Switching from atropine to MiSight - one or both treatments?

When atropine isn't working as a monotherapy, is it valuable to combine it with a myopia controlling contact lens? Could switching from atropine to a contact lens be the better option? In this post on the Facebook discussion group, KB was seeking opinions on combining atropine and MiSight contact lenses.

The commenters were generally supportive of the idea and reported having good success. Interestingly, PC commented that MiSight as a monotherapy would likely have better efficacy than atropine 0.01% alone. This is a reasonable assumption based on recent data whereby the MiSight 3 year study showed 0.73D (59%) less refractive progression and 0.32mm (52%) less axial length progression than the control single vision soft contact lens wearers.¹ By comparison, the recent low-dose atropine for myopia progression (LAMP) study showed 0.22D (27%) and 0.05mm (12%) less progression than placebo treated children over one year.²

When considering 0.02% atropine compared to MiSight, each as a single treatment or monotherapy, the LAMP study showed 0.025% atropine controlled myopia by 0.35D (43%) and 0.12mm (29%) over one year. On direct comparison, this could be considered similar to the MiSight results. The note of caution in comparison here, though, is that shorter myopia control studies typically show larger results than longer studies - recent modelling has shown that on average, around half of longer term treatment efficacy occurs in the first year.³ Hence, this comparison between 0.025% atropine and MiSight, based on these two studies, may look more favourably on MiSight than would be indicated by a simple extrapolation of the LAMP study to three years.

Hence, LM above suggests starting with contact lenses first as a monotherapy, and adding 0.025% atropine as a combination treatment if adequate myopia control is not achieved. This seems a sensible approach to correct and control myopia, and also potentially avoid any interaction between atropine eye drops and successful contact lens wear, such as preserved formulations influencing contact lens comfort or pupil dilation influencing visual comfort.

Currently, the research on combination treatments is limited. Whilst there are no studies investigating the efficacy of combining atropine and MiSight for myopia control specifically, there are a few studies investigating atropine and other contact lens combinations.

• Kinoshita et al⁴ compared axial length growth between combination treatment (orthok and 0.01% atropine) and orthoK. After 1 year, the increase of axial length of the combination treatment group was less than in the orthok sole treatment group. This was a small study to which the authors commented further research is required.
• The atropine and orthok (AOK) study in Hong Kong⁵ is comparing the efficacy of 0.01% atropine with orthoK combination treatment, to ortho k treatment alone. The results are expected to be released in 2021.

• The baseline data from Huang et al⁶ suggests that this arrangement is well-tolerated with good compliance. The authors are combining the CooperVision Biofinity D centred multifocal lens with a +2.50 Add and 0.01% atropine. More results will follow.

• Shih et al⁷ showed that the group with 0.5% atropine with multifocal spectacle showed significantly less refractive error progression compared to the group prescribed only multifocal spectacles for myopia control. However, there was no significant difference between the group prescribed with multifocal spectacles compared to the control group wearing single vision spectacles - the multifocal spectacles had no significant myopia controlling effect.

• Early results suggest that combination treatment give better myopia control efficacy compared some to single-treatment or monotherapy strategies, although the evidence is limited and this should be communicated to parents.
• However, some monotherapy strategies are better than others. In this case, MiSight alone could be considered more effective than 0.01% atropine based on comparative research results... and perhaps even 0.025% atropine too.
• Optical strategies have the benefit of both correcting and controlling myopia, so MiSight could be considered as an alternative monotherapy in this case rather than in combination with atropine. Then again, continuing with atropine 0.01% in a compliant patient and willing parents, in combination with MiSight, would almost certainly show an improved myopia controlling effect to that experienced by this patient so far. Any potential interactions between atropine eye drops and contact lens wear should be considered, both from visual and contact lens comfort aspects.
• With the benefits of contact lens myopia control in mind, it is still worthwhile considering combination treatment with atropine for patients whose myopia is not under adequate control with single-treatment strategies.