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Jawaid I, Saunders K, Hammond CJ, Dahlmann-Noor A, Bullimore MA. Low concentration atropine and myopia: a narrative review of the evidence for United Kingdom based practitioners. Eye (Lond) 2024; 38:434-441. [PMID: 37717107 PMCID: PMC10858250 DOI: 10.1038/s41433-023-02718-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2023] [Revised: 07/05/2023] [Accepted: 08/25/2023] [Indexed: 09/18/2023] Open
Abstract
The prevalence of myopia is increasing across the world. Controlling myopia progression would be beneficial to reduce adverse outcomes such as retinal detachment and myopic maculopathy which are associated with increased axial length. Pharmacological control of myopia progression with atropine has been investigated since the 19th century and the benefits of slowing myopia progression are considered against the side-effects of near blur and photophobia. More recently, randomised trials have focused on determining the optimum concentration of atropine leading to low-concentration atropine being used to manage myopia progression by practitioners across the world. Currently, in the United Kingdom, there is no licensed pharmacological intervention for myopia management. The aim of this review is to interpret the available data to inform clinical practice. We conducted a narrative review of the literature and identified peer-reviewed randomised controlled trials using the search terms 'myopia' and 'atropine', limited to the English language. We identified two key studies, which were the Atropine in the Treatment Of Myopia (ATOM) and Low-concentration Atropine for Myopia Progression (LAMP). Further studies were identified using the above search terms and the references from the identified literature. Atropine 0.01% has a modest effect on controlling axial length progression. Atropine 0.05% appears to be superior to atropine 0.01% in managing myopia progression. There is a dose-dependent rebound effect when treatment is stopped. Atropine is a well-tolerated, safe, and effective intervention. Treatment would be needed for several years and into adolescence, until axial length progression is stable.
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Affiliation(s)
- Imran Jawaid
- Nottingham University Hospitals NHS Trust, Derby Road, Nottingham, UK.
| | - Kathryn Saunders
- School of Biomedical Sciences, Ulster University, Northern Ireland, UK
| | - Christopher J Hammond
- Section of Academic Ophthalmology, School of Life Course Sciences, King's College London, London, UK
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Lee CY, Yang SF, Chang YL, Huang JY, Lian IB, Chang CK. The Effect of Myopic Control between the Dual-Focus Contact Lenses and High-Concentration Atropine in an Asian Population. Life (Basel) 2024; 14:118. [PMID: 38255733 PMCID: PMC10817657 DOI: 10.3390/life14010118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Revised: 01/09/2024] [Accepted: 01/13/2024] [Indexed: 01/24/2024] Open
Abstract
We aim to investigate the myopic control effect of high-concentration atropine (ATR) and dual-focus contact lenses (DFCLs). A retrospective cohort study was conducted. A total of 182 eyes in 91 individuals who used high-concentration ATR (0.125%) and another 70 eyes in 35 individuals who used DFCLs were enrolled in the ATR and DFCL groups, respectively. The primary outcomes were spherical equivalent refraction (SER) progression and axial length (AXL) elongation. The generalized estimate equation was utilized to yield the adjusted odds ratio (aOR) and 95% confidence interval (CI) of cycloplegic SER progression and AXL elongation between groups. According to the multivariable analysis, the change in cycloplegic SER progression was similar between the DFCL and ATR groups (aOR: 1.305, 95% CI: 0.247-2.515, p = 0.803). The DFCL group demonstrated a numerically higher rate of AXL elongation compared to the ATR group (aOR: 1.530, 95% CI: 0.980-1.894, p = 0.051). In the subgroup analysis, cycloplegic SER progression was insignificant between ATR and DFCL users in different subgroups (all p > 0.05). The DFCL patients with moderate astigmatism and high AXL (both p < 0.001) presented a high risk of AXL elongation. In conclusion, DFCL usage demonstrated similar myopic control of cycloplegic SER and AXL compared to high-concentration ATR, while DFCLs showed lower AXL control, mainly in patients with moderate astigmatism and high AXL.
