Pharmacological Control of Myopia With Atropine

Reading, specifically extended reading or near work has been implicated as one of the causes of myopia progression. It has been suggested that the over accommodation of the eye during extended reading or near work leads to stretching, hence lengthening of the eye which contributes to the worsening of myopia in children. There is a long history of studying the effect of paralyzing the focusing of the eye and applying glasses that perform the focusing for the eye as a treatment for worsening vision or nearsightedness.Dr Chua Weihan and his team at National Eye Centre Singapore have conducted large scale studies on the effect of Atropine of varying strength in stabilizing, and in some case, reducing myopia. The use of reading glasses when doing close work may provide success by reducing or eliminating the need to accommodate. Altering the use of eyeglasses between full-time, part-time, and not at all does not appear to alter myopia progression.

Yen MY et al in Ann Ophthalmol. 1989 May;21(5):180-2, 187 compared the effect of atropine and another drop that paralyzes accommodation, cyclopentolate, on myopia. Analysis showed that atropine and cyclopentolate are effective in slowing the progression of myopia. The effect of atropine is better than that of cyclopentolate.
Bedrossian in Ophthalmology. 1979 May;86(5):713-9 studied The effect of atropine on myopia. In his study, control eyes showed significant increases in myopia compared to treated eyes. Some treated eyes showed decreases in myopia; no decreases were seen in control eyes. Post treatment data analysis indicates the effects are long-term. Another study, Eye (Lond). 2008 Apr;22(4):576-81. Epub 2007 Oct 19 , found the most common causes of the increase in axial length include genetic predispositionThe most common causes of the increase in axial length include genetic predisposition

A study published in Ophthalmology, Volume 116, Issue 3, Pages 572-579 (March 2009) assessed the effect on myopia progression after cessation of topical atropine treatment. They concluded after stopping treatment, eyes treated with atropine demonstrated higher rates of myopia progression compared with eyes treated with placebo. However, the absolute myopia progression after 3 years was significantly lower in the atropine group compared with placebo.

Chua WH in Ophthalmology. December 2006 evaluated the efficacy and safety of topical atropine, a nonselective muscarinic antagonist, in slowing the progression of myopia and ocular axial elongation in Asian children. They concluded Topical atropine was well tolerated and effective in slowing the progression of low and moderate myopia and ocular axial elongation in Asian children
Dyer, JA, studied the Role of cyclopegics in progressive myopia. (Ophthalmology. 1979 May;86(5):692-4) They compared a similar group of children having only glasses prescribed during a similar time span revealed that atropine is effective in reducing the progression of myopia in children; a permanent reduction in the degree of myopia may be achieved. Relaxation of accommodation by means of cycloplegic drugs may be a safe and effective treatment of myopia.

Shih YF, et al, in a study entitled “An intervention trial on efficacy of atropine and multi-focal glasses in controlling myopic progression”. (Acta Ophthalmol Scand. 2001 Jun;79(3):233-6) ran a randomized clinical trial which assessed the treatment effects of atropine and/or multi-focal lenses in decreasing the progression rate of myopia in children. They concluded The 0.5% atropine with multi-focal lenses can slow down the progression rate of myopia. However, multi-focal lenses alone showed no difference in effect compared to control.

Syniuta LA, Isenberg SJ in Binocul Vis Strabismus Q. 2001;16(3):203-8 attempted to address observer bias in previous studies by To address this issue, we evaluated our experience including the duration that atropine maintains a child at 20/30 or better in one spectacle correction compared with controls. They found Atropine ophthalmic solution nearly halted myopic progression in this investigation. Patients on atropine remained 20/30 or better with a single pair of glasses significantly longer than the control group. While a larger and better controlled study is desirable, atropine appears to be a viable method to retard myopic progression.

