Myopia Profile


Which atropine dosage should I prescribe for myopia control?

Posted on June 25th 2020 by Connie Gan

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In this article:

A Myopia Profile Facebook group poll to understand what dosage of atropine is currently being prescribed in clinical practice and why.

The research information about using atropine to manage myopia progression is constantly evolving. To understand what is currently being applied in clinical practice more, PC created an interesting poll about atropine usage on the Myopia Profile Facebook discussion group. Note this poll was taken in October 2019.

PC What dosage of atropine eye drops for myopia control do you prescribe most often?40% I cannot prescribe atropine for MC34% 0.01%16% 0.02% / 0.025%8% 0.05%2% Start at 0.01% then go up if they progress

Out of 244 voters, 40% responded that they could not prescribe atropine for myopia control - likely due to scope of primary eye care practice in their country. Of the primary eye care professions, only appropriately trained optometrists in the US, Australia and New Zealand can prescribe atropine at this stage. All ophthalmologists can prescribe atropine.

Of those who do prescribe atropine eye drops for myopia control, the majority of this group either use only 0.01% or start with 0.01% with the intention to increase the concentration over time or depending on myopia progression. The remainder of the respondents use higher concentrations. Here is what the community said on the topic.

The suitability of 0.01% atropine has split the community

This poll showed us that a large proportion of practitioners still prescribe atropine at the 0.01% concentration.

1. Some have had great success with 0.01%

SDF I’ve not had a case where 0.01 has failed. It also has no side effects. It’s amazing.PC No AXL increase is the ultimate success, which actually does happen with an effective treatment. I wouldn’t be happy with around 0.35mm/year or more (that is around -0.75D/year) - those need a better control strategy. But it depends the age as well, as baseline AXL.SDF Success, I define, as control in axial length and minimal side effect. 0.01 has been a winner for me 👍 -0.25 over 12 months is a practice winner. Blurred vision and photophobia is a business killer.BR I measure axial length on all my myopes and effectively have had success with 0.01% all of these studies do have a flaw that they all abruptly stop it which we know you cannot do. I don’t think it is an end all be all but it definitely helps slow that curve until you can get the kid into another modality.AT Yeah I always offer CL as an option, I have a girl who's actually on 0.01 percent from the opthal who referred to me to get Misight put as well…

It is interesting that practitioners mention patient tolerance and minimal side effects as a key factor of treatment success; and also how studies which abruptly halt treatments do not reflect typical clinical care.

Prescribing 0.01% as a monotherapy, though, appears to be at odds with the findings of the LAMP study1, whereby 0.01% was found to be ineffective for controlling axial length elongation. Perhaps there are additional differences in clinical practice that contribute to the anecdotal success that does not play into the results of clinical trials - this can include the use of spectacles/contact lenses to control myopic progression and patients being on the drops for a longer period of time than the length of the study.

2. Some only use 0.01% at the start of the treatment

ME Depending on the case ..... 0.01% usually but had a very fast progressing Pt last week and started with 0.02%; and thinking I should just go 0.02% for most patients now and only go down if any side-effects?...AT I'm not sure if there's any peer reviewer scientific basis in this but I generally build up the dosage, 0.01 for first dose, then review in 1 month followed by 0.025 with 2 repeats, review in 3 months, then 0.05…HAK We always begin with 0.01% and then shift to higher concentrations at the end of 1 year on lowest dose if the progression is equal to the year without Atropine. All patients don't behave the same.

For some others, 0.01% serves as a starting point and this concentration is adjusted over time to either wean a patient onto higher concentrations, or if myopic progression is faster than desired.

3. Some believe 0.01% should not be even considered

AM Why start with 0.01% when you know the response is concentration dependent? If fact, the correct method of treatment is opposite. Start with the higher concentrations and work your way down if the side effects of the drug produce too much mydriasis or cycloplegia. When you use a steroid for an acute inflammatory event, you don’t prescribe the lowest possible concentration and hope it works, you prescribe the concentration that will likely have maximal effect and back down if you get a pressure elevation. Most kids will never complain about glare from mydriasis (they already have huge pupils with no issues) and cycloplegia is a variable effect with dilute atropine.LM Look at your AL. 0.01% is effective to control dioptres not eye elongation. It was the case in ATOM and now also proven in LAMP study. 0.05% is as safe as 0.01% but much more effective to control eye elongation.PC Not many measure axial elongation so if they are only looking at Rx change 0.01% might look ok when it’s really not doing much about eye growth. Hoping prescribing habits will change in time.

AM's comparison with steroid treatment is interesting. It's not typical or even safe prescribing to start with a lower strength steroid and increase if the treatment isn't working, but safe prescribing also dictates the minimum strength medication should be chosen to resolve the condition. Is this a fair comparison to compare an acute event (ocular inflammation needing a steroid) versus a treatment for a non-acute condition which needs to be tolerated over the long term? This is worth reflection.

The argument against 0.01% is that recent literature suggests it does not have any effect on axial elongation, and that increased concentrations leads to greater efficacy. The aim is to prescribe minimum dosage for maximum effect on axial elongation with minimum side effects, and studies appear to show this is more likely to be around 0.025% or 0.05% with the current compounded formulations available.

