Atropine slows myopia progression more in Asian than white children by meta-analysis

Efficacy of repeated low-level red-light therapy in the prevention and control of myopia in children

OBJECTIVE

In this study, we aimed to determine how different factors influence the effectiveness of repeated low-level red-light (RLRL) therapy in preventing and treating myopia in children.

METHODS

Between June 2022 and April 2023, 336 children who visited our hospital due to myopia or significant decreases in hyperopia reserve were enrolled. The children were treated twice daily for three minutes with a head-mounted low-level red-light (single wavelength of 650 nm) therapeutic device. Each of the two treatment sessions was separated by at least four hours. The axial lengths and diopters of the children's eyes were compared before and three months after treatment, and the effects of gender, age, and baseline diopter on the efficacy of RLRL therapy were analyzed.

RESULTS

Following three months of treatment, the average axial length of the eyes decreased by 0.031 mm. The condition was better for the boys than for girls, but the difference was not statistically significant. As age increased (F = 8.112, P = 0.000) or as the absolute value of baseline myopia degree increased (F = 10.51, P = 0.000), axial lengths of the eyes tended to decrease. The spherical equivalent refraction (SER) of children decreased by an average of 0.012 ± 0.355D. The condition was better for the boys than for girls, but the difference was not statistically significant. SER increased in the direction of hyperopic drift as age increased (F = 2.48, P = 0.031), or as the absolute value of baseline myopia degrees increased (F = 6.835, P = 0.000). There were no obvious side effects following the treatment.

CONCLUSION

This study showed that RLRL therapy is a potential efficient, easily operable, and practically feasible method for the prevention and control of myopia.

Impact of Various Concentrations of Low-Dose Atropine on Pupillary Diameter and Accommodative Amplitude in Children with Myopia

Purpose: To assess over 2 weeks, the effect of 3 different low concentrations of atropine on pupillary diameter and accommodative amplitude in children with myopia. Methods: Fifty-eight children with myopia [spherical equivalent (SE) of -0.50 diopters (D) or worse, astigmatism of less than or equal to 2.00 D] were randomly allocated to 3 groups receiving 0.01%, 0.02%, or 0.03% atropine eye drops, once nightly for 2 weeks. The primary outcome was the change from baseline in pupillary diameter and accommodative amplitude with each of the concentrations. Results: Fifty-seven participants (114 eyes), aged between 6 and 12 years, completed the 2-week trial (mean age 9.3 ± 1.7 years and mean SE -3.53 ± 1.79 D). After 2 weeks of use, all the 3 concentrations were found to have a statistically significant effect on both the pupillary diameter and accommodative amplitude. Accommodative amplitude reduced by an average of 5.23 D, 9.28 D, and 9.32 D, and photopic pupil size increased by an average of 0.95 ± 1.05 mm, 1.65 ± 0.93 mm, and 2.16 ± 0.88 mm with 0.01%, 0.02%, and 0.03%, respectively. Of the eyes, a total of 5.3% and 5.9% of the eyes on 0.02% and 0.03% atropine had a mean residual accommodative amplitude of <5 D. The percentage of eyes having a pupillary dilation >3 mm were 4.8%, 10.5%, and 23.5% for 0.01%, 0.02%, and 0.03% atropine, respectively. Conclusions: Low-dose atropine had an effect on pupillary diameter and accommodative amplitude. With the highest concentration assessed, that is, 0.03% nearly 1 of 4 eyes had pupillary dilation of >3 mm. Clinical Trial Registration number: NCT03699423.

Low-dose atropine 0.01% for the treatment of childhood myopia: a pan-India multicentric retrospective study

OBJECTIVE

The objective of this study was to assess the efficacy of low-dose atropine 0.01% in controlling myopia progression among Indian children over a 2-year period.

METHODS

This retrospective study, conducted across 20 centres in India, monitored the progression of myopia over 2 years after initiating treatment with 0.01% atropine eye drops. This included children between 6 and 14 years with baseline myopia ranging from -0.5 D to -6 D, astigmatism≤-1.5 D, anisometropia ≤ -1 D and documented myopia progression of ≥0.5 D in the year prior to starting atropine. Subjects with any other ocular pathologies were excluded.

RESULTS

A total of 732 children were included in the data analysis. The mean age of the subjects was 9.3±2.7 years. The mean myopia progression at baseline (1 year before starting atropine) was -0.75±0.31 D. The rate of myopia progression was higher in younger subjects and those with higher baseline myopic error. After initiating atropine, myopia progression significantly decreased to -0.27±0.14 D at the end of the first year and -0.24±0.15 D at the end of the second year (p<0.001). Younger children (p<0.001) and higher baseline myopia (p<0.001) was associated with greater myopia progression and poor treatment response (p<0.001 for both).

CONCLUSION

Low-dose atropine (0.01%) effectively reduces myopia progression over 2 years in Indian children.

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].

Real-world outcomes of low-dose atropine therapy on myopia progression in an Australian cohort during the COVID-19 pandemic

BACKGROUND

To report the outcomes of low-dose atropine (0.01% and 0.05%) for preventing myopia progression in a real-world Australian cohort during the COVID-19 pandemic.

METHODS

Records of children presenting with myopia, from January 2016 to 2022, were retrospectively reviewed at a comprehensive ophthalmic practice. Children who discontinued treatment, ages >18, and cases with hereditary conditions were excluded. The rate of progression of myopia after treatment with atropine was compared with historical data to evaluate the effectiveness of the regime.

RESULTS

One hundred and one children (mean baseline spherical equivalent [SphE] [-3.70 +/- 2.09 D] and axial length [AL] [24.59 +/- 1.00 mm]) were analysed. The mean age of the children was 10.4 +/- 2.89 years and 61% were females. The average follow-up time was 17.9 +/- 12.5 months. The mean rate of progression of AL and SphE on 0.01% atropine eyedrops was 0.219 +/- 0.35 mm and - 0.250 +/- 0.86 D/year, respectively. 68.1% of the children treated with 0.01% atropine were mild progressors (<0.5 D change/year). Non-responders when commenced on a higher dose of atropine (0.05%) experienced a 93% (p = 0.012) and 30% reduction in SphE and AL growth rate, respectively. Family history, higher myopia or younger age at baseline and shorter duration of treatment were associated with steeper progression (p < 0.01). Both doses were well tolerated.

