Topical Atropine for Myopia Management: What Does the Latest Research Tell Us?

By Jianfeng Zhu, MD
Consultant Pediatric Ophthalmologist
Shanghai Eye Disease Prevention and Treatment Center
Visiting Research Scientist, Brien Holden Vision Institute

A network meta-analysis on myopia control found that use of atropine at different concentrations was significantly superior to other interventions (for example, progressive addition spectacle lenses, multifocal soft contact lenses, orthokeratology, more outdoor activities, etc.)1 Other reviews and meta-analysis similarly concluded that there was less myopic progression with atropine and that both the efficacy and adverse effects were dose-dependent.2, 3

Atropine is a non-selective muscarinic acetylcholine receptor antagonist (mAchR), and the underlying mechanisms by which it controls myopia progression remain unclear. Initially, it was thought that the drug acted via accommodative mechanisms. Later evidence suggested that the mechanism was via non-accommodative pathways,4 with some reports suggesting that atropine exerted its action via retinal amacrine cells and dopamine; when atropine binds to mAchR on the cells, they could release dopamine, which is considered to play a role in slowing myopia.5-7 Other studies reported that atropine could be directly acting on sclera8 and might play a role in inhibiting glycosaminoglycan production and, thus, eye growth. 9, 10

Of all the concentrations assessed, 1% (the highest concentration assessed) atropine used daily has the best efficacy for slowing myopia. However, the concentration is also associated with severe side effects that include photophobia, blurred near vision and worse vision-related quality of life. Additionally, on discontinuation of the drug, the magnitude of rebound observed was greatest with this concentration. Lower concentrations of atropine notably 0.01% was considered to be an effective concentration as there was still a significant slowing of myopia with respect to spherical equivalent, adverse effects were minimal, and there was less rebound after cessation. However, both ATOM2 and LAMP studies showed that while 0.01% atropine was beneficial over placebo as determined by change in spherical equivalent (SE), there was no benefit observed with the change in mean axial length (AL) 11,12. Therefore, 0.01% might not be the ideal dose of atropine for controlling axial myopia.

So, should we attempt a higher concentration? Shih et al. reported 0.5% atropine was the most effective for controlling myopia progression (-0.04±0.63D per year) compared with 0.25% (-0.45±0.55D per year) and 0.1% atropine (-0.47±0.91D per year), but they had not considered adverse effects with the various doses.13 In comparison, ATOM2 study confirmed the efficacy of 0.5% and 0.1% atropine to be superior to 0.01% but reported more severe adverse effects with higher concentrations.11 More recently, the LAMP study reported 0.05% to be the most effective dose for slowing myopia compared with 0.025% and 0.01% while not affecting vision-related quality of life.12 Lee et al. found similar efficacy of 0.05% atropine.14 In conclusion, based on these reported data, low concentration atropine (0.05% to 0.1%) atropine might be a desirable starting concentration. It should be noted that the frequency of atropine use in most clinical trials is once per day and this respect, the use of high-dose atropine at a reduced frequency might be an alternative way to lower the adverse effects while maintaining efficacy, but it remains to be explored.

When should one start atropine treatment for myopes? Most clinical trials showed atropine to exert a satisfactory effect for participants aged 4 to 16 years old. In control eyes, slowest myopia progression was observed in older children (>18 years) and the fastest progression occurred between 8 to 12 years.15 Thus it is advisable to commence at an age when progression is faster. However, younger age was also found to be a risk factor for poor atropine response,16 and additionally, early use of atropine on infant monkeys had an impact on anterior segment eye growth and emmetropization.17 Thus, caution should be exercised in very young children (possibly <4 years) with atropine. Although the majority of studies with atropine were aimed at children with moderate myopia (mean baseline SE ranging from -3.0D to -5.0D) a study found 0.5% atropine to be equally effective for low myopia (-0.5D to -2.0D).18 Additionally, 1% atropine was found to show better myopia control with low myopia (-0.5D to-2.0D) (SE change: 0.32±0.22D per year; AL change: -0.03±0.07mm)19 than moderate-high myopia (≥-3D) (SE change: 0.06±0.79D; AL change: 0.09±0.19mm).20 Thus, it appears that it would be beneficial to start a person on atropine at the onset of myopia. In terms of duration of treatment, the optimal length of treatment is not clear, although most recommend one to two years of active treatment. In Taiwan, use of atropine is continuous till late adolescence (around 15–18 years old), as myopia progression is considered to stabilize around this period.21

