A Vignette in Atropine-Based Myopia Management

Orthokeratology and some soft contact lens designs have demonstrated efficacy for providing myopia control in pediatric patients. But children may be unwilling or unable to undergo such treatments. Andrew Pucker, OD, of the University of Alabama’s School of Optometry walks through a hypothetical case report detailing the process of providing atropine-based myopia management.

Visit 1: Baseline Visit 

Olivia, a 10-year-old girl with Hispanic heritage, reports to your clinic in the spring with her mother for a myopia management consultation. She was referred by her pediatrician because there was a sudden increase in her eyeglass prescription during the last few months. Olivia’s mother states that Olivia got her first pair of glasses when she was about 7 years old and reports that both she and Olivia’s father have myopia. You ask Olivia about her hobbies, and she tells you that she loves to read books, play video games, and watch movies. She also indicates that she sees well with her new glasses, which she picked up 2 weeks ago from her primary care optometrist. You attempt to gauge Olivia’s interest in wearing contact lenses (CLs), but she is squeamish about touching her eyes, and her mother confirms that she likely is not ready for the responsibility of CL wear. You pivot to discussing some of the benefits of CL wear which include better perception of vision correction and improved self-appearance, but neither Olivia nor her mother are persuaded.¹ Sensing the hopelessness in initiating CL myopia management, you all agree to revisit this strategy next year. 

Olivia’s mother provides you with a copy of Olivia’s most recent vision exam, which indicates myopia with no other significant ocular conditions. She also confirms there are no concerns with Olivia’s systemic health. You perform a standardized myopia management evaluation and obtain the values reported in table 1.  

You discuss your findings with the family after the evaluation, explaining that Olivia has a moderate level of myopia based on her refractive error and axial length (AL). You stress that one of the goals of myopia management is to keep patients from developing high myopia, which can be defined as -6.00 diopters (D) of myopia or worse or AL longer than 26.00 mm.² You stress that you hope to keep Olivia’s myopia under these values because high myopia increases the risk of retinal detachments and other ocular comorbidities.³ You assert that it is imperative Olivia begin myopia management and suggest atropine treatment due to her unwillingness to undergo contact lens or orthokeratology treatments. 

Before initiating treatment, you take some time to educate the family on some of the details of atropine-based myopia treatment. You begin by attempting to determine the appropriate concentration. Starting with higher concentrations of the medication, you explain that although 1.0% atropine has been used to treat myopia progression for years, it may be accompanied by highly bothersome side effects which include light sensitivity and a decreased ability to view near objects.⁴ You reference the Atropine for the Treatment of Myopia (ATOM) study, which found that while 1.0% atropine provides the best overall slowing of myopia progression during treatment for 2 years, eyes treated with this concentration demonstrate a rebound effect that essentially negated years of treatment.^5,6 You examine other concentrations of atropine evaluated by the ATOM study and communicate the findings to Olivia’s family. While investigators determined that 0.01% atropine was less effective for reducing myopia progression compared with 1.0% atropine during treatment, patients who stopped treatment had a clinically meaningful reduction in myopic progression after discontinuing 0.01% atropine.⁶ However, the ATOM study only noted a significant reduction in myopic progression and not AL progression among individuals treated with 0.01% atropine.⁶ Myopia management with 0.01% atropine also involves fewer side effects, which has  allowed it to remain a viable treatment choice. 

You also summarize the findings from the Low-Concentration Atropine for Myopia Progression (LAMP) study — an investigation that found that both 0.025% and 0.05% atropine provide superior myopia control compared with 0.01% atropine with respect to slowing both refractive error and axial elongation.^7,8 The slightly higher atropine concentrations used in the study did not result in an increase in side effects and myopic rebound was limited after treatment cessation. 

