September 21, 2026
By Ashley Tucker, OD, FAAO, FSLS
Image generated with AI
A new prospective study published in Ophthalmology Science explored a practical question that comes up frequently in myopia management: Should every child start with a higher concentration of atropine, or can we start low and increase the concentration only when necessary? The investigators evaluated a stepwise approach in which all children began treatment with 0.01% atropine and were moved to higher concentrations based on their individual response.
Study Design
The study enrolled 150 children ages 8 to 14 years with myopia between −1.00D and −6.00D. It was a prospective, 18-month study conducted at Beijing Tongren Hospital. Importantly, this was not a randomized controlled trial. All participants followed the same initial treatment pathway.
For the first six months, every child used 0.01% atropine once daily. At six months, treatment was adjusted according to refractive progression:
- <0.25D progression: remain on 0.01%
- 0.25–0.375D progression: increase to 0.02%
- >0.375D progression: increase to 0.04%
The new concentration was then continued for another 12 months. Cycloplegic spherical equivalent refractive error (SER), axial length (AL), pupil size and intraocular pressure were measured throughout the study.
How Many Children Needed a Higher Dose?
After six months on 0.01% atropine, 52.7% of children demonstrated less than 0.25D of progression and remained on 0.01%. However, 31.5% were switched to 0.02%, and 15.8% required escalation to 0.04%. In other words, nearly half of the children did not meet the study’s definition of adequate control on 0.01% atropine.
What Happened After Increasing the Dose?
The results following escalation were encouraging. Children ultimately assigned to 0.02% had progressed −0.31D during their first six months on 0.01%. After switching to 0.02%, progression was only −0.21D over the following 12 months. The children requiring 0.04% had initially progressed even faster at −0.53D in six months. After increasing to 0.04%, progression slowed dramatically to −0.18D over the subsequent year.
Axial length showed a similar pattern. During the 12 months following the treatment decision, axial elongation was 0.15 mm with 0.01%, 0.13 mm with 0.02% and 0.14 mm with 0.04%. Interestingly, despite starting phase two as very different responders, the groups ended up with relatively similar axial elongation.
What About Side Effects?
Higher concentrations produced somewhat more pupil dilation and photophobia, but overall tolerability was good. Photophobia occurred in 5.2% of the 0.01% group, 6.5% of the 0.02% group and 13.0% of the 0.04% group. Only two children required progressive lenses for near vision, and no adverse event required atropine discontinuation or dose reduction.
The Important Limitation
This study provides an intriguing treatment strategy, but the results need to be interpreted cautiously. There was no control group of poor responders who remained on 0.01%. Because children were assigned to higher concentrations specifically because they had progressed rapidly during the preceding six months, some subsequent slowing could represent regression to the mean rather than the effect of increasing atropine concentration. The authors appropriately describe the study as exploratory and hypothesis-generating rather than definitive evidence for this approach.
Clinical Takeaway
Perhaps the most useful message from this study is not that we should necessarily start every child at 0.01%. Instead, it supports the concept that atropine treatment can be dynamic rather than fixed. More than half of these children achieved the study’s target on 0.01%, while poor responders appeared to improve after escalation to 0.02% or 0.04%.
For clinicians, this reinforces the importance of measuring treatment response and being willing to modify therapy when progression continues. The study provides an interesting framework—start, reassess at six months and escalate when necessary. However, a randomized controlled trial is still needed before we can conclude that this specific stepwise protocol is superior to simply beginning treatment with a higher concentration.
Abstract
Stepwise Increase in Concentrations of Atropine Treatment for Myopia Control Study
Shifei Wei, PhD, Wenzai An, PhD, Yunyun Sun, PhD, Xintong Liang, PhD, Weiling Bai, MD, Zhining Cai, MD, Shengjun Zhao, MD, Shi-Ming Li, PhD, Ningli Wang, PhD
Purpose
Design
Participants
Methods
Main Outcome Measures
Results
Conclusions