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Affiliation(s)
- Chia-Yi Lee
- Institute of Medicine, Chung Shan Medical University, Taichung 402, Taiwan
- Nobel Eye Institute, Taipei 115, Taiwan
- Department of Ophthalmology, Jen-Ai Hospital Dali Branch, Taichung 412, Taiwan
| | - Shun-Fa Yang
- Institute of Medicine, Chung Shan Medical University, Taichung 402, Taiwan
- Department of Medical Research, Chung Shan Medical University Hospital, Taichung 402, Taiwan
| | - Yu-Ling Chang
- Department of Medical Education, Cathay General Hospital, Taipei 106, Taiwan
| | - Jing-Yang Huang
- Department of Medical Research, Chung Shan Medical University Hospital, Taichung 402, Taiwan
| | - Ie-Bin Lian
- Institute of Statistical and Information Science, National Changhua University of Education, Changhua 500, Taiwan
| | - Chao-Kai Chang
- Nobel Eye Institute, Taipei 115, Taiwan
- Department of Optometry, Da-Yeh University, Chunghua 515, Taiwan
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Zambrano Peralta P, Ortiz Quito M, Guerrero Ortiz F, Cervantes Anaya L. Orthokeratology vs. orthokeratology combined with atropine for the control of myopia in children: systematic review. ARCHIVOS DE LA SOCIEDAD ESPANOLA DE OFTALMOLOGIA 2023; 98:568-576. [PMID: 37619667 DOI: 10.1016/j.oftale.2023.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Accepted: 06/20/2023] [Indexed: 08/26/2023]
Abstract
The purpose of this investigation is to determine the efficacy of orthokeratology (OK) compared to orthokeratology combined with atropine (AOK) for the control of myopia in children. A systematic review that included systematic reviews with meta-analyses, as well as randomized and controlled clinical trials, was carried out in the PubMed, Web of Science, Scopus, Cochrane Library, ProQuest, Taylor & Francis, Science Direct databases, as well as a manual search. Of the Q1-Q4 journals of the Scimago Journal & Country Rank, published in the last 5 years in English and Spanish. Eighteen studies that met the eligibility criteria were considered. The articles selected included 6,866 patients for analysis, where orthokeratology combined with 0.01% atropine was found to be more effective due to its ability to reduce the progression of myopia and axial elongation. In our investigation, it was determined that there could be an additive effect in the combination of 0.01% atropine with orthokeratology in a period of 1-2 years of treatment in patients with mild myopia; however, more multiethnic studies should be carried out, in where a correct evaluation of the progression of myopia, genetic and environmental factors that may influence the results is considered.
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Affiliation(s)
| | - M Ortiz Quito
- Universidad Católica de Cuenca, Sede Matriz, Cuenca, Ecuador
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Lawrenson JG, Shah R, Huntjens B, Downie LE, Virgili G, Dhakal R, Verkicharla PK, Li D, Mavi S, Kernohan A, Li T, Walline JJ. Interventions for myopia control in children: a living systematic review and network meta-analysis. Cochrane Database Syst Rev 2023; 2:CD014758. [PMID: 36809645 PMCID: PMC9933422 DOI: 10.1002/14651858.cd014758.pub2] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/18/2023]
Abstract
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.
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Affiliation(s)
- John G Lawrenson
- Centre for Applied Vision Research, School of Health & Psychological Sciences , City, University of London, London, UK
| | - Rakhee Shah
- Centre for Applied Vision Research, School of Health & Psychological Sciences , City, University of London, London, UK
| | - Byki Huntjens
- Centre for Applied Vision Research, School of Health & Psychological Sciences , City, University of London, London, UK
| | - Laura E Downie
- Department of Optometry and Vision Sciences, The University of Melbourne, Melbourne, Australia
| | - Gianni Virgili
- Department of Neurosciences, Psychology, Drug Research and Child Health (NEUROFARBA), University of Florence, Florence, Italy
- Centre for Public Health, Queen's University Belfast, Belfast, UK
| | - Rohit Dhakal
- Myopia Research Lab, Prof. Brien Holden Eye Research Centre, L V Prasad Eye Institute, Hyderabad, India
| | - Pavan K Verkicharla
- Myopia Research Lab, Prof. Brien Holden Eye Research Centre, L V Prasad Eye Institute, Hyderabad, India
| | - Dongfeng Li
- Centre for Public Health, Queen's University Belfast, Belfast, UK
- Department of Ophthalmology, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, China
| | - Sonia Mavi
- Centre for Public Health, Queen's University Belfast, Belfast, UK
| | - Ashleigh Kernohan
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Tianjing Li