The puzzling aspect of 0.01% performance in scientific studies is the mismatch between axial length and refractive control whereby there is axial length elongation whilst refractive error is unchanged. As most clinicians don't measure axial length, they may be unwittingly administering ineffective treatment which appears successful on the face of refraction, but does not meet the goal of myopia control, which is to reduce the rate of axial length elongation.

Concern about side effects is the main barrier to prescribing higher dosages

MM Primarily pupil dilation and reduction in accommodation. E.g. Cooper et al (2013) "Atropine 0.02% is the highest concentration that does not produce significant clinical symptoms from accommodation paresis or pupillary dilation." BB A lot of kids are symptomatic using 0.05%. Their GP's tell the parents to take them off itPC Agree, despite the papers suggesting that up to 0.05% is well tolerated.PC My current thoughts are that if a patient needs 0.05% atropine (eg. a patient showing significant AXL progression on 0.02%) then CL options should be considered. Unless they can’t / won’t wear CLs.AT ... depending on the NPA and symptoms I may then decide to add anti-fatigue lenses on topEH Back in the day, there was no evidence on the lower doses. And there was already quite a lot of evidence that 1% was effective if you were happy to wear mf transitions (and many of our patients were)

There were multiple comments that reported children having symptoms with 0.05% atropine whilst children have no issue with 0.02% or lower concentrations of atropine. Side effects of atropine most commonly include photophobia, poor near visual acuity, allergy. Other adverse effect such as headaches, chalazion and systemic effects occurred in a small minority of patients.2 

Feedback from the community suggests that 0.02% atropine generally does not cause any side effects, whilst higher concentrations can bring disconcerting side effects for some patients and their parents. Some clinicians mitigate this by prescribing multifocal/bifocal spectacles to help the child with accommodation side effects, and transition lenses to reduce glare. On the other hand, PC suggested myopia control contact lens options as an adjunct if the myopia control is ineffective with 0.02% atropine instead of increasing dosage.

What does the research say?

MM The second year LAMP results from the ARVO abstract did seem to show an improved axial length slowing with 0.01% in the second year compared to the first (very similar axial elongation to 0.025% in the second year). Given that result, that the ATOM2 control group was not concurrent, higher chance of side effects with 0.02% and above, and that we don't yet have rebound data for 0.025% and above, I think more data on both 0.01% and 0.025% and above will be very useful.MM Primarily pupil dilation and reduction in accommodation. E.g. Cooper et al (2013) "Atropine 0.02% is the highest concentration that does not produce significant clinical symptoms from accommodation paresis or pupillary dilation." (See reference Cooper et al)SK As nice as [the LAMP study] looks, note the lack of control group in the second year, which makes it impossible to make a valid conclusion about efficacy…PC Lack of a control group is also an issue with ATOM2 in regards to 0.01%... so no real conclusion could actually be made about it. I suspect age played a part in the seeming effectiveness of 0.01%.SK It might well have. But, a historical control group is still better than ‘no control group’. I agree that ATOM2 study design is not ideal in several aspects.

On suggested dosage of atropine:

  • LAMP Phase 21 has suggested 0.05% atropine as the maximum concentration that is well tolerated for clinical use where as ATOM23 suggested 0.01% atropine. However, there is a lack of a control group for both LAMP Phase 2 and ATOM2 studies concerning the efficacy 0.01% which casts doubt on its true efficacy.

On the side effects:

  • The LAMP study1 suggests that 0.05% atropine is well tolerated. However, Cooper et al4 concluded that 0.02% atropine is the highest concentration that do not give symptoms to the children. However, it is also worth noting that the LAMP study had a far larger sample size than that done by Cooper et al. Also, blue eyed children may be more likely to suffer side effects than brown eyed children.

Take home messages:

  • While the studies seem to suggest at least 0.02% atropine as being retarding the progression of axial elongation, 0.01% atropine is still the dosage of choice for some practitioners, with some reporting success with it in clinical practice. For those who choose to continue prescribing 0.01% atropine, it is important that the success of this should be measured by change of axial length instead of refractive error.
  • For those who do not have access to axial length measurement devices, it is worthwhile considering starting at 0.02% atropine as a minimum dosage. This is more likely to arrest the development of axial length.
  • If concerned about axial length progression occurring whilst on 0.02% atropine, yet wary about side effects of increasing dosage, consider myopia control contact lens/spectacle options as an adjunct treatment.
  • Perhaps the biggest factor in this variability in performance of 0.01% is related to the stability of low concentration atropine once it's compounded. New studies are underway investigating novel formulations aiming to make atropine more stable. Until science tells us more, though, the advice above is likely to be the best evidence-based approach to atropine concentration.

Read our six-part blog series on atropine

Check out this additional clinical case

You can also listen to our three podcasts on atropine with world-leading researchers

  1. Atropine, engaging with science and responsible practice with Professor Karla Zadnik from Ohio State University, USA.

  2. More on atropine 0.01% treatment for myopia management with Professor Mark Bullimore from the University of Houston, Texas USA.

  3. Atropine 0.01% for myopia management with Professor James Loughman from Technological University Dublin, and the Centre for Eye Research Ireland

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 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 Kimberley also manages our Myopia Profile and My Kids Vision Instagram and My Kids Vision Facebook platforms.

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