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Pre-myopia and young age: topical atropine or not?

 Posted on March 7th 2022 by Connie Gan

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In this article:

Is 3-year-old too young for low-concentration atropine treatment? Is it prudent in pre-myopia? Learn more about the evidence and approaches.

What level of intervention is ideal for a pre-myopic child? What is the youngest age suitable for atropine treatment? This case involves a 3-year-old hyperopic and astigmatic child who has been prescribed low-concentration atropine to delay myopia onset by an eye care practitioner other than the one posting this case.

TY What is the youngest age that you’ll recommend atropine 0.01% ? I have a patient whom I’ve been seeing from age 2 years for aniso-astigmatism and hyperopia (averagely R +1.00 -0.50 x 165 L +1.50 -1.50 x 10) but I didn’t prescribe glasses yet as I was still monitoring the astigmatism and mild esophoria. I briefly “lost” the patient for the last 7 months, only to see the patient again today but he is already using 0.01% Atropine for the past four months. He just turned 3 years old when he started atropine and now his prescriber wants to take it to 0.05%. Pupils are minimally reactive to light and approximately 8mm, and child frowns frequently during near testing, such as near point convergence and cover test. Both parents are highly myopic and worried but the patient’s refraction is still similar to before, although astigmatism has lessened to approx R +0.50 -0.25 x 165 L +1.00 -1.00 x 10. I am wondering if there is any evidence that Atropine 0.01% can help prophylactically in pre-myopia stages and what could be the reason for the prescriber to recommend 0.05% Atropine ? Am I missing anything here? I checked the axial length today, it’s R 23.12 L23.05. Please let me know!!

Is low-concentration atropine treatment necessary in this case? If it is, which concentration is suitable? The discussion of the Myopia Profile Facebook community is detailed below.

Is the child's axial length and refractive error normal?

TY Do you find an axial length of 23mm to be longer than the norms for a 3 year old child?DS It is longer than the bottom end of the age range for the CLEERE study for example. … I’d still watch until atypical axial length progression is able to be documented. We do have an ethical responsibility to the child not to over-treat.

In a meta-analysis of ocular of axial length in newborns and infants, the mean axial length of 3-year-old children is 21.8mm.1 In this analysis, the authors also found that males have longer axial length than females at birth.1 TY's patient has longer axial eye length when compared to the average.

In addition, his spherical equivalent is slightly more minus than the average 3-year-old child, which is +1.00D.2 At this age, the emmetropization process is active, which will likely see this child lose their small amount of hyperopia and progress into myopia.

Is topical atropine necessary?

DS ... I would cease the atropine and monitor the axial length for atypical elongation changes over time…CK Stop atropine, there is already considerable near vision blur and this is going to affect development. Prescribe lots of sun and outdoors, if sufficient it can even cancel out the effect of DNA.

Many commenters suggested to stop atropine treatment due to lack of information on the rate of refractive change and/or the rate of axial elongation. There was also concern raised about the side effects of treatment, with the child exhibiting very large pupils and apparent near vision difficulties. Instead, the more conservative approach was suggested - to advise the parents on sufficient outdoor time and managing near vision time to delay the onset of myopia.

The efficacy of low-concentration atropine in delaying myopia onset still requires research. One retrospective study, published in 2010, showed that 0.025% atropine may delay myopia onset on pre-myopic school children. These children were aged 6 to 12 years with a spherical equivalent refraction of less than +1.00D. Tolerance was good and the 0.025% atropine group progressed 0.14D in a year compared to -0.58D/year in the control group (no treatment, no placebo). Over one year, 54% of the control group progressed past -1.00D while only 21% did in the treatment group.3

The ATOM3 study is currently underway in Singapore, investigating the efficacy of 0.01% atropine in "preventing the onset and progression of myopia in high risk children with pre-myopia or low-myopia." This placebo controlled, randomized clinical trial has enrolled children aged 5 to 9 years with at least one myopic parent and a spherical equivalent refraction between +1.00 and -1.50. No preliminary data has yet been reported, but data completion is estimated to range between mid-2021 and mid-2023.

