Efficacy of 1% atropine eye drops in retarding progressive axial myopia in Indian eyes

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

PURPOSE

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

METHODS

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

RESULT

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

CONCLUSION

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

Role of 0.01% atropine in high myopic children of Moradabad, India (RAMCOM Study)

Purpose

Low-concentration atropine is an emerging therapy for myopia progression, but its efficacy remains uncertain among high myopic children. This study aimed to evaluate the efficacy and safety of low-concentration atropine eye drop (0.01%) in high myopic children.

Methods

A non-randomized, parallel-group, longitudinal interventional cohort study. Myopic children were divided into two groups: (1) the intervention arm of children who received one drop of topical 0.01% atropine once a day at bedtime and (2) the control arm, in which enrolled children who were on observation only. Repeated measurements of spherical equivalent refractive errors (SERs) were performed at baseline and 1 and 2 years after treatment.

Results

A total of 37 eyes were enrolled in the intervention arm (allocated to 0.01% atropine at year 1 follow-up) and 23 eyes in the control arm. After 1 year of 0.01% atropine therapy, the myopia progression was 0.15 ± 0.9 D in the intervention group versus 1.1 ± 1 D in the control group (P = 0.001). Similarly, after 2 years of treatment, the myopia progression was 0.3 ± 1.1 D in the intervention group versus 1.4 ± 1.1 D in the control group (P ≤ 0.001).

Conclusion

Compared to no treatment, 0.01% atropine treatment had shown better effect on myopia progression in high myopic children.

Changes of Choroidal Thickness in Children after Short-Term Application of 1% Atropine Gel

INTRODUCTION

The aim of the study was to assess changes in choroidal thickness (ChT) after administration of 1% atropine for 1 week in myopic, emmetropic, and hyperopic children.

METHODS

A total of 235 children aged 4-8 years, which included 46 myopia, 34 emmetropia, and 155 hyperopia patients, were recruited and divided into three groups according to the spherical equivalent with the use of 1% atropine twice a day for 1 week. The ChT was measured at baseline and 1 week.

RESULTS

In the myopia and emmetropia groups, following administration of 1% atropine gel, the ChT thickened significantly under the fovea (i.e., from 278.29 ± 53.01 μm to 308.24 ± 57.3 μm, p < 0.05; from 336.10 ± 78.60 μm to 353.46 ± 70.22 μm, p < 0.05, respectively), and at all intervals from the fovea, while in the hyperopia group, there was no significant difference in the ChT except the nasal side (p < 0.05).

CONCLUSION

Topical administration of 1% atropine gel for 1 week significantly increased the subfoveal and parafoveal ChT in children with myopia and emmetropia. Atropine did not increase the ChT in hyperopic children, except on the nasal side.

A Review of Intraocular Pressure (IOP) and Axial Myopia

The pathogenesis of myopia is driven by genetic and environmental risk factors. Accommodation not only alters the curvature and shape of the lens but also involves contraction of the ciliary and extraocular muscles, which influences intraocular pressure (IOP). Scleral matrix remodeling has been shown to contribute to the biomechanical susceptibility of the sclera to accommodation-induced IOP fluctuations, resulting in reduced scleral thickness, axial length (AL) elongation, and axial myopia. The rise in IOP can increase the burden of scleral stretching and cause axial lengthening. Although the accommodation and IOP hypotheses were proposed long ago, they have not been validated. This review provides a brief and updated overview on studies investigating the potential role of accommodation and IOP in myopia progression.

Myopia in India

India is a culturally and geographically diverse nation. Its vast demographic nature does not allow a single definition for any of the given medical conditions in its territory. One important clinical condition which has created an uproar in the rest of the world is myopia. Its cause, prevalence, etiopathogenesis and other factors are being explored constantly; however, data with respect to Indian subcontinent are genuinely missing. Hence, in this review, we enumerate the country’s myopia journey from last 4 decades. The epidemiology, genetics, ocular/systemic association, quality of life, imaging, and management in myopia with necessary future directives are discussed to augment the overall management in future.

