Pediatrics board addresses low-dose atropine treatment, myopia progression
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Data published in July in JAMA Ophthalmology showed that 0.01% atropine drops safely curbed myopia progression in children with intermittent exotropia and myopia.
Robert S. Gold, MD, and Healio | OSN Pediatrics/Strabismus Board Members discussed the latest updates in pediatric myopia management, including the use of atropine, during a roundtable.
Source: Robert S. Gold, MD
Robert S. Gold, MD: What are our current myopia treatment progression approaches? Have they changed? There were a lot of presentations at the American Association for Pediatric Ophthalmology and Strabismus meeting on this. I know each of us probably has a different choice.
Let’s say a 6-year-old patient comes into your office with –1 D refractive error, a family history of myopia and uncorrected vision of 20/40 in each eye. What would be your approach with this child?
Roundtable Participants
- Douglas R. Fredrick
- Robert S. Gold
- Rudolph S. Wagner
- Roberto Warman
- M. Edward Wilson
Douglas R. Fredrick, MD: The first thing to keep in mind is that family history is important because parents will come in with great concerns about myopia, and they will be preloaded because of the family history. This is often dependent on their racial or ethnic background. They may have learned a lot about myopia because the public awareness of myopia is great. After that, we can assess other risk factors. But we should bear in mind that the main risk factor is a family history of high myopia and/or retinal detachment.
With –1 D, I do not use low-dose atropine on all myopic individuals. I want to make certain that I have documented that they are having a rapid progression of myopia. I generally would not use low-dose atropine for a –1 D patient. I would not even get an axial length on that patient, but I would see them back in 6 months.
If they have gone up 1 D in that 6-month time frame, then I will consider starting low-dose atropine or at least introduce the discussion. I am still a low-dose atropine user in the Kaiser health system. We have switched to 0.05% atropine for the reasons we are all familiar with — the LAMP study and the issues of consistency of preparation.
In the Kaiser health system, we do not do orthokeratology for older children. If they are ready to move to contact lenses, we will offer either MiSight (CooperVision) or off-the-rack multifocal soft contact lenses with a +2.5 D add. We still do not have availability of peripheral defocus spectacle lenses in the U.S. When those become available, certainly we will offer them to some children.
I do not agree with the conclusion of the PEDIG study that states that 0.01% atropine should not be used “in U.S. children.” Atropine 0.01% is efficacious in some children, so if somebody comes into my office on low-dose 0.01%, then I think it is perfectly reasonable to continue that if their myopia is not progressing. What I did not like about that publication was the fact that it stated American children should not use 0.01% because I think an American child of East Asian descent is completely different from an American child of African American descent.
I think that you have to tailor your therapy based on all the considerations that we talked about.
Rudolph S. Wagner, MD: I agree with pretty much everything that Dr. Fredrick said as far as management. To me, a 6-year-old patient who is –1 D might not even need to be given a pair of glasses. At that point, my treatment depends somewhat on what the complaints are from the parents. I will ask, “How is he or she doing in school?” I will ask questions about their visual functioning that can help me make a treatment decision. I would not start them on atropine at that time, but I would like to see the patient again because progression of the myopia is likely.
I have been starting most patients who require atropine on 0.025% just because I had a few patients who did not tolerate the 0.05% formulation.
M. Edward Wilson, MD: It should be a team approach. Every pediatric ophthalmology group needs to decide how they are going to handle it. I do not want to treat these patients myself, but I want to identify them and make sure that within our group they are taken care of. I don’t think every surgically oriented pediatric ophthalmologist is going to spend the amount of time necessary to do myopia prevention and control. But we should all make sure that within our team, whether that is pediatric ophthalmologists or pediatric optometrists who work for you, that we can handle it.
The most important thing for me is that we need a product with a long shelf life, and I am happy that the Sydnexis trial of SYD-101 is complete. The FDA, I believe, has the data. If the Sydnexis product is approved by the FDA, I think the company is going to have two different doses available.
Many people have not jumped on the atropine bandwagon because of compounding. We know that low-dose atropine is unstable when compounded, which is why it has such a short shelf life. I think once we have an FDA-approved product, this treatment will take off.
Roberto Warman, MD: I agree that I normally do not start atropine treatment in a patient with –1 D, certainly on the first visit. There are parents who have requested and insist on the treatment — that is a different story. I don’t think there is any harm in doing it, but I agree with Dr. Fredrick. I want to see myopia progression before we jump into atropine.
One problem is that there is a large group of patients that do not get atropine, and their myopia does not increase significantly, while others progress. We don’t know yet how to separate which is which. That is why I think some of the PEDIG study and others are a little confusing. My discussion with the family is always that the treatment is safe, and I am all for it. But I don’t know if a particular child is going to progress or not. Once we start treatment, I think we need to continue it for a minimum of 2 or 3 years, and we have to agree that we may be treating somebody who was not going to progress. I have many of those patients already. I have run data comparing treated and nontreated patients, and there is no way to separate which are which.
