Of all the exciting things going on in eye care right now, I think the movement to focus on myopia (nearsightedness) as a public health issue is not getting the attention it deserves. Part of that focus is on Myopia Intervention, aimed at stopping or greatly reducing the progression of myopia in children. I’ll be focusing a lot on Myopia Intervention, and the king of the hill right now in this area is low-dose atropine.
A little background: normal dose atropine is a very strong dilation drop. It’s sometimes used for diagnostic purposes to provide a very full pupil dilation to allow for wide angle evaluation of the retina. More often, it’s used for treatment purposes in certain inflammatory conditions of the eye that require temporary paralysis of the pupil muscles. To be blunt, it’s not fun to take full dose. Besides severe pupil dilation it causes significant light sensitivity and blurry vision up close.
Low-dose atropine, however, is a whole different (and exciting) story.
Low-dose atropine involves a diluted form of its big brother. A groundbreaking study concluded that, at 0.01% concentration, it did not cause side effects such as pupil dilation, light sensitivity, or blurred vision. That’s key because it means 0.01% low-dose atropine is tolerable! Even better, it was shown to be even more effective in the long-term control of myopia than full dose.
The ground-breaking studies in this area were Atropine for the Treatment of Myopia (ATOM)-1 and ATOM-2, published in Ophthalmology. ATOM-1 compared different doses of atropine on the control of myopia progression after one year of treatment. ATOM-2 looked at the 5 year outcomes of these same doses. In ATOM-2 there was also a “wash-out” phase after 2 years of treatment where children were taken off the drops to see if progression restarted. This allowed researchers to catch any rebound effects of the medication.
The number one take home was that 0.01% low-dose atropine decreased progression of myopia in children by 50% over a 5 year period. That’s huge! And, as mentioned before, it did it without the side effects of regular dose atropine. Also, there was almost no rebound effect with low-dose atropine–meaning, when the drops were stopped after 2 years, there was very little chance for rapid progression. Interestingly, regular dose atropine did have a rebound effect which only reinforces low-dose atropine as the clear winner and most effective long term control of myopia progression in children.
Out of the ATOM-2 data, researchers suggested a minimum treatment period of two years. Actually, atropine proved more effective in the second year so stopping after one year would not give the full intervention effects of the medication. If, after 2 years there is no significant progression of myopia, the drops could be stopped (especially if the child is 13 years or older). If small amounts of progression were noted after that, the medication could be restarted. If a child’s myopia is still showing significant progression after 2 years, combining low-dose atropine with other methods of myopia intervention may be necessary (multi-focal contact lenses, orthokeratology, etc).
In the United States, 0.01% low-dose atropine is not yet available commercially. This means that you can’t fill the prescription at most of your local pharmacies. The prescription needs to be formulated at a compounding pharmacy. I’ve had success with a compounding pharmacy that will mail the medications directly to the patient’s home.
To have such a simple and an effective tool in my arsenal to combat the year-after-year progression of a child’s myopia is very encouraging. It’s encouraging that someday, soon, we could start to combat pandemic myopia like we do other public health concerns. After all, severe myopia is not just a financial issue, it’s a quality of life issue and comes with very real risks to eye health over time.
If your child is showing progression in his or her myopia, it could be time to discuss low dose atropine with your eye care provider.
As always, I’d love to hear your feedback or questions!