A case of how to manage side effects of atropine

Atropine is one of the most effective treatments for preventing myopia from worsening. Learn more about some strategies to mitigate the most common side effects of atropine and help your kid stay in control.   

“Dad, I am having a problem reading the question. It is blurry.” My son said while doing his last few pages of the Summer Brain Quest workbook last week. He experienced blurry near vision due to atropine’s side effects.  

Since mid-1800’s atropine was used in ophthalmology as a mydriatic to dilate the pupils for examining the back of the eye. It works by blocking the chemical acetylcholine, which relaxes the ciliary muscle of the eye as well as paralyzes the accommodation reflex. 

It was found later that atropine could be used for the treatment of myopia. And acetylcholine seemed to play an important role in the developing retina and regulating the growth of the eye. Furthermore, atropine was recognized as one of the most effective treatments to prevent the worsening of myopia. 

Despite its effectiveness, its side effects, e.g., light sensitivity and blurry near vision, may lead to treatment non-adherence. In a study published in 2016, more than 80% of patients who ceased their treatment in one year reported it was due to adverse events. And the most prominent reasons were due to photophobia and reading problems.      

My son started 0.05% atropine – the higher of the low dose options –  every night (and Ortho-K) to treat his myopia two months ago. The 0.05% dose was the preferred dose for minimalizing possible side effects while ensuring optimal efficacy. However, my sons still experienced some mild side effects.

Since we still haven’t found a local eye doctor to partner with yet, we were more proactive and detailed regarding the adverse event, so we could determine the causes and discuss them with our eye doctor remotely.

Blurry near vision

When we started his atropine treatment in Taiwan, we monitored for signs of side effects closely. Except for some minor light sensitivity, the blurry near vision was not identified. During that time, the books that my son was reading had large font sizes of 12. But, once back, he had to read words that were, or smaller than, size 10 for the first time.

We found that he could see words well when the reading distance was more than 30-40cm. He didn’t have any problem with words larger than size 13. The issue slightly improved when I increased the brightness to about 800 lux from 250 lux. It was like he had the symptoms of presbyopia.

This side effect improved in the late afternoon.  And on the second day after administering (skipping one night as per our doctor’s recommendation), it went away. 

Adjusting atropine dose or interval?

After sharing our observations, our eye doctor suggested that we could apply his 0.05% atropine every two nights instead of every night.

Initially, I was uncomfortable with this since my thoughts were we should reduce the dose and stay with the once nightly application to ensure consistent efficacy while reducing the adverse event.

After some research, contrary to my initial thought, my research confirmed that every two nights might be the optimal option for my son’s situation.

Firstly, how does changing the 0.05% atropine to every two nights impact its efficacy? In a lecture session presented by Dr. Tang Yao at the International Myopia Congress this year, a study was presented looking at different treatment intervals of 0.05% atropine. Over six months, the once daily, once per week, and twice per week groups were equally effective in preventing myopia from progressing. This suggested for at least six months, changing to once every two nights, my son’s treatment is likely to be equally effective.   

On the other hand, in two publications that studied 0.05% and other lower doses – 0.025% and 0.01% – the percentage of patients with a loss of near vision was not significantly different between the doses. (1, 3) Further, in one of the studies, the change in near visual acuity between 0.05% and 0.01% atropine was also not statistically significant. This suggests I shouldn’t anticipate a dose reduction will for sure lead to the elimination or alleviation of the side effect.   

Since my son felt it didn’t bother him most of the time, and the side effect seemed to wear off on the second day, we continued on with the new dosing intervals of once every two nights.

How to mitigate blurry near vision side effects of atropine?

My son experienced both common side effects of atropine – light sensitivity and blurry near vision. 

Light sensitivity could easily be addressed by wearing sunglasses. And, in the situation when it is extremely bright, and the sunglasses was not enough, additionally putting on his baseball cap was sufficient. 

Blurry near vision, which led to his reading problem, could also be mitigated by using magnifying glasses and improving brightness.

We got some magnifying visual aids of different designs to help him – a full-page magnifying sheet for reading books, a magnifying bookmark ruler for convenient use, and a card-sized one for backup. These visual aids were incredibly helpful. 

Improving lighting also helped. The following morning after treatment, by increasing the brightness from 250 lux to 850 lux around his desk, my son could read 25% more words with a font size of 11. At home, we added a reading lamp by his desk. We also informed his teacher of his special needs, so he could use his visual aids and be seated by the window where it was the brightest in the classroom.

Key Takeaways

Even though low-dose atropine may have fewer adverse events, some patients may still experience side effects. Light sensitivity and reading problems are the prominent reasons for treatment cessation. Adjusting dose and/or dosing intervals could help mitigate these side effects. 

In cases of adverse events, similar strategies for sun protection and managing presbyopia could be employed. Wearing sunglasses and/or a hat can help mitigate light sensitivity. Improving lighting and using magnifying aids can help reduce blurry near vision.

Help your kids adhere to their atropine treatment. Keep their myopia in control.

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1. Yam, J. C. et al. Two-year clinical trial of the low-concentration atropine for myopia progression (LAMP) study: Phase 2 report. Ophthalmology 127, 910–919 (2020).

2. Wei, S. et al. Safety and efficacy of low-dose atropine eyedrops for the treatment of myopia progression in Chinese children: A randomized clinical trial. JAMA Ophthalmol. 138, 1178–1184 (2020)

3. Joachimsen, Lutz et al. “Side effects of topical atropine 0.05% compared to 0.01% for myopia control in German school children: a pilot study.” International ophthalmology vol. 41,6 (2021): 2001-2008. doi:10.1007/s10792-021-01755-8