Atropine for myopia management is a leading strategy in eye care, helping to slow progression in children. Combined with OrthoK therapy, it enhances treatment effectiveness.
Atropine for myopia management has been at the forefront of eye care research as a promising approach to slow the progression of nearsightedness, a condition that is expected to affect half the world’s population by 2050. Myopia progression in children and adolescents is a growing concern globally, and our eye doctors are examining how low-dose atropine treatments can reduce risks associated with significant myopic shifts. This page reviews the research on atropine for myopia management, highlighting scientific findings and ongoing discussions in the field.
Atropine eye drops have been extensively studied for their potential to slow myopia progression. Researchers believe that atropine affects the eye’s ability to change focus by paralyzing the ciliary muscles, which in turn may reduce the accommodative lag—a factor linked to myopia progression in children. Additionally, atropine appears to increase choroidal thickness, interfere with the remodeling of the sclera, and modulate retinal dopamine release, all of which are thought to contribute to a slower axial eye growth.
Here’s the thing: while the exact biological pathways of atropine are not fully elucidated, several theories have emerged. One theory suggests that by reducing the accommodative effort of the eye, atropine minimizes the lag in focusing when reading or doing near work. This is crucial because sustained accommodative stress has been linked to an increased risk of myopia progression. In addition, by increasing the choroidal thickness, atropine might help stabilize the overall structure of the eye, thereby reducing the risk of axial elongation. Researchers have also explored atropine’s effects on retinal neurotransmitters, where an altered dopamine release appears to have a moderating effect on eye growth.
Research has shown that atropine, when used in higher doses (such as 0.5% or 1%), can inhibit myopia progression by up to 88.7% compared to a placebo. However, these high doses often come with side effects and a phenomenon known as rebound, where myopia progression accelerates after treatment cessation. In contrast, lower doses—typically 0.01% to 0.05%—have demonstrated the ability to slow myopia progression by 49% to 60%, with fewer side effects and a reduced risk of rebound. A 2020 meta-analysis highlighted 0.05% as an optimal balance between efficacy and tolerability, yet many countries in East Asia, such as Taiwan and Singapore, have widely adopted the 0.01% concentration based on their clinical practices.
Alongside atropine, orthokeratology (OrthoK) has been a popular intervention for myopia control. While both treatments aim to slow the axial elongation of the eye, they operate through distinct mechanisms. OrthoK lenses reshape the cornea overnight to temporarily correct myopia, creating changes in the corneal curvature that help reduce peripheral defocus. However, studies have illustrated that the greatest potential for myopia management might arise from combining these treatments.
When used in tandem, atropine and OrthoK may work synergistically. The combination appears to be more effective than OrthoK lenses alone in slowing the rate of axial eye elongation. One hypothesis is that atropine-induced pupil dilation exposes more of the peripheral retina to the myopic defocus produced by the reshaped cornea from OrthoK lenses. Furthermore, atropine’s slight reduction in accommodation may decrease the hyperopic defocus during near work, which is particularly beneficial for controlling myopia in children. Some studies have noted that when 0.01% atropine is added to OrthoK therapy, there is a measurable additional slowing in the axial elongation of the eye, sometimes in the range of 0.11 to 0.18 mm over a one-year period.
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The landmark ATOM1 and ATOM2 studies have shaped our understanding of atropine’s beneficial effects on myopia progression. These prospective, randomized, double-masked studies provided level 1 evidence of the efficacy of atropine for reducing myopic progression when administered over a two-year period. ATOM1 employed a study design where the treatment was administered in one eye only, while ATOM2 treated both eyes and tested a range of atropine concentrations, including 0.01%, 0.1%, and 0.5%.
ATOM2’s findings have influenced how eye care professionals approach dosage selection for myopia management. The study suggested that all doses of atropine provided measurable benefits when patients were actively on treatment, but importantly, lower doses such as 0.01% resulted in less rebound after stopping the drops. This phenomenon indicates that lower doses may have a more durable treatment effect over the long term. A closer look at the ATOM2 cohort revealed that children treated with 0.01% atropine had less myopia progression at long-term follow-up, supporting the notion that “less can be more” when it comes to balancing treatment efficacy and minimal side effects.
The ATLAS study provided observational data looking at patients 10 to 20 years after the completion of the original ATOM trials. It evaluated changes in refractive errors and axial length along with the incidence of ocular complications such as myopia macular degeneration (MMD). The study found that while there were no significant differences in final refractive errors between atropine-treated and untreated eyes, trends within the ATOM2 cohort indicated a dose-response relationship. Specifically, lower doses of atropine, particularly 0.01%, were associated with reduced progression and lower incidences of MMD compared to higher doses.
While the research on atropine for myopia management has been instrumental in demonstrating its potential, there are important limitations that both researchers and patients need to understand. One significant challenge lies in the heterogeneity of study designs. For example, ATOM1 and ATOM2 had different dosing paradigms—one treating one eye and the other treating both—which complicates direct comparisons. Additionally, differences in diagnostic equipment and follow-up protocols between various studies add layers of complexity to interpreting long-term results.
Here’s some context: When comparing results across studies, scientists must account for several methodological differences. In the ATLAS study, for instance, the elapsed time between the conclusion of the original study and the follow-up analysis varied markedly. ATOM1 participants were evaluated approximately 21 years after baseline, while ATOM2’s follow-up occurred at around 15 years post-baseline, with considerable differences in the ages of the participants at follow-up. Such disparities can confound conclusions drawn from inter-study comparisons.
Moreover, the ATLAS study had a limited follow-up cohort, with only 17.8% of ATOM1 participants and 39.5% of ATOM2 participants providing data. This introduces the potential for selection bias, as patients who experienced adverse events or had a particular progression pattern may have been less likely to participate in the long-term follow-up. These limitations underscore the importance of cautious interpretation of the data and a need for further research with more robust, longitudinal methodologies.
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Atropine for myopia management offers promising solutions for slowing myopia progression in children with fewer side effects.