CONCLUSIONS

Low-dose atropine was shown to be beneficial in a real-world clinical setting, despite interruptions to follow-ups secondary to COVID-19 pandemic. A 0.05% dose of atropine may be effective in cases where 0.01% was ineffective.

Efficacy and safety of atropine in myopic children: A meta-analysis of randomized controlled trials

PURPOSE

To evaluate the safety and efficacy of atropine for childhood myopia and further explore the optimal concentration of atropine, so as to provide more reference for clinical application.

METHODS

PubMed, Embase, Cochrane Library and ClinicalTrials.gov were comprehensively searched for randomized controlled trials (RCTs) up to October 14, 2021. The efficacy outcomes were progression of spherical equivalent (SE) and axial length (AL). The safety outcomes included accommodation amplitude, pupil size and adverse effects. The meta-analysis was performed using Review Manager 5.3.

RESULTS

Eighteen RCTs involving 3002 eyes were included. The results showed that at 6-36 months of treatment, atropine was effective in slowing the progression of myopia in children. At 12 months, the WMD of SE and AL of low-dose atropine was 0.25 diopters (D) and 0.1 millimeter (mm), moderate-dose atropine was 0.44 D and 0.16mm, high-dose atropine was 1.21 D and 0.82mm, respectively, compared with the control group. Similarly, at 24 months, low-dose atropine was 0.22 D and 0.14mm, moderate-dose atropine was 0.60 D, high-dose atropine was 0.66 D and 0.24mm, respectively. Interestingly, we also found that there was no significant difference in the effects of low-dose atropine on accommodation amplitude and photopic pupil size compared with the control group, and the rate of photophobia, allergy, blurred vision and other side effects was similar between the low-dose atropine group and the control group. In addition, atropine appears to be more effective in myopic children in China than in other countries.

CONCLUSIONS

Atropine in various concentrations can effectively slow myopia progression in children, and its effect is dose-dependent, while low-dose atropine (0.01% atropine) appears to be safer.

Comparison of the efficacy and safety of different doses of atropine for myopic control in children: a meta-analysis

Purpose: To comprehensively reassess the efficacy and safety of different concentrations of atropine for retarding myopia progression and seek the most appropriate therapeutic concentration for clinical practice. Methods: We searched PubMed, Cochrane Library, Embase, Chinese Science and Technology Periodicals (VIP) and China National Knowledege Infrastructure (CNKI) from their inception to 23 March 2023, to obtain eligible randomized controlled trials (RCTs) and cohort studies that had atropine in at least one treatment arm and placebo/no intervention in another arm. We evaluated the risk of bias of the RCTs according to the recommendations of the Cochrane Collaboration for RCTs and quality of cohort studies by the Newcastle‒Ottawa Scale. Weighted mean difference (WMD), 95% confidence interval were calculated for meta-analysis. All data analyses were performed using Review Manager 5.3, STATA 12.0 and SPSS 26.0 software. Results: A total of 44 studies were included in the meta-analysis. Weighted mean difference (WMD) were 0.73 diopters (D), 0.65 D, 0.35 D per year in refraction progression (χ 2 = 14.63, I 2 = 86.3%; p < 0.001) and -0.26 mm, -0.37 mm, -0.11 mm per year in axial length progression (χ 2 = 5.80, I 2 = 65.5%; p = 0.06) for high (0.5%-1%), moderate (0.1%-0.25%), and low (0.005%-0.05%) dose atropine groups, respectively. Logarithmic dose‒response correlations were found between atropine and their effect on change of refraction, axial length, accommodation and photopic pupil diameter. Through these curves, we found that atropine with concentrations ≤0.05% atropine resulted in a residual value of accommodation of more than 5 D and an increase in pupil diameter no more than 3 mm. Higher doses of atropine resulted in a higher incidence of adverse effects, of which the incidence of photophobia was dose-dependent (r = 0.477, p = 0.029). Conclusion: Both the efficacy and risk of adverse events for atropine treatment of myopia were mostly dose dependent. Comprehensively considered the myopia control effect and safety of each dose, 0.05% may be the best concentration of atropine to control myopia progression at present, at which myopia is better controlled and the side effects are tolerable. Systematic Review Registration: https://www.crd.york.ac.uk/PROSPERO/#recordDetails, CRD42022377705.

Prevention and management of childhood progressive myopia: National consensus guidelines

Myopia is a major public health problem worldwide, including India, with the global prevalence of myopia increasing rapidly over decades. The clinical and socioeconomic impact of myopia is also expected to rise with rising prevalence. Therefore, the focus has now been shifted to prevent the incidence and progression of myopia. However, there is lack of any standardized guidelines for myopia management. This document aims to generate a national-level expert consensus statement on the management of childhood myopia in the Indian scenario. The expert panel of pediatric ophthalmologists consisted of 63 members who met in a hybrid meeting. A list of topics deliberating discussion in the meeting was provided to the experts in advance and they were instructed to provide their opinions on the matter during the meet. The panel of experts then gave their views on each of the items presented, deliberated on different aspects of childhood myopia, and reached a consensus regarding the practice patterns in the Indian scenario. In case of opposing views or lack of a clear consensus, we undertook further discussion and evaluated literature to help arrive at a consensus. A written document is prepared based on recommendations explaining definition of myopia, refraction techniques, components and methods of workup, initiation of anti-myopia treatment, type and timing of interventions, follow-up schedule, and indications for revised or combination treatment. This article formulates evidence-based guidelines for progressing myopes and pre-myopes and also establishes uniformity in the management of childhood myopia in the country.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Effect of Atropine 0.01% Eye Drops on the Difference in Refraction and Axial Length between Right and Left Eyes

INTRODUCTION

This study sought to determine whether the application of 0.01% atropine eye drops could impact the disparity in refraction and axial length (AL) between the right and left eyes in Chinese children.

METHODS

The study was designed as a double-blind, placebo-controlled randomized trial. A total of 220 children aged 6-12 years were recruited from the Beijing Tongren Hospital in Beijing, China. Participants were randomized in a 1:1 ratio and were prescribed 0.01% atropine or placebo eye drops to be administered once a night to both eyes for the duration of 1 year. The cycloplegic refraction and AL were recorded including baseline, 6 months, and again at the 12 months.

