Combined Myopia Therapy: A Vignette in Atropine Plus Contact Lens Treatment

Combined myopia therapy consisting of both atropine and soft contact lens treatment may be a useful strategy for managing myopia in some pediatric patients. However, research has only recently assessed the efficacy of this treatment strategy and the literature has led clinicians to different conclusions. Andrew D. Pucker, OD, PhD, FAAO, walks through a case report of a 9-year old girl undergoing myopia management using both treatment methods. 

Visit 1: Baseline Visit 

Emma, a 9-year-old girl, presents to your clinic with her father for a myopia management consultation. She appears very shy and only speaks to you when asked a direct question. When asked about hobbies, she does not offer much of a response, but her father indicates that she enjoys video games and playing with her cat, Jenkins. A review of Emma’s chart shows no significant ocular history other than myopia, which has been corrected with glasses since age 6 years. After discussing the purpose of myopia management and the treatments your clinic offers, you perform your standard myopia management evaluation and obtain the values noted in table 1. 

After completing your evaluation, you determine that low dose atropine, orthokeratology, or soft contact lenses (CLs) are all viable management strategies for Emma’s myopia.¹ You educate the family about the potential benefits and challenges associated with these options, and after some pushback against wearing contacts, you proceed with prescribing Emma 0.01% atropine. You e-prescribe the medication and instruct your staff to touch base with the family 2 weeks later to ensure that Emma obtained her medication and that she is not experiencing any clinically meaningful side effects. Your next intended meeting with Emma will be during her 6-month evaluation.

Table 1: Baseline Myopia Management Evaluation Results 

EYE	REFRACTION	SNELLEN ACUITY	AXIAL LENGTH	KERATOMETRY	HORIZONTAL VISIBLE IRIS DIAMETER
Right	-4.00 DS	20/20	24.15 mm	44.3/44.5 D	11.60 mm
Left	-3.75 -0.25 x 078	20/20	24.37 mm	43.9/44.1 D	11.88 mm

Visit 2: 18-Months 

Emma and her father return to your clinic about 18 months after their initial consultation, claiming that COVID-19-related challenges prevented them from returning sooner. Emma reports good distance and near vision through her most recent pair of spectacles, which are about 1.5 years old. However, when you ask the family about the atropine drops, they admit that they have not been compliant with their treatment regimen and have not used the drops for about 6 months because the prescription has expired. Nevertheless, they are interested in obtaining a new atropine prescription today. After reviewing Emma’s medical history, you proceed with your myopia management evaluation, and obtain the values in table 2. You also determine that Emma’s ocular health is stable and that her binocular vision is within normal limits. 

Table 2: Refractive Evaluation Results 

EYE	REFRACTION	SNELLEN ACUITY	AXIAL LENGTH
Right	-5.25 -0.50 x 023	20/20	24.78 mm
Left	-4.75 -0.75 x 164	20/20	24.83 mm

After comparing your refractive evaluation results with those obtained during the baseline visit, you explain that Emma’s spectacle prescription has increased by about 1 diopter (D) and her eye length has increased by about 0.5 mm since her last visit (table 3). You stress that Emma’s myopia is progressing and that it is now roughly at the level of high myopia, which elevates Emma’s risk of developing ocular pathologies such as retinal detachments and glaucoma later in life.^{2, 3} You silently recall data from the Low-Concentration Atropine for Myopia Progression (LAMP) study and explain to Emma and her father that 0.05% and 0.025% atropine have demonstrated superior efficacy slowing both axial length and refractive error progression compared with a 0.01% concentration. You increase Emma’s atropine concentration to 0.025% in an effort to curb her recent myopic jump and re-emphasize the need to use the drops each night before scheduling Emma for another 6-month follow-up visit. 