You explain that since there is no current US Food and Drug Administration (FDA)-approved atropine option for treating myopia progression, the family will need to obtain the drops from a compounding pharmacy. You state your preference for initiating treatment with 0.025% atropine based on your desire to avoid the side effects associated with a 0.05% concentration. You also add that there may be a variation in atropine formulations obtained from compound pharmacies in the United States; thus, 0.025% atropine in some markets may be more potent than higher concentrations in other markets.⁹ 

After reviewing this information with Olivia and her mother, they elect to discuss the treatment options with Olivia’s father before initiating treatment. And you agree that the family should reach a consensus. Myopia management involves a long-term commitment and both patients and caretakers should be fully invested  in the treatment strategy before starting an atropine regimen.^5,10 You allow the family some time to discuss your suggestions among themselves and tell them to call if they decide to begin atropine treatment. You emphasize the importance of providing a timely response stating that if they take longer than 3 months to start treatment, you will need to see them again for new baseline measurements. 

Visit 2: Phone Consultation 1

After about 2 weeks, Olivia’s mother calls your office and indicates that she would like to initiate treatment with 0.025% atropine. You review the potential side effects and get permission to e-prescribe the atropine drops to a local pharmacy. Your instructions indicate that Olivia’s caretaker applies 1 drop to each eye before bed each night — your experience has shown that it is easier than applying them before school and Olivia will be less likely to experience side effects while sleeping. You tell Olivia’s mother to expect a call from the pharmacy within the next 2 days and to expect a follow-up phone call from your office in 2 weeks. 

Visit 3: Phone Consultation 2

After 2 weeks, your office manager calls Olivia’s mother and confirms that she was able to successfully obtain the drops. She states that Olivia is not experiencing any side effects, so the office manager schedules Olivia for a 6-month follow-up visit with instructions to return to the office sooner if any issues such as light sensitivity or decreased near vision are noted. 

Visit 4: 6-Month Follow-Up

Olivia and her mother report for the 6-month visit and Olivia claims that she still sees well while wearing her most recent pair of glasses. She also says that she uses her atropine drops most nights and is not experiencing any side effects. You perform a myopia management workup and obtain the  values noted in table 2. 

You compare Olivia’s 6-month values with her baseline values (table 3). After reviewing data from the 2 visits, you determine that her refractive error and AL progression are adequately controlled by the treatment. While there is no universally accepted method for judging myopic progression, you do know that children with emmetropia who are Olivia’s age often experience AL progression of approximately 0.10 mm per year.¹¹ In comparison, a 10-year-old child with myopia who is not of Asian ethnicity experiences AL and refractive error progression of 0.25 mm and 0.56 D per year, respectively.² Citing this research, you explain that Olivia’s myopic progression appears to be under control and that she should continue with her current treatment. You schedule her for another 6-month evaluation. 

Visit 5: 18-Month Follow-Up

Olivia fails to report for her 6-month visit, but does return to the clinic 1 year later stating that her distance vision is starting to get a little fuzzy. Although she is still using the drops without issues, she recently ran out of them. Olivia’s mother expresses interest in renewing the prescription and emphasizes that Olivia is still not interested in trying CLs. After reviewing Olivia’s ocular and systemic health history and determining that there are no new conditions to record, you proceed to perform a myopia management exam (table 4). Once again, you compare Olivia’s most recent data with her data from her previous visit (table 5).  

After reviewing the data, you inform the family that there has been a slight progression in Olivia’s refractive error and an AL progression of approximately 0.20 mm in each eye since her last visit. While this AL increase is more than you expected, it may possibly be attributed to normal emmetropization since there was a minimal change in refractive error despite the change in astigmatism in the right eye. Nevertheless, you stress that you have some concern about progression since there was a jump over the past year compared with the first 6 months under your care. While some of this myopic progression could be related to seasonal variation — children with myopia tend to progress faster in the winter than in the summer — you are still concerned, and suggest increasing the atropine concentration from 0.025% to 0.05%.¹² Since Olivia is not having side effects with the 0.025% concentration, you rationalize that this slight increase will not be problematic and may offer additional myopia control. Olivia’s family, however, is concerned about potential side effects and chooses to continue her current 0.025% dose. You schedule a 6-month follow-up visit, update Olivia’s eyeglass prescription, and stress that she needs to return to the clinic sooner if she notices additional visual changes or side effects. 

While atropine may not be the myopia control modality of choice for all pediatric patients, it has been clinically shown to slow axial length and refractive error progression in children. Therefore, it is a great choice for patients who are unwilling or unable to take on the responsibility of wearing contact lenses.