Change and Recovery of Choroid Thickness after Short-term Application of 1% Atropine Gel and Its Influencing Factors in 6-7-year-old Children

PURPOSE

To investigate the change and recovery of choroid thickness after short-term application of 1% atropine gel and its influencing factors in 6-7-year-old children.

MATERIALS AND METHODS

71 right eyes of 71 children were enrolled and divided into myopia and control group. 1% atropine gel was administered twice a day for one week and then stopped. Spherical equivalent (SE), accommodative amplitude (AA), keratometry (K), axial length (AL), and choroidal thickness (CT) were obtained at baseline and 1^st, 4^th, and 8^th weeks. CT was measured at subfovea and 1 mm, 2 mm, and 3 mm temporal, superior, nasal, and inferior from the fovea using spectral-domain optical coherence tomography.

RESULTS

In both groups, all CTs increased following the change in SE, AA, and AL after administration of 1% atropine for one week. They gradually recovered to baseline levels seven weeks after withdrawal. The change (Δ) in CT at 3 mm superior from the fovea was significantly higher in the myopia group than in the control group. In both groups, ΔCT at subfovea had no significant correlation with SE, AA, and AL, both at baseline and one week. However, ΔCT at subfovea was negatively correlated with ΔAL in the control group.

CONCLUSIONS

One-week application of 1% atropine gel may increase CT in 6-7-year-old Chinese children. Meanwhile, the recovery process after withdrawal lasts seven weeks. During the recovery process, the changes in structural parameters (AL, CT) and functional parameters (AA, SE) in both groups occurred synchronously. The SE, AA, and AL at baseline may not predict the extent of atropine's effect on CT.

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.

Convergence excess consecutive esotropia associated with 0.01% atropine eye drops usage in patients operated for intermittent exotropia

To report convergence excess esotropia (CEET) following 0.01% atropine eye drops (Low dose atropine [LDA]). Children who developed CEET that resolved promptly after discontinuation of LDA are described. Three myopes aged 5.3 ± 1.2 years and mean sphere -4.5D were included. All were operated for intermittent exotropia earlier. Mean esotropia was +28.3PD for near and 10.6PD for distance. LDA induced high AC/A ratio and fusion normalized in 3 weeks after discontinuation of LDA. LDA should be used with caution in patients with esophoria or previously operated for intermittent exotropia. Any evidence of the emergence of a CEET should warrant discontinuation of LDA.

Physical, chemical, and microbiological stability study of diluted atropine eye drops

Background

Atropine eye drops are indicated for juvenile myopia progression, cycloplegia, amblyopia, and strabismus. According to the package insert, 10 mg/mL atropine eye drops must be diluted for pediatric patients to prevent systemic adverse effects. Compounding units in hospital pharmaceutical departments or community pharmacies are compelled to prepare this essential medication; however, validated atropine stability data is limited and the shelf life after preparation is extremely short. As it is a long-term treatment, a longer shelf life is necessary to improve patient care. This study aimed to demonstrate the physical, chemical, and microbiological stability of diluted atropine eye drops over a period of six months.

Methods

Preparation consists of dilution of a 10 mg/mL atropine solution (Nitten Atropine Ophthalmic Solution 1%; Nitten Pharmaceutical Co., Ltd.) in 0.9% NaCl to concentrations of 0.1, 1.0, 2.5, and 5.0 mg/mL, followed by a sterilizing filtration procedure and then an aseptic filling process of 5 mL in 5 mL polyethylene eyedropper bottles. The entire process is carried out in an overpressure isolator. All concentration products were kept for six months at 25 °C or 5 °C. Visual inspection was conducted and pH, osmolality, and atropine concentration were measured at day 0, day 14, day 28, and every month until six months. Atropine concentration was measured using liquid chromatography tandem mass spectrometry. The sterility was monitored using a method adapted from the Japanese Pharmacopoeia sterility assay.