Table 3: Refractive Error and Axial Length Values by Visit

RIGHT EYE	REFRACTION	AXIAL LENGTH	LEFT EYE	REFRACTION	AXIAL LENGTH
Baseline	-4.00 DS	24.15 mm	Baseline	-3.75 -0.25 x 078	24.37 mm
18-Months	-5.25 -0.50 x 023	24.78 mm	18-Months	-4.75 -0.75 x164	24.83 mm
24-Months	-5.00 -0.50 x 020	24.97 mm	24-Months	-5.00 -0.75 x 014	25.02 mm
33-Months	-5.00 -0.75 x 011	Unavailable	33-Months	-5.25 -1.00 x 012	Unavailable
38-Months	-5.25 -1.00 x 012	25.00 mm	38-Months	-5.25 -1.25 x 004	25.05 mm
44-Months	-5.00 -1.00 x 013	24.96 mm	44-Months	-5.00 -1.00 x 016	25.05 mm

Cumulative Axial Length Difference	0.81 mm	Cumulative Axial Length Difference	0.68 mm
Mean Difference/Year	0.22 mm	Mean Difference/Year	0.19 mm

Visit 3: 24-Months 

Emma and her father return for their 6-month visit as scheduled. Emma reports stable vision in her current spectacles, and her father confirms Emma’s compliance with her treatment regimen. Emma seems a bit more willing to engage in conversations about her treatment and expresses an interest in trying CLs. After completing a medical history, you perform your myopia management workup and obtain the data in table 4. 

While Emma has experienced more axial growth compared with children of similar age with emmetropia, you explain that her spectacle prescription has remained stable — an indicator that her axial length has likely experienced normal, proportional growth.⁵ Using the refractive evaluation results obtained in table 4, you discuss the benefits and challenges of the various CL options. You discuss the differences between daily disposable CLs, regular replacement soft CLs, and orthokeratology. The family is mostly concerned with safety and opts to initiate treatment with daily disposable CLs after you inform them that the risk associated with developing a microbial keratitis with daily disposable soft CLs is about 2 per 10,000 patient years compared with 4 per 10,000 patient years and 8 per 10,000 patient years for regular replacement CLs and orthokeratology, respectively.^{6, 7} 

You fit Emma with daily disposable CLs satisfying the parameters noted in table 5, demonstrate proper insertion and removal techniques, and provide her with a multi-purpose CL solution for training purposes. You adopted this practice because 2 of your patients in the past year quickly depleted their 6-month supply of daily disposable CLs because they discarded their CLs every time they dropped them. After evaluating the CLs, you determine that they provide great vision and have acceptable centration, coverage, and movement. You provide Emma with 10 sample CLs per eye and schedule her for a 1-week follow up. You instruct her to immediately begin full-time CL wear, citing research that has shown no benefit to gradually increasing CL wear time over the first week of wear.⁸ 

Table 4: Refractive Evaluation Results 

EYE	REFRACTION	SNELLEN ACUITY	AXIAL LENGTH
Right	-5.00 -0.50 x 020	20/20	24.97 mm
Left	-5.00 -0.75 x 014	20/20	25.02 mm

Table 5: Daily Disposable CL Parameters 

EYE	DESIGN	POWER	BASE CURVE	OVERALL DIAMETER	ADD
Right	Center-Distance	-5.75 D	8.7 mm	14.2 mm	2.00 D
Left	Center-Distance	-5.00 D	8.7 mm	14.2 mm	2.00 D

Visit 4: CL Follow Up 

Emma and her father return for Emma’s 1-week CL follow up. Emma reports struggling with CL application and removal during the first few days of wear, yet she now feels proficient and is happy with her overall vision and comfort. When asked, she reports that she has been wearing her CLs for about 5 hours that day. You proceeded to evaluate Emma’s vision while wearing the CLs, the CL fit, and her ocular health. Your assessment reveals no ocular surface or CL fitting concerns, but you determine that increasing her prescription by -0.25 D per eye could improve her vision (table 6). You update her prescription and provide her with an additional set of trial CLs. You discuss your exam findings with Emma and her father and decide to wait 2 days before finalizing the prescription, giving Emma a chance to determine whether she likes her CL power adjustment. You instruct them to proceed with ordering new lenses if they are satisfied with the vision and comfort and to return for a follow up visit if Emma is not content. You also decide to renew Emma’s atropine prescription, because research suggests that combining atropine with CLs may provide an additional benefit.⁹ You will examine the effectiveness of this combined treatment during her next 6-month follow-up visit.   