RESULTS

After 1-year follow-up period, 76 (69%) and 83 (75%) subjects of the initial 220 participants were identified as the 0.01% atropine and placebo groups, respectively. The inter-ocular difference in spherical equivalent refraction (SER) and AL demonstrated stable values in the 0.01% atropine treatment group (SER: p = 0.590; AL: p = 0.322) analyzed after 1 year, but found a significant increase (SER: p < 0.001; AL: p = 0.001) in the placebo group. Furthermore, over 1 year, eyes with greater myopia in the atropine group exhibited slower myopia progression (0.45 ± 0.44 D) than the lesser myopic eye (0.56 ± 0.44 D) (p = 0.003).

CONCLUSION

This study demonstrated that 0.01% atropine could maintain the inter-ocular SER and AL difference. And 0.01% atropine appeared to be more effective in delaying the progression of myopia in eyes with more myopia than in the less myopic eyes.

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

Purpose

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

Results

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

Conclusion

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

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.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Efficacy of 0.01% low dose atropine and its correlation with various factors in myopia control in the Indian population

We aimed to evaluate the efficacy and safety of low-dose atropine compared to placebo in the Indian population and also to study the impact of various modifiable and non-modifiable factors on myopia progression (MP) and drug efficacy (DE). It was a single-centre prospective placebo-controlled interventional study. 43 participants aged 6–16 years with progressive myopia received 0.01% atropine in the right eyes (treatment) and placebo in the left eyes (control) for 1-year. The main outcome measures were annual MP and axial length elongation (ALE) in treatment and control eyes and their percentage difference between two eyes (drug efficacy). Secondary outcome measures were the occurrence of any adverse events and the correlation of MP, ALE, and DE with various factors. 40 participants (80 eyes) completed the follow-up. After 1-year, MP was 0.25 D (IQR 0.13–0.44) and 0.69 D (IQR 0.50–1.0) (p < 0.001) in treatment and control respectively (63.89% reduction) with respective ALE of 0.14 mm (IQR 0.05–0.35) and 0.32 mm (IQR 0.19–0.46) (p < 0.001) (44.44% reduction). No adverse events were noted. Reduction in MP and ALE was statistically significant in all children irrespective of age-group, baseline MP, family history, screen-time, near and outdoor-time. The strongest determinants of annual MP were age (Treatment: r = − 0.418, p = 0.007; Control: r = − 0.452, p = 0.003) and baseline MP (Treatment: r = 0.64, p = 0.000; Control: r = 0.79, p = 0.000). Screen-time in control eyes was associated with greater ALE (r = 0.620, p = 0.042). DE was higher when outdoor time exceeded 2 h/day (p = 0.035) while the efficacy was lower with prolonged near activities (p = 0.03), baseline fast-progressors (p < 0.05) and history of parental myopia (p < 0.05). 0.01% atropine is effective and safe in retarding MP and ALE in Indian eyes.

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.

Effect of Violet Light-Transmitting Eyeglasses on Axial Elongation in Myopic Children: A Randomized Controlled Trial

The fact that outdoor light environment is an important suppressive factor against myopia led us to invent violet light-transmitting eyeglasses (VL glasses) which can transmit violet light (VL), 360-400 nm in wavelength, for the suppression of myopia, and can meanwhile block harmful ultraviolet waves from sunlight. The current study is a double-blinded randomized clinical trial to investigate the myopia-suppressive effect of VL glasses compared to conventional eyeglasses (placebo glasses) that do not transmit VL. The subjects were children aged from 6 to 12 years old, the population in which myopia progression is generally accelerated, and the myopia suppressive effect was followed up for two years in a city in Japan. Periodical ophthalmic examinations, interviews, and measurements of reflection and axial length under mydriasis were performed at the initial visit (the baseline) and at 1, 6, 12, 18, and 24 months. The mean change in axial length in the VL glasses group was significantly smaller than in the placebo glasses group when time for near-work was less than 180 min and when the subjects were limited to those who had never used eyeglasses before this trial (p < 0.01); however, this change was not significant without subgrouping. The suppressive rate for axial elongation in the VL glasses group was 21.4% for two years.

Safety and efficacy of 0.02% and 0.01% atropine on controlling myopia progression: a 2-year clinical trial

Four hundred myopic children randomly received atropine 0.02% (n = 138) or 0.01% (n = 142) in both eyes once-nightly or only wore single-vision spectacles (control group) (n = 120) for 2 years. Spherical equivalent refractive error (SER), axial length (AL), pupil diameter (PD), and amplitude of accommodation (AMP) were measured every 4 months. After 2 years, the SER changes were - 0.80 (0.52) D, - 0.93 (0.59) D and - 1.33 (0.72) D and the AL changes were 0.62 (0.29) mm, 0.72 (0.31) mm and 0.88 (0.35) mm in the 0.02% and 0.01% atropine groups and control group, respectively. There were significant differences between changes in SER and AL in the three groups (all P < 0.001). The changes in SER and AL in the 2nd year were similar to the changes in the 1st year in the three groups (all P > 0.05). From baseline to 2 years, the overall decrease in AMP and increase in PD were not significantly different in the two atropine groups, whereas the AMP and PD in the control group remained stable (all P > 0.05). 0.02% atropine had a better effect on myopia control than 0.01% atropine, and its effects on PD and AMP were similar to 0.01% atropine. 0.02% or 0.01% atropine controlled myopia progression and AL elongation synchronously and had similar effects on myopia control each year.

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.

Prevention of Choroidal Thinning by 0.01% Atropine Administered 24 h Before Exposure to Hyperopic Blur in Young Myopes

Purpose: To evaluate the persistence of atropine's effect upon choroidal thickness and ocular biometrics and its interaction with hyperopic blur in a population of young adult myopes. Methods: Twenty young (aged 18-35 years) myopic participants with spherical equivalent refractive error of -0.75 to -6.00 D (mean ± SD -2.85 ± 1.64 D) had subfoveal choroidal thickness (SFCT) measurements derived from scans collected from the right eye only with a SD-OCT instrument (Copernicus SOCT-HR) before, as well as 60 min following the introduction of 3 testing conditions: (1) placebo/hyperopic (-3 D) blur, (2) placebo/hyperopic blur one day after administration of 0.01% atropine, and (3) placebo/no blur. Each combination of blur and pharmacological agent was tested on a separate day at approximately the same time of day between 9 am and 2 pm. Results: Repeated measures ANOVA revealed that hyperopic blur and placebo were associated with a decrease in choroidal thickness (mean change: -10.7 ± 2.7 μm, P < 0.001 after 60 min), whereas administration of 0.01% atropine one day before the introduction of hyperopic blur prevented the thinning of the choroid (mean change of +1.1 ± 3.7 μm after 60 min) compared to baseline (both, P > 0.05). There was also no significant difference between the baseline choroidal thickness measurements for any of the conditions tested. Conclusion: Low dose atropine can inhibit signals associated with hyperopic defocus that cause thinning of the choroid for at least 24 h after initial instillation.