Results

Atropine remained within ±5% of the target value in the six batches. Osmolality (285 mOsm/kg) as well as pH (5.88) were kept constant. No variations in solution characteristics (crystallization, discoloration) were noted. Sterility was maintained.

Conclusions

This study validated the physical, chemical, and microbiological stability of 0.1, 1.0, 2.5, and 5.0 mg/mL atropine sulfate eye drops conserved inside polyethylene eyedroppers for six months at 25 °C or 5 °C.

Consensus statement and guidelines for use of dilute atropine sulphate in myopia control

Purpose:

To develop a consensus statement for use of dilute atropine in control of myopia progression in children based on review of existing literature, opinions and suggestions of the members of the Group of Paediatric Ophthalmologist and Strabismologists, Mumbai (GPOS).

Methods:

Literature review, group discussions, questionnaire study and consensus building by supermajority voting.

Results:

About 65% of paediatric ophthalmologists in Mumbai have started prescribing atropine sulphate 0.01% as routine in their patients showing myopia progression. Majority of the respondents who have used it for >1 year in their patient population are extremely happy with the results. About 47% respondents expressed concerns regarding some yet unknown side effects of long-term use in our patient population. Majority of the respondents agree that it is safe and have rarely encountered side effects with its use.

Conclusion:

Atropine sulphate 0.01% is a safe and effective treatment for myopia control. Most trained paediatric ophthalmologists recommend its use in children with progressive simple myopia.

Systematic Analysis of Transcriptomic Profile of the Effects of Low Dose Atropine Treatment on Scleral Fibroblasts using Next-Generation Sequencing and Bioinformatics

This study has two novel findings: it is not only the first to deduct potential genes involved in scleral growth repression upon atropine instillation from a prevention point of view, but also the first to demonstrate that only slight changes in scleral gene expression were found after atropine treatment as side effects and safety reasons of the eye drops are of concern. The sclera determines the final ocular shape and size, constituting of scleral fibroblasts as the principal cell type and the major regulator of extracellular matrix. The aim of our study was to identify differentially expressed genes and microRNA regulations in atropine-treated scleral fibroblasts that are potentially involved in preventing the onset of excessive ocular growth using next-generation sequencing and bioinformatics approaches. Differentially expressed genes were functionally enriched in anti-remodeling effects, comprising of structural changes of extracellular matrix and metabolic pathways involving cell differentiation. Significant canonical pathways were correlated to inhibition of melatonin degradation, which was compatible with our clinical practice as atropine eye drops are instilled at night. Validation of the dysregulated genes with previous eye growth-related arrays and through microRNA-mRNA interaction predictions revealed the association of hsa-miR-2682-5p-KCNJ5 and hsa-miR-2682-5p-PRLR with scleral anti-remodeling and circadian rhythmicity. Our findings present new insights into understanding the anti-myopic effects of atropine, which may assist in prevention of myopia development.

Allergic reactions to atropine eye drops for retardation of progressive myopia in children

Purpose

To report clinical manifestations of ocular allergy to atropine eye drops used for retardation of progressive myopia in children.

Methods

Myopic children, who developed bothersome itching that subsided promptly after cessation of atropine eye drops, were included. History of systemic or ocular allergy, preexisting ocular conditions, and clinical features of allergy were noted.

Results

Six children, age 5-15 years, were included. Four developed allergy to 1% atropine sulfate eye drops and two to 0.01% concentration of atropine sulfate. The onset of allergy was within a month to as late as 4 years after using atropine eye drops. The severity of allergy was higher with 1% concentration. The most common symptoms of atropine allergy were itching and burning. The most common signs were lid swelling and hyperemia. The allergic manifestations promptly reversed with the stoppage of eye drops. Reintroduction was possible in three patients, either by reducing the concentration of atropine or using benzalkonium free formulation.

Conclusion

Allergy to atropine eye drops in children may develop within a few weeks or after many years of usage. Prompt cessation followed by a reintroduction and continuation of therapy may be possible in few patients.

Prevention of Progression in Myopia: A Systematic Review

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