How do you include atropine in your treatment of myopia?
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Atropine first choice for rapid progression
As everybody knows, the incidence and prevalence of myopia are increasing in every country around the world.
The causes of myopia are still subject to debate, but we know that the most important determinant of whether a child ends up being myopic or not is their parents’ refractive status. Other risk factors that seem to be strongly associated with both the development and progression of myopia are more time spent indoors and more time at near work.
When we take these factors into consideration, along with racial background, and we see a child who is becoming more than 0.5 D myopic per year or who becomes myopic at an early age, we consider that high risk for rapid progression.
There are a number of treatment modalities for children with rapid progression of myopia, but my first choice is low-dose atropine. While use of atropine for myopia control is not yet FDA approved, low-dose atropine is the most widely studied treatment, and research shows us that it works.
I usually start at a concentration of 0.05%, which comes with an excellent safety and acceptance profile. We also know that at higher concentrations, it becomes even more efficacious. If I see a patient who is progressing very rapidly, 1 D to 2 D per year, I will even use 0.5%, even if that means having to put the child in progressive bifocals or photochromatic lenses if they are bothered by photophobia.
The idea is to stop the progression of myopia with whatever concentration you need, and then we can taper down the strength of atropine to the lowest concentration that prevents myopia progression. So, I tend to be more aggressive when there are high degrees of myopia. I want to shut it down really fast.
Douglas R. Fredrick, MD, is an OSN Pediatrics/Strabismus Board Member.
Selective use
There are several treatment modalities commonly used in myopia, including the MiSight lens (CooperVision) or orthokeratology, as well as low-dose atropine. While atropine is one of the most common treatments, for most of my patients, I do not use it.
The reason for that is that low-dose atropine has to be prescribed as an off-label medication. You can get it done by a compounding pharmacy, but I have not always been happy with the production of these drops at such a low dose. I can never be sure what the quality control is like at these facilities. Most likely they are fine, but it is still not totally regulated as it would be using an FDA-approved medication with the indication for treating myopia.
Some of these drops can be buffered differently, which can lead to stinging when administered to the eye. Children get these drops every night, and you want them to be comfortable so they will not resist using them.
Some people will use it on all patients with myopia, such as children who come in at –4 D to –5 D. I am not as aggressive as that because I do not think you are preventing too much when they are just beginning at those higher rates of myopia. I feel like I can make a bigger difference on the children with low myopia who have a real likelihood of developing progressive myopia because of family history. I do not have a lot of patients on atropine, but the ones who are on it, I have selected because I feel like they would benefit from it the most.
There is no right or wrong answer, but for the reasons I said, I use atropine selectively in those cases.
Rudolph S. Wagner, MD, is an OSN Pediatrics/Strabismus Board Member.
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