How to taper atropine in myopia management

Atropine can be used for extended periods of time, but the World Health Organization currently recommends limiting treatment to 2 years.1 

Continuous treatment 0.05% atropine can provide consistent myopia control efficacy and tolerability, but most children may need to restart atropine after cessation due to progression.2

For myopia control treatments in general, it is safest to consider stopping treatment around late adolescence to early adulthood, when myopia progression is expected to slow or stabilize. The emerging consensus from research is that about 50% of individuals with myopia will stabilize by 15-16 years, and the other 50% will continue to progress.3 It is still relatively common for myopia to continue to progress in young adults, particularly individuals engaged in extensive near work (e.g. university students).4

Discontinuation of atropine may also be appropriate in other circumstances, e.g. side effects and switching treatment. 

Atropine in higher concentrations (<0.1%) can lead to higher rates of adverse effects such as photophobia or blurred vision at near. Low-concentration atropine is associated with fewer side effects, but a small proportion of children may still find symptoms intolerable.

Additionally, children may discontinue atropine in order to switch to another treatment. As atropine therapy still requires vision correction, changing to an effective optical intervention provides the dual benefit of myopia correction and myopia control.

Rebound is a major concern in myopia control, as the long-term goal is to reduce the final level of myopia in adulthood, along with the corresponding risks to ocular health. If the potential benefit gained during treatment is lost after discontinuation through rebound, this compromises the purpose of the treatment.

The rebound phenomenon has been associated with atropine cessation, and particularly with higher concentrations.

The original ATOM1 and ATOM2 clinical trials (and the long-term ATLAS follow-up study) demonstrated that higher concentrations were potentially more effective at slowing myopia progression, but were associated with greater adverse effects and rebound.7-9 Conversely, with lower concentrations such as 0.01–0.05% atropine, trials such as the LAMP study have demonstrated minimal rebound effects.10

Among lower dosages, 0.05% atropine is emerging as the most effective concentration for balancing efficacy with minimal adverse effects.11 The IMI Clinical Management Guidelines Report suggests that tapering by decreasing either the dosage or dose frequency at the end of treatment may minimize rebound effects.12

Although the WHO recommends that atropine should be tapered,1 there are no published guidelines for an optimal tapering protocol. Below are two possible approaches.

After stopping treatment, the patient should be monitored for a further 6 to 12 months,13 depending on their age and situation, and your level of concern. That way, any apparent acceleration in progression can be quickly addressed by recommencing treatment.

1. Evidence supports atropine use for up to 2-5 years, but extended treatment requires close monitoring to ensure sustained efficacy and manage potential side effects.
2. Tapering the use of atropine eye drops (i.e. a gradual reduction in dosing frequency or concentration) is a potential approach to reduce the risk of a rebound effect.
3. Continue to monitor the patient for a further 6-12 months for evidence of rebound, and recommence treatment promptly if progression resumes.