Information

Is this child a pre-myope?

The International Myopia Institute defines a pre-myope as "a refractive state of an eye of ≤ 0.75 D and > 0.50 D in children where a combination of baseline refraction, age, and other quantifiable risk factors provide a sufficient likelihood of the future development of myopia to merit preventative interventions."4

The IMI paper does not define a lower age for pre-myopia, but notes that the CLEERE study, which involved children aged 6-13 years, showed that a refraction close to emmetropia was the best single predictor of future myopia. The cut offs for predicting myopia by age 13 were < +0.75 D at age 6, ≤ +0.50 D at ages 7 to 8, ≤ +0.25 D at ages 9 to 10, and ≤ 0 D at age 11 years.5

There simply isn't any data on refraction at age 3 and future risk of myopia, but given that this child's low level of hyperopia would raise concern at age 6 or 7, and their family history of high myopia, it is a reasonable conclusion.

How proactively should we manage this child, given their clear myopia risk but young age and lack of evidence-base for suitable treatment? Ultimately this comes down to considering the benefits versus the side effects; and collaborative communication with the parents to determine their goals and understanding of treatment, to gain informed consent.

How would you manage this child?

PC The only time I would use 0.01% (or higher) atropine for a low hyperope or pre-myope is if they have actually shown axial elongation far in excess of what is considered normal that puts them at imminent risk of becoming myopic, + known risk factors (strong FH of high myopia), AND the parents are requesting early intervention. These tend to be kids whose myopic sibling are already on myopia management, and that I’ve taken baseline AXL data and monitoring their eye growth. But the case you describe doesn’t seem to justify any intervention at this stage. I would monitor his axial length before starting any intervention.TP Myopia management should not be used unless indicated, it's not a "let's treat everyone just in case". At 3yo, this is the lower end of normal for an Rx. Has there been any progression, what is the repeat axial length saying?? What are the other risk factors? Race, time outdoors, near work, parent and sibling Rx? If no progression then this child should be left to develop naturally on their own. Recommend extended outdoor time (at least 2 hours per day) and decreased near vision.SP Stick with the science, evidence based approach. Discuss your management plan based on the current evidence/research and maybe direct the parents to some of this if they wish to do their own reading too, and then let the parents decide. If they are anxious about myopia then offer frequent reviews, say every 3 months to establish whether there is any progression or not. Again explain and document why you have suggested crew reviews- for parent reassurance. At the moment, monitoring is by far the most appropriate action.

The commenters supported a careful approach to managing this young child, leaning towards providing advice on visual environment and more frequent monitoring rather than prescribing topical atropine for preventative myopia treatment.

If or when this child becomes myopic, the youngest age for which there is currently evidence is 4 years of age - the inclusion criteria for the Low-Concentration Atropine and Myopia Progression (LAMP) Study.6

Two current, multi-site clinical trials on commercially prepared atropine formulations are currently enrolling children down to 3 years of age: the CHAMP Study investigating a preservative-free, single use formulation and the STAAR Study investigating "proprietary technology... designed for maximum stability and tolerability."7 Three year data is expected for the CHAMP Study in 2022, while the STAAR Study lists estimated primary completion as mid-2024.

Take home messages:

  1. There is currently only a small amount of evidence for prescribing 0.025% atropine in pre-myopia and research underway in the use of 0.01%. Until publication of the latter, the best evidence-based treatment to delay myopia onset is increasing time spent outdoors.8 Some practitioners may choose to prescribe topical atropine for myopia prevention, though, after considering the myopia risk factors, balance of benefits to side effects, and parental understanding and goals for treatment.
  2. Obtaining informed consent for any myopia control treatment is important, but especially so for treatments which fall outside of the current range of evidence. In this case, prescribing for very young children requires parents to understand that efficacy cannot be assured and side effects could vary where there is a lack of research evidence. For myopic children, there will soon be evidence for atropine treatment down to 3 years of age as data from current clinical trials is revealed.

Read more on topical atropine and on pre-myopia

Check out these clinical cases

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.

This content is brought to you thanks to unrestricted educational grant from

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