the prevention of myopia progression]

Given the prevalence of myopic refraction (from 50 to 84% in Asian countries and 35 to 49% in European countries and the United States in young people), the development of methods for monitoring and preventing myopia continues to be an urgent task. One of the directions of pharmacological intervention on the progression of myopia is associated with the use of a non-selective M-cholinoreceptors antagonist - atropine. The review presents the results of studies on various aspects of the potential for topical application of atropine to control the progression of myopia (experimental and clinical data on the mechanism of action, the effectiveness of clinical use, the possible side effects of various concentrations of the drug).The heterogeneity of the data presented does not yet lead to the conclusion that the long-term instillations of atropine are effective in prevention of progressive myopia. In addition, the wide application of this method, for example, in the territory of the Russian Federation, is limited by approved official instruction for the local application of the atropine solution in ophthalmology.

Current trends among pediatric ophthalmologists to decrease myopia progression-an international perspective

PURPOSE

To explore what the current worldwide preferred practice patterns of pediatric ophthalmologists are to decrease myopia progression among their patients.

METHODS

A questionnaire was sent to all members of supranational and national pediatric ophthalmology and strabismus societies.

RESULTS

The questionnaire was fully completed by most respondents 90.10% (847 of 940 responses). Fifty-seven percent (457) routinely treat to decrease myopia progression. The most common parameter to initiate treatment was a myopic increase of 1 diopter/year or more (74.8%, 246). Seventy percent (345) prescribed eye drops. Atropine 0.01% was the most popular (63.4%, 277) followed by atropine 1% (10.9%, 48) and atropine 0.5% (8.9%, 39). Eighty-six percent (394) of the respondents advised to spend more time outdoors, to reduce the amount of time viewing screens (60.2%, 277), and cutback the use of smart phones (63.9%, 294).

CONCLUSIONS

Most pediatric ophthalmologists treat to decrease myopia. They employ a wide variety of means to decrease myopia progression. Atropine 0.01% is the most popular and safe modality used similarly to recent reports. However, there is no consensus when treatment should be initiated. Further prospective studies are needed to elucidate the best timing to start treatment and the applicability of recent studies in the Asian population to other ethnic groups. This will improve the ability to update pediatric ophthalmologist with evidenced-based treatment options to counter the myopia epidemic.

Update in myopia and treatment strategy of atropine use in myopia control

The prevalence of myopia is increasing globally. Complications of myopia are associated with huge economic and social costs. It is believed that high myopia in adulthood can be traced back to school age onset myopia. Therefore, it is crucial and urgent to implement effective measures of myopia control, which may include preventing myopia onset as well as retarding myopia progression in school age children. The mechanism of myopia is still poorly understood. There are some evidences to suggest excessive expansion of Bruch’s membrane, possibly in response to peripheral hyperopic defocus, and it may be one of the mechanisms leading to the uncontrolled axial elongation of the globe. Atropine is currently the most effective therapy for myopia control. Recent clinical trials demonstrated low-dose atropine eye drops such as 0.01% resulted in retardation of myopia progression, with significantly less side effects compared to higher concentration preparation. However, there remain a proportion of patients who are poor responders, in whom the optimal management remains unclear. Proposed strategies include stepwise increase of atropine dosing, and a combination of low-dose atropine with increase outdoor time. This review will focus on the current understanding of epidemiology, pathophysiology in myopia and highlight recent clinical trials using atropine in the school-aged children, as well as the treatment strategy in clinical implementation in hyperopic, pre-myopic and myopic children.

A Review of Myopia Control with Atropine

Myopia is a global public health issue with a worldwide prevalence of ∼30% and is estimated to rise to 50% by 2050. In addition to the burden associated with routine management of the condition, high myopia predisposes the eye to sight-threatening complications such as myopic maculopathy and glaucoma in adult life. Controlling onset and progression of myopia at a young age can reduce the risk of morbidity associated with high myopia. Progression of myopia can be slowed with various optical, environmental, and pharmaceutical strategies, of which atropine has proven to be the most effective. High-dose atropine (0.5%-1%) is the most effective, but it has significant trade-offs with respect to rebound of myopia on discontinuation and side effects such as photophobia and difficulty with near work (decreased accommodation). Low doses of atropine have been trialed and show a dose-dependent efficacy. However, its mode of action on the ocular tissues leading to slowing eye growth remains unclear and multiple mechanisms and sites in the eye have been postulated to play a role. This review summarizes the role of atropine in controlling myopia and the mechanisms studied to date.

Axial length growth and the risk of developing myopia in European children

PURPOSE

To generate percentile curves of axial length (AL) for European children, which can be used to estimate the risk of myopia in adulthood.

METHODS

A total of 12 386 participants from the population-based studies Generation R (Dutch children measured at both 6 and 9 years of age; N = 6934), the Avon Longitudinal Study of Parents and Children (ALSPAC) (British children 15 years of age; N = 2495) and the Rotterdam Study III (RS-III) (Dutch adults 57 years of age; N = 2957) contributed to this study. Axial length (AL) and corneal curvature data were available for all participants; objective cycloplegic refractive error was available only for the Dutch participants. We calculated a percentile score for each Dutch child at 6 and 9 years of age.

RESULTS

Mean (SD) AL was 22.36 (0.75) mm at 6 years, 23.10 (0.84) mm at 9 years, 23.41 (0.86) mm at 15 years and 23.67 (1.26) at adulthood. Axial length (AL) differences after the age of 15 occurred only in the upper 50%, with the highest difference within the 95th percentile and above. A total of 354 children showed accelerated axial growth and increased by more than 10 percentiles from age 6 to 9 years; 162 of these children (45.8%) were myopic at 9 years of age, compared to 4.8% (85/1781) for the children whose AL did not increase by more than 10 percentiles.

CONCLUSION

This study provides normative values for AL that can be used to monitor eye growth in European children. These results can help clinicians detect excessive eye growth at an early age, thereby facilitating decision-making with respect to interventions for preventing and/or controlling myopia.

Superdiluted atropine at 0.01% reduces progression in children and adolescents. A 5 year study of safety and effectiveness

OBJECTIVE

To confirm the clinical security and effectiveness of the daily application of 0.01% superdiluted atropine eyedrops in the progression of myopia in children.

MATERIAL AND METHODS

A total of 200 children 9-12 years of age were randomised into a treated group and a control without treatment. Refraction under cycloplegia was performed.

RESULTS

Myopia progression of the treated group was -0.14±0.35 versus -0.65±0.54 in the control group without treatment. Only 2% of patients were forced to stop treatment due to side effects.

CONCLUSION

Atropine superdiluted atropine 0.01% eyedrops is effective and well tolerated, and reduced myopia progression by 25%.