Table 6: Daily Disposable CL Parameters 

EYE	DESIGN	POWER	BASE CURVE	OVERALL DIAMETER	ADD
Right	Center-Distance	-6.00 D	8.7 mm	14.2 mm	2.00 D
Left	Center-Distance	-5.25 D	8.7 mm	14.2 mm	2.00 D

Visit 5: 33-Months 

During her next follow-up visit, Emma reports that she is comfortable and satisfied with her vision while wearing the CLs, which she wears for 7 days per week for about 12 hours per day. Emma also reports good compliance with using her atropine drops. You proceeded with the myopia management workup (table 7), but are unable to get axial length measurements due to a malfunctioning optical biometer that is being repaired by the manufacturer. During the visit, you determine that no changes are needed for Emma’s CL prescription. You decide based on refractive error alone that Emma’s myopia is stable. After informing the family that treatment is going well, you renew Emma’s CL and atropine prescriptions and schedule her for another 6-month follow-up visit.

Table 7: Refractive Evaluation Results

Eye	Refraction	Snellen Acuity	Axial Length
Right	-5.00 -0.75 x 011	20/20	Unavailable
Left	-5.25 -1.00 x 012	20/20	Unavailable

Visit 6: 38-Months 

Emma reports for her next follow-up visit stating that her CLs are great and that she would not change anything about them. You evaluate her CLs and perform your myopia management exam, obtaining the values in table 8. You inform the family that no CL changes are necessary and that her spectacle prescription and axial length are stable. You also suggest continuing myopia management for at least 6 more months, but if her myopia is stable at the next visit, Emma could graduate from the myopia management program. The family agrees and you schedule Emma for her next follow-up visit following a brief re-education on good CL hygiene habits. 

Table 8: Refractive Evaluation Results

EYE	REFRACTION	SNELLEN ACUITY	AXIAL LENGTH
Right	-5.25 -1.00 x 012	20/20	25.00 mm
Left	-5.25 -1.25 x 004	20/20	25.05 mm

Visit 7: 44-Months 

Emma reports that her vision and CL comfort are great at her next visit and demonstrates a good knowledge of contact lens hygiene. You evaluate her CLs and perform your myopia management evaluation (table 8). During your exam, you determine that Emma’s CLs still fit great and note no significant changes in her refractive error or axial length. You discuss your exam findings with the family (tables 3 and 9) and determine that Emma should graduate from your myopia management clinic and begin annual exam follow ups. You and Emma’s father also agree that Emma should continue wearing her CLs since she likes them and may still find some additional myopia management benefit from them. Nevertheless, you decided to discontinue atropine treatment at this time. 

Table 9: Refractive Evaluation Results

EYE	REFRACTION	SNELLEN ACUITY	AXIAL LENGTH
Right	-5.00 -1.00 x 013	20/20	24.96 mm
Left	-5.00 -1.00 x 016	20/20	25.05 mm

While the literature suggested that using 0.01% atropine plus orthokeratology provided an additional benefit when Emma first visited your clinic, research has since found that combination atropine with orthokeratology may only provide benefits during the first 6 months of combination treatment, and may not benefit individuals with rapidly progressing myopia, which is often the target group for combination therapy.^9-12 There are also limited data that support combining 0.01% atropine with soft CLs or spectacles, and much of this research has only begun to surface recently.^13-16 While combination myopia management treatments may have some benefits, more research is needed to understand how factors such as age, starting refractive error, and atropine concentration affect these combination treatments.