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.

Safety and Efficacy of Low-Dose Atropine Eyedrops for the Treatment of Myopia Progression in Chinese Children: A Randomized Clinical Trial

Importance

Because studies have suggested that atropine might slow the progression of myopia in children, randomized clinical trials are warranted to understand this potential causal relationship.

Objective

To evaluate the efficacy and safety of atropine, 0.01%, eyedrops on slowing myopia progression and axial elongation in Chinese children.

Design, Setting, and Participants

This was a randomized, placebo-controlled, double-masked study. A total of 220 children aged 6 to 12 years with myopia of -1.00 D to -6.00 D in both eyes were enrolled between April 2018 and July 2018 at Beijing Tongren Hospital, Beijing, China. Cycloplegic refraction and axial length were measured at baseline, 6 months, and 12 months. Adverse events were also recorded.

Interventions

Patients were randomly assigned in a 1:1 ratio to atropine, 0.01%, or placebo groups to be administered once nightly to both eyes for 1 year.

Main Outcomes and Measures

Mean changes and percentage differences in myopia progression and axial elongation between atropine, 0.01%, or placebo groups.

Results

Of 220 participants, 103 were girls (46.8%), and the mean (SD) age was 9.64 (1.68) years. The mean (SD) baseline refractive error and axial length were -2.58 (1.39) D and 24.59 (0.87) mm. Follow-up at 1 year included 76 children (69%) and 83 children (75%) allocated into the atropine, 0.01%, and placebo groups, respectively, when mean myopia progression was -0.49 (0.42) D and -0.76 (0.50) D in the atropine, 0.01%, and placebo groups (mean difference, 0.26 D; 95% CI, 0.12-0.41 D; P < .001), with a relative reduction of 34.2% in myopia progression. The mean (SD) axial elongation in the atropine, 0.01%, group was 0.32 (0.19) mm compared with 0.41 (0.19) mm in the placebo group (mean difference, 0.09 mm; 95% CI, 0.03-0.15 mm; P = .004), with relative reduction of 22.0% in axial elongation. Fifty-one percent and 13.2% of children progressed by at least 0.50 D and 1.00 D in the atropine, 0.01%, group, compared with 69.9% and 34.9% in the placebo group. No serious adverse events related to atropine were reported.

Conclusions and Relevance

While the clinical relevance of the results cannot be determined from this trial, these 1-year results, limited by approximately 70% follow-up, suggest that atropine, 0.01%, eyedrops can slow myopia progression and axial elongation in children and warrant future studies to determine longer-term results and potential effects on slowing sight-threatening pathologic changes later in life.

Trial Registration

http://www.chictr.org.cn Identifier: ChiCTR-IOR-17013898.

The Efficacy of Atropine Combined With Orthokeratology in Slowing Axial Elongation of Myopia Children: A Meta-Analysis

OBJECTIVES

Previous studies have found that atropine can slow axial elongation and control the progression of myopia. Some ongoing trials have applied atropine combined with orthokeratology for myopia control, but few studies explored the effect of the strategy on axial elongation. This meta-analysis made a preliminary evaluation of the effect of atropine combined with orthokeratology on axial elongation to provide a reference for further researches.

METHODS

We performed a specific search on PubMed, EMBASE, Cochrane library, Web of Science, Ovid and Chinese electronic databases of VIP and Wanfang for randomized controlled trials, cohort studies and case-control studies conducted up to December 2019. The weighted mean difference (WMD) of mean change in axial elongation between the combination group of atropine and orthokeratology and the orthokeratology group was used for evaluation. Publication bias was detected using the Funnel plots test.

RESULTS

A total of five studies involving 341 participants younger than 18 years old met our inclusion criteria. The axial elongation was lower in the combination group of atropine and orthokeratology than that of the orthokeratology group (0.25 vs. 0.35; WMD=-0.09 mm, [95% confidence intervals, -0.15 to -0.04], Z=3.39, P=0.0007).

CONCLUSIONS

This meta-analysis demonstrates atropine combined with orthokeratology is effective in slowing axial elongation in myopia children. This effect may be superior to that of the orthokeratology alone.

Under-correction or full correction of myopia? A meta-analysis

PURPOSE

To compare the effect of full-correction versus under-correction on myopia progression.

METHODS

A literature search was performed in PubMed, Scopus, Science Direct, Ovid, Web of Science and Cochrane library. Methodological quality assessment of the literature was evaluated according to the Critical Appraisal Skills Program. Statistical analysis was performed using Comprehensive Meta-Analysis (version 2, Biostat Inc., USA).

RESULTS

The present meta-analysis included six studies (two randomized controlled trials [RCTs] and four non-RCTs) with 695 subjects (full-correction group, n=371; under-correction group, n=324) aged 6 to 33 years. Using cycloplegic refraction, the pooled difference in mean of myopia progression was - 0.179 D [lower and higher limits: -0.383, 0.025], which was higher but not in full correction group as compared to under correction group (p=0.085). Regarding studies using non-cycloplegic subjective refraction according to maximum plus for maximum visual acuity, the pooled difference in myopia progression was 0.128 D [lower and higher limits: -0.057, 0.312] higher in under-correction group compared with full-correction group (p=0.175). Although, difference in myopia progression did not reach significant level in either cycloplegic or non-cycloplegic refraction.

CONCLUSIONS

Our findings suggest that, myopic eyes which are fully corrected with non-cycloplegic refraction with maximum plus sphere, are less prone to myopia progression, in comparison to those which were under corrected. However, regarding cycloplegic refraction, further studies are needed to better understand these trends.