Chiang MF, et al (Binocul Vis Strabismus Q. 2001;16(3):209-15) report the largest known series of patients treated simultaneously with bifocals and topical atropine. They concluded full compliance with topical atropine therapy and bifocal spectacles was associated with decreased progression of myopia compared to partial compliance with treatment. For each of the treated groups, the mean rate of myopic progression was significantly less (P<0.05) than the mean annual rates of myopic progression published for the pediatric population. Kennedy RH, et al in Binocul Vis Strabismus Q. 2000;15(3 Suppl):281-304. Concluded the data support the view that atropine therapy is associated with decreased progression of myopia and that beneficial effects remain after treatment has been discontinued. Kennedy et al ran another study in Progression of myopia. Trans Am Ophthalmol Soc. 1995;93:755-800 where they found the data support the view that atropine therapy is associated with decreased progression of myopia and that beneficial effects remain after treatment has been discontinued. Brodstein et al, ran the study . “The treatment of myopia with atropine and bifocals. A long-term prospective study”. Ophthalmology. 1984 Nov;91(11):1373-9 followed Two hundred fifty-three patients were followed for up to nine years (mean, 4 1/4 years). They were on a regimen of atropine 1% once a day in an attempt to retard myopic progression. The results from several analyses showed a marked flattening in the rate of myopic progression during treatment, and the rate of myopic progression after treatment ran parallel to those in the control group. The fastest rate of myopic progression occurred between eight and 12 years of age, and the slowest rate of myopic progression developed in those patients over 18 years of age. In “Atropine reduces experimental myopia and eye enlargement via a nonaccommodative mechanism.(Invest Ophthalmol Vis Sci. 1993 Jan;34(1):205-15), clinicians set out to determine whether the muscarinic antagonist atropine effectively reduces or prevents experimentally induced myopia via a nonaccommodative mechanism. The findings demonstrate that chronic administration of the muscarinic antagonist atropine prevents experimentally induced myopia in chick via a nonaccommodative mechanism. Ong E. et al. studied “Effects of spectacle intervention on the progression of myopia in children” (Optom Vis Sci. 1999 Jun;76(6):363-9). Their study failed to demonstrate any overall effects of spectacle intervention on the progression of human myopia. The British Journal of Ophthalmology, 1989 Jul;73(7):547-51 published a study “Effect of spectacle use and accommodation on myopic progression: final results of a three-year randomized clinical trial among schoolchildren”. Two hundred and forty mildly myopic schoolchildren aged 9-11 years were randomly allocated to three treatment groups and the progression of myopia was followed-up for three years. The treatment groups were: (1) minus lenses with full correction for continuous use (the reference group), (2) minus lenses with full correction to be used for distant vision only, and (3) bifocal lenses with +1.75 D addition. They found that myopic progression is connected with much use of the eyes in reading and close work and with short reading distance but that progression cannot be reduced by diminishing accommodation with bifocals or by reading without spectacles. Chou AC, Shih, YF, Ho, TC, Lin, LLK. studied “The effectiveness of 0.5% atropine in controlling high myopia in children” (J Ocul Pharmacol Ther. 1997 Feb;13(1):61-7) This randomized clinical trial assessed the treatment effects of atropine and/or multi-focal lenses in decreasing the progression rate of myopia in children. They studied Two hundred and twenty-seven schoolchildren with myopia, aged from 6 to 13 years, who were stratified based on gender, age and the initial amount of myopia were randomly assigned to three treatment groups: 0.5% atropine with multi-focal glasses, multi-focal glasses, and single vision spectacles. Each subject was followed for at least eighteen months. These results report on the 188 patients available for the follow-up. They concluded the 0.5% atropine with multi-focal lenses can slow down the progression rate of myopia. However, multi-focal lenses alone showed no difference in effect compared to control. Gimbel HV. In “The control of myopia with atropine”. (Can J Ophthalmol. 1973 Oct;8(4):527-32) Studied the safety and efficacy of topical 1% atropine eye ointment in retarding myopic progression in children with moderate to severe myopia. He concluded Topical 1% atropine ointment is a safe and effective treatment for retarding myopic progression in moderate to severe myopia. Further large-scale randomized controlled study with longer follow-up seems warranted. Potential Side Effects of Atropine and Other Cycloplegic Agents The focusing paralysis and pupil dilation caused by atropine cause light sensitivity and reduce children's ability to perform well at school and during sports. Plus, a constantly dilated pupil looks odd, a problem for kids because they tend to want to fit in, not stand out from the crowd. Pirenzepine gel has also shown potential as a drug therapy for slowing myopia progression, but it is not FDA-approved, and, like atropine, it has unwanted side effects. Atropine has an extensive potential for reactions. These include hallucinations and sensitivity to light. Certain investigators suggest prolonged exposure to atropine may lead to retinal toxicity (Romano PE. Binocul Vis Strabismus Q. 2001;16(1):12) Jpn J Ophthalmol 2007;51:27–33 Published a study on the safety and efficacy of topical 1% atropine eye ointment in retarding myopic progression in children with moderate to severe myopia. Pirenzepine 2% gel has been evaluated by some clinical trials in the United States for treatment of myopia. It has better patient acceptance and is easy to use, but myopia control is not as good as that achieved with atropine. The cost of pirenzepine is unknown because it has not completed U.S. clinical trials. They concluded topical 1% atropine ointment is a safe adn effective treatment for retarding myopic progression in moderate to sever myopia. Further large-scale randomized controlled study with longer follow-up seemed warranted. January 15, 2012 - Current treatments to slow the progresion of myopia in children either don't work or cause problematic side effects, according to a recent review published by pediatric eye doctors and study methodologists. The reviewers analyzed ddata from 23 randomized controlled trials, which included a total of 4696 participants. They considered a number of potential myopia treatments including bifocal glasses, eye drops, intraocular pressure-lowering drugs and contact lenses. The follow up was at least one year for all studies. Of all the treatment, anti-muscarinic eye drops (atropine) offered the largest positive effects for slowing myopia progression, the authors found, but they caused either light sensitivity or blurred near vision.