Wilson: But don’t you require progression? Most of us would require progression before we put them in the category that may require atropine.
Warman: Correct, I agree. But even then, there are many patients who come from another doctor who had given them glasses, and now they say they increased more than –1.5 D. These patients come to you, and they are –3 D now. I have patients who stopped using atropine for multiple reasons, and their myopia did not continue to progress. We don’t know why that is the case. There is definitely a group of kids that do not progress without treatment.
In the future, we need to be able to identify what is the difference in these patients, at least in my mind. Of course, I will go ahead and treat in the meantime. I have 4 years’ worth of data now, and I am happy with the results I have seen in a large number of patients.
I went ahead and started treating young children with high myopia, around 3 years old with –5 D, and told the parents, “I have no idea if this is going to work.” When I talk to the parents now, I tell them less often that I think that it works. But I still put them on it because if I am going to try to get a response, it is going to be in patients with higher myopia. There are some who progress and some who do not, and it is still puzzling to know which is which.
Gold: This is interesting. We all use atropine, but we all do it differently. In my private practice, I discuss this with the parents. I always take the time to have that conversation because I do not have a pediatric optometrist who can do that. We have a method in our office where, if a child comes in with this situation, we have the discussion. We have information sheets to hand out about myopia and its progression as well as the different treatments that can be done.
Similar to what Dr. Fredrick said, I will see these kids back in 6 months and address where their myopia is, regardless of the patient’s age.
I am hesitant to put patients on a medication that they are going to need to be on for 2, 3, 4, 5 and 6 years or more. It is an expense, so I talk with the parents and give them options. Some leave the office and the next day call and say they want the atropine. Some come back in 6 months and have a small progression and end up not needing atropine, while others come back and do need it.
I know the 0.01% to 0.05% formulations were previously in controversy. In the last 2 years of offering atropine treatment, I have had two patients who I had to increase from 0.01% up to either 0.025% or 0.05%. My patients have tolerated it well, and the progression has been reasonable.
Wilson: Does your informational material go through the basic 20-20-20 and outdoor activity info? All of that is in your initial packet?
Gold: Correct. Some of the patients’ parents do not read it. You give it to them, and you hope they read it. But that 20-20-20 and outdoor exposure information is discussed with them in the exam room, too.
Fredrick: I have one question and I agree with Dr. Wilson. The value equation, as we like to say in the Kaiser system, is important. In the Kaiser system, this is all done by optometry. There is one compounding pharmacy for all 9 million Kaiser patients in Northern and Southern California. We have good quality control of the product that is being delivered, and it is a $15 copay.
And so, we are becoming a little bit worried. What is going to happen when the commercial product becomes available? I don’t know whether our pharmacy and therapeutic committee will allow us to continue to compound something if a commercial product is available, especially if it costs a lot more. We are looking at population health management. I think this is a conversation that is not going to end anytime soon.
Wilson: Isn’t the cost for most people more than that? Your costs seem low.
Gold: For me, it is about $60 a month.
Wilson: Does the average pediatric ophthalmologist in private practice or an academic setting, who usually has a patient backlog so large that it is hard to get a new patient in within 2, 3 or 4 months, have time to do this? I don’t think we do. I think we have to approach myopia control with a team approach. We are going to have to be efficient when adding this task to what we are already doing, and we have strabismus that needs to be taken care of in addition to other diseases that are more urgent. I worry that the average pediatric ophthalmologist is going to read this and say, “Wow, that sounds great, but I can’t spend that much time and see these patients every 6 months.”
- References:
- The safety and efficacy of SYD-101 in children with myopia (STAR). https://clinicaltrials.gov/study/NCT03918915. Updated Feb. 14, 2024. Accessed Aug. 8, 2024.
- Repka MX, et al. JAMA Ophthalmol. 2023;doi:10.1001/jamaophthalmol.2023.2855.
- Wang Z, et al. JAMA Ophthalmol. 2024;doi:10.1001/jamaophthalmol.2024.2295.
- Zhang XJ, et al. Ophthalmology. 2024;doi:10.1016/j.ophtha.2024.03.013.
- For more information:
- Douglas R. Fredrick, MD, of Kaiser Permanente South San Francisco, can be reached at douglas.r.fredrick@kp.org.
- Robert S. Gold, MD, of Eye Physicians of Central Florida, can be reached at rsgeye@gmail.com.
- Rudolph S. Wagner, MD, of Rutgers New Jersey Medical School, can be reached at r.s.wagner@rutgers.edu.
- Roberto Warman, MD, of Miami Children’s Hospital, can be reached at rwarman@eyes4kids.com.
- M. Edward Wilson, MD, of Storm Eye Institute, Medical University of South Carolina, can be reached at wilsonme@musc.edu.
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