Wavefront excimer laser refractive surgery for adults with refractive errors

BACKGROUND

Refractive errors (conditions in which the eye fails to focus objects accurately on the retina due to defects in the refractive system), are the most common cause of visual impairment. Myopia, hyperopia, and astigmatism are low-order aberrations, usually corrected with spectacles, contact lenses, or conventional refractive surgery. Higher-order aberrations (HOAs) can be quantified with wavefront aberration instruments and corrected using wavefront-guided or wavefront-optimized laser surgery. Wavefront-guided ablations are based on preoperative measurements of HOAs; wavefront-optimized ablations are designed to minimize induction of new HOAs while preserving naturally occurring aberrations. Two wavefront procedures are expected to produce better visual acuity than conventional procedures.

OBJECTIVES

The primary objective was to compare effectiveness and safety of wavefront procedures, laser-assisted in-situ keratomileusis (LASIK) or photorefractive keratectomy (PRK) or laser epithelial keratomileusis (LASEK) versus corresponding conventional procedures, for correcting refractive errors in adults for postoperative uncorrected visual acuity, residual refractive errors, and residual HOAs. The secondary objective was to compare two wavefront procedures.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL, which contains the Cochrane Eyes and Vision Trials Register; 2019, Issue 8); Ovid MEDLINE; Ovid Embase; Latin American and Caribbean Health Sciences (LILACS); the ISRCTN registry; ClinicalTrials.gov and the WHO ICTRP. The date of the search was 6 August 2019. We imposed no restrictions by language or year of publication. We used the Science Citation Index (September 2013) and searched the reference lists of included trials to identify additional relevant trials.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) comparing either wavefront modified with conventional refractive surgery or wavefront-optimized with wavefront-guided refractive surgery in participants aged ⪰ 18 years with refractive errors.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methodology.

MAIN RESULTS

We identified 33 RCTs conducted in Asia, Europe and United States, totaling 1499 participants (2797 eyes). Participants had refractive errors ranging from high myopia to low hyperopia. Studies reported at least one of the following review-specific outcomes based on proportions of eyes: with uncorrected visual acuity (UCVA) of 20/20 or better, without loss of one or more lines of best spectacle-corrected visual acuity (BSCVA), within ± 0.50 diopters (D) of target refraction, with HOAs and adverse events. Study characteristics and risk of bias Participants were mostly women, mean age 29 and 53 years, and without previous refractive surgery, ocular pathology or systemic comorbidity. We could not judge risks of bias for most domains of most studies. Most studies in which both eyes of a participant were analyzed failed to account for correlations between two eyes in the analysis and reporting of outcomes. Findings For the primary comparison between wavefront (PRK or LASIK or LASEK) and corresponding conventional procedures, 12-month outcome data were available from only one study of PRK with 70 participants. No evidence of more favorable outcomes of wavefront PRK on proportion of eyes: with UCVA of 20/20 or better (risk ratio [RR] 1.03, 95% confidence interval (CI) 0.86 to 1.24); without loss of one or more lines of BSCVA (RR 0.94, 95% CI 0.81 to 1.09); within ± 0.5 D of target refraction (RR 1.03, 95% CI 0.86 to 1.24); and mean spherical equivalent (mean difference [MD] 0.04, 95% CI -0.11 to 0.18). The evidence for each effect estimate was of low certainty. No study reported HOAs at 12 months. At six months, the findings of two to eight studies showed that overall effect estimates and estimates by subgroup of PRK or LASIK or LASEK were consistent with those for PRK at 12 month, and suggest no difference in all outcomes. The certainty of evidence for each outcome was low. For the comparison between wavefront-optimized and wavefront-guided procedures at 12 months, the overall effect estimates for proportion of eyes: with UCVA of 20/20 or better (RR 1.00, 95% CI 0.99 to 1.02; 5 studies, 618 participants); without loss of one or more lines of BSCVA (RR 0.99, 95% CI 0.96 to 1.02; I2 = 0%; 5 studies, 622 participants); within ± 0.5 diopters of target refraction (RR 1.02, 95% CI 0.95 to 1.09; I2 = 33%; 4 studies, 480 participants) and mean HOAs (MD 0.03, 95% CI -0.01 to 0.07; I2 = 41%; 5 studies, 622 participants) showed no evidence of a difference between the two groups. Owing to substantial heterogeneity, we did not calculate an overall effect estimate for mean spherical equivalent at 12 months, but point estimates consistently suggested no difference between wavefront-optimized PRK versus wavefront-guided PRK. However, wavefront-optimized LASIK compared with wavefront-guided LASIK may improve mean spherical equivalent (MD -0.14 D, 95% CI -0.19 to -0.09; 4 studies, 472 participants). All effect estimates were of low certainty of evidence. At six months, the results were consistent with those at 12 months based on two to six studies. The findings suggest no difference between two wavefront procedures for any of the outcomes assessed, except for the subgroup of wavefront-optimized LASIK which showed probable improvement in mean spherical equivalent (MD -0.12 D, 95% CI -0.19 to -0.05; I2 = 0%; 3 studies, 280 participants; low certainty of evidence) relative to wavefront-guided LASIK. We found a single study comparing wavefront-guided LASIK versus wavefront-guided PRK at six and 12 months. At both time points, effect estimates consistently supported no difference between two procedures. The certain of evidence was very low for all estimates. Adverse events Significant visual loss or optical side effects that were reported were similar between groups.

AUTHORS' CONCLUSIONS

This review suggests that at 12 months and six months postoperatively, there was no important difference between wavefront versus conventional refractive surgery or between wavefront-optimized versus wavefront-guided surgery in the clinical outcomes analyzed. The low certainty of the cumulative evidence reported to date suggests that further randomized comparisons of these surgical approaches would provide more precise estimates of effects but are unlikely to modify our conclusions. Future trials may elect to focus on participant-reported outcomes such as satisfaction with vision before and after surgery and effects of remaining visual aberrations, in addition to contrast sensitivity and clinical outcomes analyzed in this review.

Myopia

Myopia, also known as short-sightedness or near-sightedness, is a very common condition that typically starts in childhood. Severe forms of myopia (pathologic myopia) are associated with a risk of other associated ophthalmic problems. This disorder affects all populations and is reaching epidemic proportions in East Asia, although there are differences in prevalence between countries. Myopia is caused by both environmental and genetic risk factors. A range of myopia management and control strategies are available that can treat this condition, but it is clear that understanding the factors involved in delaying myopia onset and slowing its progression will be key to reducing the rapid rise in its global prevalence. To achieve this goal, improved data collection using wearable technology, in combination with collection and assessment of data on demographic, genetic and environmental risk factors and with artificial intelligence are needed. Improved public health strategies focusing on early detection or prevention combined with additional effective therapeutic interventions to limit myopia progression are also needed.

