​Discover the history behind atropine and its use to control myopia in children for over a century.
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If your child has been diagnosed with myopia and you're not alone. In a world where nearsightedness is rapidly becoming a global epidemic, countless parents are facing this reality with their own children.Â
Myopia, or nearsightedness, affects a large number of people globally, with prevalence rates doubled in the US in the past 30 years and – even higher in many Asian countries. With 5 billion people at risk of developing myopia, including 10% who face a risk of high myopia, this eye condition is a leading public health issue.
Myopia control in children is important because, if left untreated, it can lead to a number of vision-threatening eye complications, such as myopic macular degeneration, cataracts, glaucoma, and retinal detachment. Additionally, myopia can also impact a child’s quality of life and school performance as it can affect their ability to play sports, see things clearly, and do well in school.
In this article, we will delve into atropine: one of the most effective myopia control treatments. We will discuss what atropine is, how it works, the research findings, and the pros and cons of atropine treatment.
By the end, you will gain a better understanding of atropine and its significance in myopia control for your child's eye health.
What is atropine?
Atropine is not new. The active ingredient of atropine, from a plant extract, has been referenced since 1550 B.C. Its name is derived from the Atropa belladonna plant, also known as “deadly nightshade”. Belladonna, meaning "beautiful woman," refers to its use by women in the 19th century to dilate their pupils for cosmetic purposes.
​In 1864, Dutch ophthalmologist Franciscus Donders was the first to recommend atropine as a treatment for myopia. However, Inglis Pollack, an ophthalmologist from the Glasgow Eye Infirmary, U.K., was the first to employ prolonged use (over several months) of atropine to treat myopia 100 years ago.
Atropine is an antimuscarinic, a subtype of anticholinergic agent, that induces pupil dilation. However, the mechanism by which it works to prevent the worsening of myopia still needs to be better understood. Atropine was originally thought to work by blocking the accommodative function of the eye. But more recent research suggests it may work through non-accommodative mechanisms.
Like many widely used old drugs (e.g. aspirin, metformin, gabapentin), atropine's mechanism of action for myopia control remains to be determined.
Studies in animal models suggest atropine may alter retinal neurotransmission by acting on extraretinal muscarinic receptors, possibly in the retinal pigment epithelium, choroid, or sclera. It has been found to increase dopamine release, which controls eye growth. Further research is needed to understand the specific mechanism by which atropine exerts its action in myopia and confirm the role of dopamine.
Current understanding of atropine in myopia control
Atropine is a medicine that has been extensively studied for controlling myopia in children. Many studies have been done to test different concentrations of atropine and combination therapies, such as atropine with orthokeratology (Ortho-K) or myopia control contact lenses and glasses.
Research showed high concentrations of atropine (1% or 0.5%) were highly effective in slowing the elongation of the eye, or myopia progression, with an average 77% reduction in well-conducted trials. However, high concentration can also cause more side effects, such as light sensitivity and difficulty with close-up reading. Low concentrations of atropine (0.01%) was found to be effective, with an average 59% reduction in myopia progression but with fewer side effects. Furthermore, in a study with a 10-year follow-up, no significant side effects were reported.Â
There are multiple risk factors for myopia progression; we may need multiple treatments to control it. Ortho-K, special contact lenses, and glasses can slow down myopia progression by changing how light enters the eye – optical mechanism, while atropine works by changing retinal neurotransmission.
​Studies showed that a combination of low concentration atropine (0.01%) and Ortho-K was highly effective – similar to high concentration atropine alone – in slowing down myopia progression in children. Further, a recent study demonstrated the combination treatment was 37% more effective than Ortho-K alone.Â
In December 2022, a study found that using a combination of 0.01% atropine and defocus-incorporated multiple segments (DIMS, also known as MiyoSmart) was also highly effective. The treatment significantly reduced myopia progression by 54%, double the reduction achieved with DIMS alone.
Another small study found that a combination of low concentration atropine (0.01%) and myopia control soft contact lens, MiSight, was effective in reducing myopia progression. Even though the difference compared to MiSight alone was numerically higher, but it was not statistically significant.
Several research results suggested that low concentration atropine was an effective and well-tolerated treatment for controlling myopia in children. More studies are needed to learn about combination therapies and the optimal way of using these treatment options.
The Pros and Cons:
As with any medication, there are potential risks and benefits to consider when using atropine for myopia control. Here are some of pros and cons to consider:
Pros:
- Atropine is one of the most effective treatments in slowing the progression of myopia in children
- Its concentration can be tailored or adjusted to individual treatment needsÂ
- It is convenient to use and has a minimal learning curve when compared to contact lenses
- Typically less expensive than other options, such as Ortho-K or daily contact lenses
- Does not carry the same risk of eye infections as contact lenses
Cons:
- Still may require wearing glasses; atropine doesn’t correct vision.
- Concentration-dependent side effects, such as light sensitivity or blurred near-visionÂ
- Atropine for myopia control in children is an off-label use (Learn more about what is an off-label practice in the podcast below)
- Factory sealed low concentration atropine is not available and may require special preparation from a specialty pharmacy (US)
- Tapering may be needed when stopping atropine treatment – to avoid rebound
It's important to carefully consider the potential risks and benefits of atropine treatment with your eye doctor, especially if your child has any underlying health conditions. Your eye doctor can help determine the appropriate concentration, frequency of use, and monitoring plan for treatment.
Key takeaways
Atropine is a medication with over a century of use in myopia. Many published studies worldwide demonstrated its effectiveness and safety in slowing myopia progression in children. A report by the American Academy of Ophthalmology in 2017 concluded: Level I evidence supports the use of atropine to prevent myopia progression.Â
Atropine can be used alone or in combination with other treatments tailored to individual needs. However, it's crucial to consult an eye doctor and weigh the potential risks and benefits before starting treatment.Â
It's also important to keep in mind that atropine is not a cure for myopia and also maintaining good eye habits is crucial. Combining good eye habits and effective treatment is essential to successful myopia control, reducing the risk of vision complications later in life.
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