Treatment for myopia progression with atropine

Although atropine is regarded as an effective and acceptable treatment for controlling myopia progression in various Asian countries, it is not a mainstream strategy in the Western world. A change may be coming, however, considering findings from recent research.

Speaking at the 3rd World Congress of Paediatric Ophthalmology and Strabismus in Barcelona, Spain, Ian Flitcroft MD presented evidence demonstrating the benefits of treatment with a low concentration of atropine, 0.01 per cent, suggesting its potential acceptance for use in a European patient population.

“Reports of atropine use for the treatment of myopia date back to the 19th century, and there is a good evidence base for its efficacy,” said Dr Flitcroft, consultant ophthalmologist, Children’s University Hospital, Dublin, Ireland.

“The most extensive experience is with atropine one per cent. However, results of a trial conducted in Singapore showing atropine 0.01 per cent slowed myopia progression and minimised side effects, will change the way we treat myopia. Certainly, a study is needed in Europe, but 200 years late is better than never,” he added.

The investigation in Singapore, known as the Atropine for the Treatment of Myopia 2 trial (ATOM2) (Ophthalmology, February 2016; 123(2), 391–399), was a double-masked study that randomised 400 myopic children to treatment with atropine 0.01 per cent, 0.1 per cent, or 0.5 per cent. Treatment was stopped after two years, the children were followed for one year off treatment, and then atropine 0.01 per cent was restarted for another two years in any child whose myopia progressed ≥0.5D.

LESS REBOUND

After the first two years when comparing the atropine treatment groups to historical placebo-treated controls from ATOM1, the progression of myopia was slowed by 75 per cent in the group using atropine 0.5 per cent, 70 per cent for those assigned to atropine 0.1 per cent, and 60 per cent for children using atropine 0.01 per cent. Not only was the lowest concentration of atropine nearly as effective in reducing myopia progression as the higher concentrations, but it had minimal effect on accommodation and was associated with less rebound during the year after treatment cessation.

“Cycloplegia and acceleration of myopia progression after stopping treatment are the two major concerns with atropine as a treatment for myopia. Atropine 0.01 per cent seems not to cause those issues,” Dr Flitcroft said.

“Compared with atropine one per cent, atropine 0.01 per cent is also associated with less glare, pupil dilation and allergy, and with minimal impact on accommodation, there is no need for bifocal or varifocal glasses.”

Dr Flitcroft noted that atropine one per cent has been extensively used as a treatment for myopia in Taiwan for more than 20 years, and atropine 0.01 per cent to 0.02 per cent is currently routinely offered in Singapore. Questions about its acceptability and efficacy in a European paediatric population relate to the fact that, compared with their Asian counterparts, European myopes are older and have less pigmented eyes.

“Older children are more opinionated and have poorer accommodation, and perhaps side effects of atropine may be greater in eyes with less pigmented irides,” Dr Flitcroft explained.

Results of the Dublin SHIELD study, however, are encouraging (BJO 2016, in press). In this pilot trial designed to evaluate the efficacy, safety and acceptability of atropine treatment in a European population, significant changes were seen after five days of use in pupil size and pupillary response. However, near visual acuity and reading speed were unchanged, and importantly, investigation of quality of life impact based on patient ratings of difficulty performing 14 daily activities showed atropine use had minimal if any adverse effect.

Data from 16 patients showed that half experienced a one-step change in performance of a single task, from ‘no limitation’ to ‘a little’, while four patients reported a one-step change in two tasks.

“All symptoms related to atropine disappeared within the first two days of usage. And, when asked if they would use this treatment if it worked to reduce myopia progression, all of the participants answered ‘yes’,” Dr Flitcroft said.

Ian Flitcroft: ian@flitcroft.com