The Combined Effect of Low-dose Atropine with Orthokeratology in Pediatric Myopia Control: Review of the Current Treatment Status for Myopia

Pediatric myopia has become a major international public health concern. The prevalence of myopia has undergone a significant increase worldwide. The purpose of this review of the current literature was to evaluate the peer-reviewed scientific literature on the efficacy and safety of low-dose atropine treatment combined with overnight orthokeratology for myopia control. A search was conducted in Pubmed and Web of Science with the following search strategy: (atropine OR low-dose atropine OR 0.01% atropine) AND (orthokeratology OR ortho-k) AND (myopia control OR myopia progression). All included studies improved myopia control by the synergistic effect of orthokeratology with low-dose atropine, compared with orthokeratology treatment alone. All studies included a short or medium follow-up period; therefore longer-term studies are necessary to validate these results.

Western Australia Atropine for the Treatment of Myopia (WA-ATOM) study: Rationale, methodology and participant baseline characteristics

IMPORTANCE

Atropine eyedrops are a promising treatment for slowing myopia progression in East Asian children. However, its effects on children in Australia, including those of non-Asian background, have not been well-studied.

BACKGROUND

The Western Australia Atropine for the Treatment of Myopia (WA-ATOM) study aims to determine the efficacy and long-term effects of low-dose atropine eyedrops in myopia control. This paper describes the study rationale, methodology and participant baseline characteristics.

DESIGN

Single-centre, double-masked, randomized controlled trial.

PARTICIPANTS

Children (6-16 years) with spherical equivalent ≤-1.50 D in each eye, astigmatism ≤1.50 D and myopia progression by ≥0.50 D/year.

METHODS

Enrolled children were randomly assigned 2:1 to receive 0.01% atropine or placebo eyedrops. Participants are examined every 6 months during first 3 years of the study (2-year treatment phase followed by a 1-year washout phase), and then at a 5-year follow-up (2 years after the end of the washout phase).

MAIN OUTCOME MEASURES

Annual progression rate of myopia and axial length, tolerability to eyedrops and incidence and severity of unwanted effects.

RESULTS

Out of 311 children who were referred, 242 were suitable for study participation, and 153 were subsequently enrolled. The baseline characteristics of enrolled participants are presented.

CONCLUSIONS AND RELEVANCE

Outcomes of the WA-ATOM study will inform on the efficacy, tolerability, safety and long-term effects of low-dose atropine eyedrops in myopia control in Australian children. The impact of ocular sun exposure, iris colour and parental myopia on the efficacy of low-dose atropine will also be assessed.

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.

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.

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.

[Treatment options for progressive myopia in childhood]

The incidence of myopia is increasing worldwide. The associated increase in secondary and vision-threatening eye diseases will pose major challenges to patients, ophthalmologists, optometrists, opticians and healthcare systems. Since myopia begins in childhood and adolescence, progression can only be influenced in this phase of life. This article gives an overview of optical and pharmacological treatment options, which show average effect sizes of up to 50% progression reduction with a comparatively favorable side effect profile.

Efficacy and safety of interventions to control myopia progression in children: an overview of systematic reviews and meta-analyses

Background

Myopia is a common visual disorder with increasing prevalence. Halting progression of myopia is critical, as high myopia can be complicated by a number of vision-compromising conditions.

Methods

Literature search was conducted in the following databases: Medical Literature Analysis and Retrieval System Online (MEDLINE), Excerpta Medica dataBASE (EMBASE), Cochrane Database of Systematic Reviews (CDSR), Database of Abstracts of Reviews of Effects (DARE) and Centre for Reviews and Dissemination (CRD) Health Technology Assessment (HTA) database. Systematic reviews and meta-analyses investigating the efficacy and safety of multiple myopia interventions vs control conditions, were considered. Methodological quality and quality of evidence of eligible studies were assessed using the ROBIS tool and GRADE rating. The degree of overlapping of index publications in the eligible reviews was calculated with the corrected covered area (CCA).

Results

Forty-four unique primary studies contained in 18 eligible reviews and involving 6400 children were included in the analysis. CCA was estimated as 6.2% and thus considered moderate. Results demonstrated the superior efficacy of atropine eyedrops; 1% atropine vs placebo (change in refraction: -0.78D, [− 1.30 to − 0.25] in 1 year), 0.025 to 0.05% atropine vs control (change in refraction: -0.51D, [− 0.60 to − 0.41] in 1 year), 0.01% atropine vs control (change in refraction: -0.50D, [− 0.76 to − 0.24] in 1 year). Atropine was followed by orthokeratology (axial elongation: − 0.19 mm, [− 0.21 to − 0.16] in 1 year) and novel multifocal soft contact lenses (change in refraction: -0.15D, [− 0.27 to − 0.03] in 1 year). As regards adverse events, 1% atropine induced blurred near vision (odds ratio [OR] 9.47, [1.17 to 76.78]) and hypersensitivity reactions (OR 8.91, [1.04 to 76.03]).

Conclusions

Existing evidence has failed to convince doctors to uniformly embrace treatments for myopic progression control, possibly due to existence of some heterogeneity, reporting of side effects and lack of long-term follow-up. Research geared towards efficient interventions is still necessary.

Electronic supplementary material

The online version of this article (10.1186/s12886-019-1112-3) contains supplementary material, which is available to authorized users.

The penetration and distribution of topical atropine in animal ocular tissues

PURPOSE

To conduct a multi-tissue investigation on the penetration and distribution of topical atropine in myopia treatment, and determine if atropine is detectable in the untreated contralateral eye after uniocular instillation.

METHODS

Nine mature New Zealand white rabbits were evenly divided into three groups. Each group was killed at 5, 24 and 72 hr, respectively, following uniocular instillation of 0.05 ml of 1% atropine. Tissues were sampled after enucleation: conjunctiva, sclera, cornea, iris, ciliary body, lens, retina, aqueous, and vitreous humors. The assay for atropine was performed using liquid chromatography-mass spectrometry (LC-MS), and molecular tissue distribution was illustrated using matrix-assisted laser desorption ionization-imaging mass spectrometry (MALDI-IMS) via an independent experiment on murine eyes.