Is atropine useful for preventing the onset of myopia? Atropine at 0.025% atropine was effective in preventing myopia onset in pre-myopes (<+1.0D) (change of -0.14D ± 0.24D per year) compared with the control group (-0.58D ± 0.34D per year)22. However, this finding needs to be validated with further studies, and, clearly, the concentration should be as low as possible without the risk of adverse effects. At the other end of the spectrum, there have been very few studies that have assessed the efficacy of atropine in high myopia (worse than -6.0D). However, these found atropine to be efficacious in highly myopic eyes. Atropine at 0.5 % was effective in slowing high myopia in a small group of children compared to tropicamide,23 and in another study, high myopia patients benefited more from 0.125% atropine than low to moderate myopia.24 Thus, the use of atropine in high myopia might have been underestimated but requires further work.

In summary, in terms of benefit versus risk, atropine at concentrations ranging from 0.05 % to 0.1% might be a desirable starting point to initiate treatment. Although these concentrations are not free of side effects, they appear to be less severe and additionally show lesser rebound on discontinuation. Initiating therapy at the onset of myopia may provide greater control and therefore reduce the risk of the eye reaching higher levels of myopia. Although the optimal length of treatment is not clear, continuing treatment until after myopia is stabilized may be a useful strategy to reduce the risk of rebound. In addition, atropine appears to have a role in preventing or delaying the onset of myopia as well as controlling progression in high myopes, but this remains to be explored further.


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  1. Like many interested in myopia control, I was excited by the initial indication that 0.01 was effective and more importantly had little rebound effect. Having gone to considerable trouble to find convenient compounding pharmacist and putting a number of patients on this dose daily, I then learned of its failure to stop axial growth which I measure and consider to be best indicator of success or not.
    How did this poor dissemination of results occur in your opinion.
    Anyway I’m now left with no satisfactory atropine option except perhaps as an add on when other treatments are not stopping axial growth. But even here i don’t have clear idea of optimal strength. Can you throw light on this?
    Finally I’m in agreement with the Taiwan approach of waiting till late adolescence to come off daily dose but as far as I was aware this is at least frowned upon elsewhere and I don’t know of any studies to support use for more than a couple of years. What’s your opinion about this issue because even if we taper off I feel rebound can’t be eliminated and this makes Atropine a poor choice in most cases here in Oz don’t you agree?

  2. Is anyone here in the US actually prescribing atropine to kids as prevention of myopia? Doesnt this create near blur and potential learning deficits??? Maybe atropine isnt as devastating to vision as i thot……BUT……I would rather have kids be a -4.00 and excellent readers and students…..than -1.00 and hate school. Am I wrong?

  3. 1. I used Atropine eye drops for almost 20 years. First I use 0.25% every night but the side effect was strong, so I started to use them twice a week or once a week. then I find 0.125% will be better, if you use them twice a week or 3 times a week. I think 0.01% is too weak, although it almost has no side effect.
    2.If you live in China, you probably will no say these words. Because in China, 20% of our high school students are now high myopia!

  4. Hello,
    The LAMP study reported 0.05% to be the most effective dose for slowing myopia compared with 0.025% and 0.01% while not affecting vision-related quality of life.1 Lee et al. found similar efficacy of 0.05% atropine.2
    Although the optimal length of treatment is not clear, continuing treatment until after myopia is stabilized may be a useful strategy to reduce the risk of rebound.
    Atropine eye-drops were recently approved by the United States Food and Drug Administration for long-term amblyopia therapy in children. There is currently no regulatory approval for the use of atropine to slow myopia progression. However, three Phase III clinical trials utilizing low-dose atropine are presently being conducted in the US for the purpose of obtaining an FDA labeling indication for myopia control.
    Best regards,
    Dwight Akerman, OD, MBA

    1Yam JC, Jiang Y, Tang SM, et al. Low-Concentration Atropine for Myopia Progression (LAMP) Study: A Randomized, Double-Blinded, Placebo-Controlled Trial of 0.05%, 0.025%, and 0.01% Atropine Eye Drops in Myopia Control. Ophthalmology 2019;126(1):113-24.
    2Lee JJ, Fang PC, Yang IH, et al. Prevention of myopia progression with 0.05% atropine solution. J Ocul Pharmacol Ther. 2006;22(1):41-6.


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