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Combining atropine and orthokeratology for a fast progressing myope

Posted on August 17th 2021 by Connie Gan

In this article:

Can a combination treatment of orthokeratology and atropine benefit a fast progressing myope? The latest on combination therapy is described.

Both orthokeratology (OK) lenses and low-concentration atropine are effective forms of myopia control.1,2 Could we expect a greater efficacy to control myopia if we combine the treatments? In this post, LH is considering whether to start a young patient on a monotherapy or go straight to combination treatment. Here is the original post.

LH

Classic Case for discussion that further adds to KG discussion about combination treatment. First patient this morning: 10 year old boy comes into my office with his mother to see me for the first time. He is in tears before he even see me as he is worried he will need stronger thicker spectacles. His mother is -11D OU. History: At age 7: R -1.25 and L -1.50 At age 9: R -2.75 and L -3.00 Today : R -4.25 and L -4.25/-0.50x180 Orthophoria at distance and near. 6mm pupils. Cornea clear without staining. Myopic cresents around both optic nerve heads. Booked further appointment for axial length measurement. I have discussed and given information about myopia control: environment, atropine, orthoK, mSCL ect. Boy and mother were keen to start atropine immediately and are considering OrthoK. So if the patient is using Atropine every evening and then starts OrthoK in the next couple of weeks. What instructions do you give the patient? I know there are so many assumptions, however if you are going to use both atropine and orthoK in best practice how would you approach this. Stop Atropine use? Taper Atropine use? Instill Atropine 5 mins prior to inserting lenses? Instill Atropine in the morning after removal of lenses? Instill Atropine drops in the back of the orthoK lenses?

To combine or not to combine treatments?

PP I would have him stop atropine Sunday.....I would think no need to taper this short of wear with the small concentration. Get him into ortho-k in the next couple of weeks. If he starts progressing after 8-9 months in program, consider adding atropine. I would think the drops could cause mild kerititis or soften the corneas, or something, so it bothers me to put ortho-k on over that. I know, after putting dilating drops on corneas, sometimes the corneas show mild irritated look with the biomicroscope. I would love for some studies looking at corneal effects of atropine drops…CW … I think it's probably best to try one thing first (e.g. Atropine or orthok) and consider adding or switching treatment if there is still progression. I don't think there are any studies done showing an additive effect of dual therapy so can be hard to justify the combined cost/risk before establishing that single treatment isn't sufficient.GB Being conservative I would not go for dual therapy in this case. PP, regarding your worries re atropine, this should be investigated.


This case was presented prior to scientific publications on combining atropine and orthokeratology, hence some commenters expressed concern about the evidence base. This is still a fair comment as we only have a handful of studies now indicating an additive effect by combining orthokeratology and atropine. Thus far, the ideal concentration and ideal targets for dual therapy are yet to be determined - early indication is that 0.01% and lower myopes of 1-3D may be the answers, respectively.3,4

There is also merit to the commenters' opinions to start one treatment first to determine its myopia control efficacy, before adding an adjunct. This indicates consideration to safety, as additive treatments could also increase the risk of complications, for example irritation from preservatives in atropine increasing risk of a contact lens adverse event.

What do we know about combination treatment efficacy?

Recently published studies do suggest that combination treatments control myopic progression better. Here is a brief outline of the handful of studies with data over 12 months or longer.

  • Tan et al showed 0.09mm slower axial elongation in their 0.01% atropine + OK lens group (0.07mm) than the OK lens group (0.16mm) in 1 year.5 The effect was significant in the first six months only, with no difference in growth between groups in the second six months.
  • Kinoshita et al found a 0.18mm additional control effect after two years, although only significant in 1-3D myopes: 0.01% atropine + OK grew 0.30mm whilst OK lens only group grew 0.48mm.6
  • In a three year study, Chen et al fit children with OK monotherapy for the first year (Phase 1) and if they progressed by more than 0.30mm in a year they were allocated to either 0.01% atropine + OK group or OK only group for a further two years. There was no significant difference in cumulative axial elongation over 3 years, and no effect of baseline age or refractive error on the response to dual therapy.7
  • Two meta-analyses concurred that adding atropine will reduce axial elongation by an additional 0.09mm over one year. One meta-analysis evaluated 4 studies which only included 0.01%,8 while the other evaluated 5 studies which included a variety of concentrations.None of the studies reported serious adverse events. Given the small number of studies currently published, these meta-analyses don't add a lot of information compared to viewing the studies in isolation.
  • There is only one study currently underway on the combination of 0.01% and a multifocal soft contact lens: the CooperVision Biofinity D lens +2.50 Add. Early results show good tolerance of the combination but no longitudinal results are available yet.9

What time of day should atropine be used?

