As school resumes during the pandemic, are you motivated to prescribe low-dose atropine?
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Important to talk about use of dilute atropine
The parents of children in my practice are worried about increased screen time during the pandemic.
In a survey recently conducted by the Global Myopia Awareness Coalition, the percentage of children spending 4 or more hours per day using electronic devices increased from 21% to 44% when the COVID-19 outbreak began. The increased near work combined with decreased outdoor time makes atropine therapy conversations (and prescriptions) in the office more important than ever before. The 5-year results from the Atropine for the Treatment of Myopia 2 (ATOM 2) clinical trial supported the conclusion that a daily dose of atropine 0.01% is an effective first-line treatment in children aged 6 to 12 years who have myopia that is progressing. It slows progression with few side effects. The ATOM 3 trial is studying low-dose atropine in children at high risk for myopia even before they develop it. The increases in near work/indoor time bring more kids into this at-risk group.
At present, there is no FDA-approved formulation of dilute atropine. However, an FDA trial is underway, and when completed, I anticipate a large increase in prescriptions written for myopia control. Atropine is unique in that it is unstable at near physiological pH. As a result, compounded products have a short shelf life. Out-of-date product stings because the pH drops. Also, compounded products are not tested for strength/potency. I have been told that the product being tested for FDA approval will be stable and maintain a constant potency and pH, making it comfortable and giving it a shelf life measured in years rather than days. We should expect many more inquiries from parents, and we need to be ready with answers.
The goal of low-dose atropine therapy is to slow myopia progression during the most active growth years so that fewer children will develop high or pathological myopia and avoid the blinding consequences that can occur. During the pandemic, lifestyle changes (less screen time and more outdoor play) that would help prevent myopia progression are not as likely to occur, increasing the need for informed conversations about the use of dilute atropine.
- Reference:
- Chia A, et al. Ophthalmology. 2016;doi:10.1016/j.ophtha.2015.07.004.
M. Edward Wilson, MD, is an OSN Pediatrics/Strabismus Board Member.
Less consistent availability may limit success
I would like to state that I am in favor of atropine drops at bedtime to try to slow the progression of myopia in childhood, and I have been using it in my clinical practice for almost 4 years. I initially used atropine 0.01% as in the ATOM 2 study, and now I have converted to 0.05% after the Hong Kong study was recently published.
However, I have found inherent compliance problems with the regimen of one drop in each eye at bedtime, just as everybody has experience with poor compliance to glaucoma drops in a chronic fashion. If this treatment is not done consistently, it will not be effective, and we need at least 2 years to be comfortable it is responding positively. I have found that at least 50% of patients give up usually by 6 months.
A second issue is having a compounding pharmacy consistently available for refills. The latter has improved, but it was a significant problem at first, and in most cases, the parents have to pay out of pocket as they are compound drops and not FDA approved. Now we add the problems with access during the past 6 months during COVID-19, and those factors worsen as parents do not want to come for routine exams because they are afraid of getting the coronavirus or because, for economic reasons, they do not want to incur any expense not deemed essential to them. When both parents have myopia, particularly moderate to high, there is more motivation for treatment, and those hurdles can be overcome. However, engagement by the physician and detailed explanations are necessary.
In summary, despite the likelihood of increased screen time and possibly decreased outdoor activities during the COVID-19 pandemic, the long-term success rate of low-dose atropine as a treatment to decrease progression of myopia will be limited. The modality with peripheral defocus contact lenses, although more costly at first, hopefully will lead to higher compliance and might give us better results.
Roberto Warman, MD, is an OSN Pediatrics/Strabismus Board Member.
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