How atropine concentration affects visual function in myopic children

Paper title: Dose-Dependent Effects of Atropine on Accommodative and Binocular Visual Function for Myopia Control in Children: A Systematic Review and Meta-Analysis

Authors: Clara Martínez-Pérez (1); Jacinto Santodomingo-Rubido (2); César Villa-Collar (3)

1. Applied Physics Department (Optometry Area), Facultade de Óptica e Optometría, Universidade de Santiago de Compostela, Santiago de Compostela, Spain. 
2. Global Research and Development, Menicon Co. Ltd, Nagoya, Japan.
3. Faculty of Biomedical and Health Sciences, Universidad Europea, Madrid, Spain.

References: Martínez-Pérez C, Santodomingo-Rubido J, Villa-Collar C. Dose-Dependent Effects of Atropine on Accommodative and Binocular Visual Function for Myopia Control in Children: A Systematic Review and Meta-Analysis. Ophthalmic Physiol Opt. 2026 May 18.

[Link to open access paper]

Atropine is widely used for myopia management in children. However, less is known about how different concentrations affect accommodative and binocular visual function. This review aimed to clarify these effects across different concentrations in children with myopia.

The authors systematically searched three databases (PubMed, Web of Science and Scopus), identifying 13 randomised controlled trials which compared atropine concentrations from 0.01% to 1% with placebo, single-vision correction or no treatment. The included studies predominantly featured Asian children aged 8 to 12 years, with study sample sizes ranging from 20 to 438 participants. The studies assessed changes in accommodative amplitude and, where available, accommodative lag, stereoacuity, heterophoria and vergence measures over follow-up periods ranging from 24 hours to 36 months.

Key findings were as follows

• Atropine 0.01% was associated with a small overall reduction in accommodative amplitude of 0.84 D, although findings varied considerably between studies and follow-up periods.
• Atropine 0.02–0.03% showed variable effects on accommodative amplitude, with inconsistent findings across studies.
• Atropine 0.05% reduced accommodative amplitude by 1.96 D and was associated with changes in near heterophoria (1.62 prism dioptres) and negative fusional vergence (8.30 prism dioptres).
• Atropine 0.1% and 0.5% reduced accommodative amplitude by 9.63 D and 11.30 D, respectively.
• Following cessation of 1% atropine treatment, accommodative amplitude recovered to levels similar to controls.

This review suggests that the effects of atropine on accommodation and binocular vision are influenced by concentration. For patients using 0.01% atropine, the overall effect on accommodative amplitude was small and findings varied between studies, supporting the view that many children are unlikely to experience substantial changes in near visual function.

Atropine 0.05% was associated with a reduction in accommodative amplitude of approximately 2D alongside measurable changes in near heterophoria and negative fusional vergence. Eyecare practitioners prescribing these concentrations should be aware that some children may experience near vision symptoms and may benefit from assessment of accommodative and binocular function if symptoms arise.

Higher atropine concentrations of 0.1% and above produced larger reductions in accommodative amplitude which was consistent with stronger cycloplegic effects. While these concentrations are less commonly used for myopia management, the findings reinforce the importance of monitoring visual function when higher doses are prescribed.  

The findings may also support more individualized patient discussions on potential effects on near vision and visual comfort during treatment.

While this review clarifies dose-dependent effects of atropine on accommodation and binocular vision, we still lack standardized data on how these functional changes affect children's daily visual tasks and quality of life. For instance, while 0.05% atropine reduces accommodative amplitude by approximately 2 diopters, it remains unclear whether this translates into meaningful reading difficulties or visual discomfort during schoolwork. The evidence was also rated as moderate, and many analyses showed variation between studies.

Several factors may have contributed to this variability. Most trials were conducted in Asian populations, and iris pigmentation was not consistently reported. This leaves practitioners uncertain whether these findings apply equally to children of different ethnic backgrounds, particularly those with lighter iris colors who may experience different cycloplegic effects. The review also provides limited information about how accommodative function recovers over time or whether repeated cycles of treatment and cessation affect visual development differently than continuous therapy.

Substantial variability in how accommodative amplitude was measured across studies makes it difficult to establish precise clinical thresholds for when accommodative reduction becomes functionally significant. We also lack adequate data on intermediate concentrations (0.02% to 0.03%), where effects appear unpredictable.

Purpose: To evaluate systematically the effect of different concentrations of atropine eye drops on accommodative amplitude and binocular visual function in children and adolescents with myopia.

Methods: A systematic review and meta-analysis of randomised controlled trials was conducted in accordance with PRISMA 2020 guidelines and registered in PROSPERO (registration number: CRD420261297760). PubMed, Web of Science and Scopus were searched up to January 15, 2025. Eligible studies compared atropine eye drops (0.01-1%) with placebo, single-vision correction or no treatment and reported accommodative or binocular vision outcomes. The primary outcome was the change in accommodative amplitude. Secondary outcomes included accommodative lag, stereoacuity, heterophoria and fusional vergence. Mean differences (MD) with 95% confidence intervals (CI) were pooled using fixed- or random-effects models based on heterogeneity.

Results: Thirteen randomised controlled trials were included, most of which were conducted in Asian populations. Low-dose atropine (0.01%) was associated with a small but statistically significant reduction in accommodative amplitude (MD: -0.84 D, 95% CI: -1.50 to -0.18), with substantial heterogeneity and no consistent effects at individual follow-up time points. Intermediate concentrations (0.02-0.03%) showed variable and heterogeneous effects. Atropine 0.05% produced a consistent and clinically meaningful reduction in accommodative amplitude (MD: -1.96 D, 95% CI: -2.36 to -1.57) and measurable changes in binocular parameters. Higher concentrations (≥0.1%) resulted in marked cycloplegic effects.

Conclusions: The effects of atropine on accommodation and binocular visual function are dose-dependent. Low-dose atropine demonstrates a favourable functional safety profile, while higher concentrations are associated with clinically relevant accommodative impairment.

[Link to open access paper]