PP … I think I have heard (no studies, though) that atropine is put on corneas shortly 10-15 minutes before lenses put on… … Also, when the atropine drops are put on the corneas, should the child close their eyes for a few seconds, etc. I wonder if the drops should be put on when the child gets home from school....followed by lubrication drops? I would think when lenses are removed in morning time would be more of a chance of irritation. I sound, I guess, a bit paranoid....I just don't know the affects on the corneas by atropine drops. Will be interested to know answers. Thoughts?PP I wouldn't put drops on back of lenses when put on....messes with normal tears, etc. I would think.DS If you are to consider concurrent treatment I would do the drops just before leaving for school, ie a few hours after CL removal.CW Atropine stings so don't think putting it in at same time with lenses is a good idea…CW Hmm I'm actually not sure if 0.01% stings as bad, tried 0.1% (I think) as a child and absolutely hated it and refused to cooperate haha

There was also discussion around the appropriate time and method to instill atropine drops, especially within the context of utilizing OK lenses. Currently, there are no guidelines for using low-concentration atropine drops with myopia controlling contact lenses.

Side effects appear to be minimal

Ocular surface exposure to preservatives in the atropine drop, such as BAK, is more likely the larger concern of combination treatment than the cycloplegic and mydriatic side effects of atropine interacting with OK treatment. Kinoshita et al6 (diluted atropine with BAK) found SPK in 2/43 of the combination group and 1/37 of the OK only group which worsened over time and required discontinuation of OK and switching to spectacles. Tan et al5 (preservative free single use atropine) reported 1 case of bacterial conjunctivitis in each group which recovered with a week out of OK lenses and topical antibiotics. Neither group reported other adverse events or allergies related to atropine or OK use.

When to instill atropine

The peak mydriatic effect of atropine starts within an hour after instillation and the peak cycloplegic action of atropine starts after approximately 3 hours, then phases off.10 In an attempt to reduce the impact of atropine side effects on near vision and pupil size, it is typically instilled at night time, before sleep. This has been followed in subsequent studies of atropine + OK, where atropine has been used 5-10 minutes before applying the OK lenses.4-7

Interestingly, in a study by Kothari et al investigating the efficacy of 1% atropine as monotherapy, 17 subjects who instilled drops at bedtime progressed more than 0.50D a year. 13 of these subjects subsequently progressed less than 0.50D a year after they were switched to instill atropine in the morning (7am).11 There were no baseline age or refraction predictors of the faster progressors. Hence, it seems that time of atropine instillation may potentially influence efficacy, but further study is required.

Take home messages:

  1. Combination treatment of atropine 0.01% and orthokeratology appears to provide increased myopia control efficacy than orthokeratology alone, although studies indicate this may work best for 1-3D myopes and/or in the first 6-12 months of treatment. Should you try monotherapy first and then add atropine? The data doesn't indicate a greater effect with younger age, although younger children progress more quickly overall so if you and/or the parents are concerned about fast progression, a combination treatment could be helpful.
  2. There are no studies yet that indicate how time of day of atropine use may influence efficacy. Using both atropine and OK at night time could increase risk to the ocular surface, but this appears to be of minimal impact in studies and especially if preservative free atropine is used.

Further reading on atropine and combination treatment


Meet the Authors:

About Connie Gan

Connie is a clinical optometrist from Kedah, Malaysia, who provides comprehensive vision care for children and runs the myopia management service in her clinical practice.

Read Connie's work in many of the case studies published on MyopiaProfile.com. Connie also manages our Myopia Profile and My Kids Vision Instagram and My Kids Vision Facebook platforms.

About Kimberley Ngu

Kimberley is a clinical optometrist from Perth, Australia, with experience in patient education programs, having practiced in both Australia and Singapore.

Read Kimberley's work in many of the case studies published on MyopiaProfile.com. Kimberley also manages our Myopia Profile and My Kids Vision Instagram and My Kids Vision Facebook platforms.


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