RESULTS

At 5 hr, the highest (mean ± SEM) concentration of atropine was detected in the conjunctiva (19.05 ± 5.57 ng/mg, p < 0.05) with a concentration gradient established anteriorly to posteriorly, as supported by MALDI-IMS. At 24 hr, preferential binding of atropine to posterior ocular tissues occurred, demonstrating a reversal of the initial concentration gradient. Atropine has good ocular bioavailability with concentrations of two magnitudes higher than its binding affinity in most tissues at 3 days. Crossing-over of atropine to the untreated eye occurred within 5 hr post-administration.

CONCLUSION

Both transcorneal and transconjunctival-scleral routes are key in atropine absorption. Posterior ocular tissues could be important sites of action by atropine in myopic reduction. In uniocular atropine trials, cross-over effects on the placebo eye should be adjusted to enhance results reliability. Combining the use of LC-MS and MALDI-IMS can be a viable approach in the study of the ocular pharmacokinetics of atropine.

Retardation of Myopia Progression by Multifocal Soft Contact Lenses

Myopia is an important public health problem due to its prevalence and significant public health cost. Elevating levels of myopia increase the risk of vision impairment, and therefore, high myopia has become one of the main causes of untreatable vision loss throughout the world due to its irreversible complications. At present, many options for slowing progression of myopia have already been proposed and evaluated such as progressive addition of executive bifocal spectacle lenses, peripheral defocusing lenses, overnight orthokeratology, pharmacological agents such as atropine eye drops, and multifocal soft contact lenses (MFSCLs). Use of MFSCLs has especially increased in recent years due to the growing demand to slow myopia progression during patient's adolescent growth period to avoid pathological myopia in adulthood. Compared with the other traditional methods of controlling myopia, MFSCLs allow myopic patients to better maintain their clear visual quality and slow myopia progression. In this manuscript, we aim to review the basics of myopia, recent advances in contact lenses to control myopia with emphasis on MFSCLs, define the elements for proper MFSCL fittings (such as pupil size, aberrations, accommodation and centering), discuss the potential rebound effect after discontinuation of contact lenses, and future directions for improvements of contact lenses for the control of myopia.

Preventing Myopia

BACKGROUND

Nearsightedness (myopia) has become more common around the world recently, mainly because of changes in visual, educational, and recreational behavior. The question arises how the risk of myopia and its progression can be reduced. This would lessen the prevalence and severity of myopia and also lower the risk of secondary diseases that impair visual acuity.

METHODS

The PubMed/Medline database was selectively searched for pertinent literature.

RESULTS

The risk of myopia is lowered by exposure to daylight and increased by activities performed at short visual distances (close-up work). A person with little exposure to daylight has a fivefold risk of developing myopia, which can rise as high as a 16-fold risk if that person also performs close-up work. Two meta-analyses and a large randomized clinical trial from Asia have shown that the progression of myopia over two years of observation can be lessened by up to 0.71 diopters by the administration of atropine eye drops in a concentration that has practically no serious side effects. At higher doses, myopia progresses more severely than in the placebo group after the cessation of therapy. This is an off-label treatment. A weaker effect on progression has been shown for multifocal optical corrections that include both a distance correction and a correction for near vision.

CONCLUSION

Effective pharmacological and optical measures are now available to lessen the progression of myopia. The increasing prevalence of myopia should motivate pediatricians, parents, and schools to pay attention to risk factors such as close-up work and lack of daylight exposure, particularly in view of the increased use of digital media.

Efficacy of Trial Fitting and Software Fitting for Orthokeratology Lens: One-Year Follow-Up Study

OBJECTIVE

To observe and compare the clinical efficacy of 1-year trial fitting and software fitting orthokeratology lenses.

METHODS

One hundred myopes who received vision correction with the use of orthokeratology lenses form July 2016 to September 2017 were included in this study. Subjects were assigned randomly into the two groups: the trial fitting group (group A) and the software fitting group (group B). For the right eye of each subject, measurements, such as uncorrected visual acuity (UCVA, logarithm of minimal angle of resolution), refractive error, corneal topography, ocular health status, and the fitting situation, were obtained at baseline, 1 week, 1 month, 3 months, 6 months, and 12 months after lens wear. Axial length and corneal endothelium cells (CECs) were also measured at baseline and 12 months after wearing the lens.

RESULTS

Compared with the baseline, the spherical equivalent refraction, UCVA, and central corneal curvature changed significantly after orthokeratology (OK) lens wear (all P<0.05). Between groups A and B, the parameters aforementioned were insignificant at each time point (all P>0.05). Axial length and CECs showed no significant changes during the first year of OK treatment (all P>0.05). Rate of corneal staining between two groups revealed no difference during 1-year visit (P<0.05).

CONCLUSION

Both the trial lens fitting and software fitting approaches were effective in temporarily reducing myopia, providing good UCVA and delaying the elongation of axial length for moderate and high myopic adolescents. Both the two approaches can be combined in OK lens fitting.

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.

Optical and pharmacological strategies of myopia control

Recent increases in global myopia prevalence rates have raised significant concerns as myopia increases the lifelong risk of various sight-threatening ocular conditions. This growing public health burden has generated significant research interests into understanding both its aetiology and developing effective methods to slow down or stop its development, methods collectively termed 'myopia control'. The growing body of research has demonstrated benefits of various optical and pharmacological treatments resulting in myopia control management increasingly becoming a part of main stream clinical practice. This review will discuss the peer-reviewed literature on the efficacy of various myopia control interventions including multifocal spectacles and contact lenses, orthokeratology and pharmaceutical eye drops, as well as potential future research directions.

The quality of systematic reviews about interventions for refractive error can be improved: a review of systematic reviews

BACKGROUND

Systematic reviews should inform American Academy of Ophthalmology (AAO) Preferred Practice Pattern® (PPP) guidelines. The quality of systematic reviews related to the forthcoming Preferred Practice Pattern® guideline (PPP) Refractive Errors & Refractive Surgery is unknown. We sought to identify reliable systematic reviews to assist the AAO Refractive Errors & Refractive Surgery PPP.