- Department of Ophthalmology, University of Colorado Denver Anschutz Medical Campus, Aurora, CO, USA
| | - Jeffrey J Walline
- College of Optometry, The Ohio State University, Columbus, Ohio, USA
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Lin W, Li N, Lu K, Li Z, Zhuo X, Wei R. The relationship between baseline axial length and axial elongation in myopic children undergoing orthokeratology. Ophthalmic Physiol Opt 2023; 43:122-131. [PMID: 36377631 PMCID: PMC10100030 DOI: 10.1111/opo.13070] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Revised: 08/07/2022] [Accepted: 10/18/2022] [Indexed: 11/16/2022]
Abstract
PURPOSE To investigate the correlation between the baseline axial length (AL) and axial elongation in myopes undergoing orthokeratology (ortho-k). METHODS This was a retrospective study. During the 1-year follow-up, 1176 children (aged 8-14 years) were included and divided into an ortho-k group (n = 588) and a single-vision spectacle group (n = 588). The ortho-k group participants (8-11 years of age) who completed the 3-year follow-up (n = 150) were further divided into three subgroups stratified by their baseline AL: subgroup 1 (AL < 24.5 mm), subgroup 2 (24.5 ≤ AL < 26 mm) and subgroup 3 (AL ≥ 26 mm). AL was measured at baseline and during the annual visit. RESULTS The ortho-k group exhibited slower 1-year axial elongation (39% reduction) than the spectacle group. The 1-year axial elongation was negatively correlated with initial age in both groups. A negative association between 1-year axial elongation and baseline AL was observed in the ortho-k group but not in the spectacle group. However, this relationship only existed in ortho-k participants 8-11 years of age. For the younger ortho-k participants who completed the 3-year follow-up, the annual axial elongation was significantly higher in subgroup 1 for the first and second years but not in the third year compared with subgroups 2 and 3. CONCLUSION Axial elongation was negatively correlated with baseline AL in the ortho-k group. Children aged 8-11 years with longer baseline AL (≥24.5 mm) demonstrated slower annual axial elongation during the first 2 years of ortho-k treatment, which may provide insight into establishing individual guidelines for controlling myopia using ortho-k in children with different baseline characteristics.
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Affiliation(s)
- Weiping Lin
- Tianjin Key Laboratory of Retinal Functions and Diseases, Tianjin Branch of National Clinical Research Center for Ocular Disease, Eye Institute and School of Optometry, Tianjin Medical University Eye Hospital, Tianjin, China
| | - Na Li
- Tianjin Key Laboratory of Retinal Functions and Diseases, Tianjin Branch of National Clinical Research Center for Ocular Disease, Eye Institute and School of Optometry, Tianjin Medical University Eye Hospital, Tianjin, China
| | - Kunpeng Lu
- Tianjin Key Laboratory of Retinal Functions and Diseases, Tianjin Branch of National Clinical Research Center for Ocular Disease, Eye Institute and School of Optometry, Tianjin Medical University Eye Hospital, Tianjin, China
| | - Zhaochun Li
- Euclid China (Euclid Trading (Shanghai) Ltd.), Shanghai, China
| | - Xiaohua Zhuo
- Euclid China (Euclid Trading (Shanghai) Ltd.), Shanghai, China
| | - Ruihua Wei
- Tianjin Key Laboratory of Retinal Functions and Diseases, Tianjin Branch of National Clinical Research Center for Ocular Disease, Eye Institute and School of Optometry, Tianjin Medical University Eye Hospital, Tianjin, China
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Bai WL, Gan JH, Wei S, Li SM, An WZ, Liang XT, Tian JX, Yin L, Wang N. Effect of low-dose atropine eyedrops on pupil metrics: results after half a year of treatment and cessation. Graefes Arch Clin Exp Ophthalmol 2022; 261:1177-1186. [PMID: 36401652 PMCID: PMC9676878 DOI: 10.1007/s00417-022-05863-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Revised: 08/27/2022] [Accepted: 10/03/2022] [Indexed: 11/20/2022] Open
Abstract
Abstract
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.
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Zheng NN, Tan KW. The synergistic efficacy and safety of combined low-concentration atropine and orthokeratology for slowing the progression of myopia: A meta-analysis. Ophthalmic Physiol Opt 2022; 42:1214-1226. [PMID: 35919929 DOI: 10.1111/opo.13029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Revised: 06/24/2022] [Accepted: 06/24/2022] [Indexed: 12/01/2022]
Abstract
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.
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Affiliation(s)
| | - Kai-Wen Tan
- SuZhou Medical College of Soochow University, Suzhou, China
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