METHODS

Systematic reviews were eligible if they evaluated the effectiveness or safety of interventions included in the 2012 PPP Refractive Errors & Refractive Surgery. To identify potentially eligible systematic reviews, we searched the Cochrane Eyes and Vision United States Satellite database of systematic reviews. Two authors identified eligible reviews and abstracted information about the characteristics and quality of the reviews independently using the Systematic Review Data Repository. We classified systematic reviews as "reliable" when they (1) defined criteria for the selection of studies, (2) conducted comprehensive literature searches for eligible studies, (3) assessed the methodological quality (risk of bias) of the included studies, (4) used appropriate methods for meta-analyses (which we assessed only when meta-analyses were reported), (5) presented conclusions that were supported by the evidence provided in the review.

RESULTS

We identified 124 systematic reviews related to refractive error; 39 met our eligibility criteria, of which we classified 11 to be reliable. Systematic reviews classified as unreliable did not define the criteria for selecting studies (5; 13%), did not assess methodological rigor (10; 26%), did not conduct comprehensive searches (17; 44%), or used inappropriate quantitative methods (3; 8%). The 11 reliable reviews were published between 2002 and 2016. They included 0 to 23 studies (median = 9) and analyzed 0 to 4696 participants (median = 666). Seven reliable reviews (64%) assessed surgical interventions.

CONCLUSIONS

Most systematic reviews of interventions for refractive error are low methodological quality. Following widely accepted guidance, such as Cochrane or Institute of Medicine standards for conducting systematic reviews, would contribute to improved patient care and inform future research.

Insight into high myopia and the macula

The incidence of myopia is constantly on the rise. Patients of high myopia and pathological myopia are young and can lose vision due to a number of degenerative changes occurring at the macula. With the emergence of new technologies such as swept-source optical coherence tomography (OCT) and OCT angiography, our understanding of macular pathology in myopia has improved significantly. New conditions such as myopic traction maculopathy have been defined. Early, noninvasive detection of myopic choroidal neovascularization and its differentiation from lacquer cracks is possible with a greater degree of certainty. We discuss the impact of these new exciting and promising technologies and management of macular pathology in myopia. Incorporation of OCT in the microscope has also improved macular surgery. New concepts such as fovea-sparing internal limiting membrane peeling have emerged. A review of literature and our experience in managing all these conditions are discussed.

Efficacy and Adverse Effects of Atropine in Childhood Myopia: A Meta-analysis

Importance

Some uncertainty about the clinical value and dosing of atropine for the treatment of myopia in children remains.

Objective

To evaluate the efficacy vs the adverse effects of various doses of atropine in the therapy for myopia in children.

Data Sources

Data were obtained from PubMed, EMBASE, and the Cochrane Central Register of Controlled Trials, from inception to April 30, 2016. The reference lists of published reviews and clinicaltrials.gov were searched for additional relevant studies. Key search terms included myopia, refractive errors, and atropine. Only studies published in English were included.

Study Selection

Randomized clinical trials and cohort studies that enrolled patients younger than 18 years with myopia who received atropine in at least 1 treatment arm and that reported the annual rate of myopia progression and/or any adverse effects of atropine therapy were included in the analysis.

Data Extraction and Synthesis

Two reviewers independently abstracted the data. Heterogeneity was statistically quantified by Q, H, and I2 statistics, and a meta-analysis was performed using the random-effects model. The Cochrane Collaboration 6 aspects of bias and the Newcastle-Ottawa Scale were used to assess the risk for bias.

Main Outcomes and Measures

The primary outcome was a difference in efficacy and the presence of adverse effects at different doses of atropine vs control conditions. The secondary outcomes included the differences in adverse effects between Asian and white patients.

Results

Nineteen unique studies involving 3137 unique children were included in the analysis. The weighted mean differences between the atropine and control groups in myopia progression were 0.50 diopters (D) per year (95% CI, 0.24-0.76 D per year) for low-dose atropine, 0.57 D per year (95% CI, 0.43-0.71 D per year) for moderate-dose atropine, and 0.62 D per year (95% CI, 0.45-0.79 D per year) for high-dose atropine (P < .001), which translated to a high effect size (Cohen d, 0.97, 1.76, and 1.94, respectively). All doses of atropine, therefore, were equally beneficial with respect to myopia progression (P = .15). High-dose atropine were associated with more adverse effects, such as the 43.1% incidence of photophobia compared with 6.3% for low-dose atropine and 17.8% for moderate-dose atropine (χ22 = 7.05; P = .03). In addition, differences in the incidence of adverse effects between Asian and white patients were not identified (χ21 = 0.81; P = .37 for photophobia).

Conclusions and Relevance

This meta-analysis suggests that the efficacy of atropine is dose independent within this range, whereas the adverse effects are dose dependent.

Identifying Children at Risk of High Myopia Using Population Centile Curves of Refraction

Purpose

To construct reference centile curves of refraction based on population-based data as an age-specific severity scale to evaluate their efficacy as a tool for identifying children at risk of developing high myopia in a longitudinal study.

Methods

Data of 4218 children aged 5–15 years from the Guangzhou Refractive Error Study in Children (RESC) study, and 354 first-born twins from the Guangzhou Twin Eye Study (GTES) with annual visit were included in the analysis. Reference centile curves for refraction were constructed using a quantile regression model based on the cycloplegic refraction data from the RESC. The risk of developing high myopia (spherical equivalent ≤ -6 diopters [D]) was evaluated as a diagnostic test using the twin follow-up data.

Results

The centile curves suggested that the 3^rd, 5^th, and 10^th percentile decreased from -0.25 D, 0.00 D and 0.25 D in 5 year-olds to -6.00 D, -5.65D and -4.63 D in 15 year-olds in the population-based data from RESC. In the GTES cohort, the 5^th centile showed the most effective diagnostic value with a sensitivity of 92.9%, a specificity of 97.9% and a positive predictive value (PPV) of 65.0% in predicting high myopia onset (≤-6.00D) before the age of 15 years. The PPV was highest (87.5%) in 3^rd centile but with only 50.0% sensitivity. The Mathew’s correlation coefficient of 5^th centile in predicting myopia of -6.0D/-5.0D/-4.0D by age of 15 was 0.77/0.51/0.30 respectively.

Conclusions

Reference centile curves provide an age-specific estimation on a severity scale of refractive error in school-aged children. Children located under lower percentiles at young age were more likely to have high myopia at 15 years or probably in adulthood.