Sunday, December 3, 2023
| Characteristics at baseline | |
|---|---|
| Patients, N | 124 |
| Gender, N (%) | |
| Female | 67/124 (54%) |
| Median age in years (IQR) | 9.5 (4) |
| Ethnicitya | |
| European | 83/124 (66.9%) |
| East Asian | 13/124 (10.5%) |
| Otherb | 29/124 (22.6%) |
| Parental presence of myopia, N (%) | |
| No myopia | 12/124 (9.7%) |
| One parent | 51/124 (41.1%) |
| Both parents | 49/124 (39.5%) |
| Missingc | 12/124 (9.7%) |
| Parental presence of high myopiad (≤−6D), N (%) | 47/124 (37.9%) |
| Median onset of myopia in yearse (IQR) | 6 (3) |
| Median SE in D (IQR) | −5.03 (IQR: 3.08) |
| Median AL in mm (IQR) | 25.14 (IQR: 1.30) |
Table 1. Distribution of demographics and clinical measures of children eligible for the study.
aObtained by medical record.
bOther ethnicities included children with a background form Surinam, Venezuela, the Dutch Antilles, Indonesia, and Pakistan.
cComplete data could not be obtained due to adoption or one parent
situation.
dIn either parent or both parents obtained by questionnaire.
eObtained by questionnaire.
| Continued therapy N = 89 (71.8%) | Ceased therapy N = 35 (28.2%) | |||||
|---|---|---|---|---|---|---|
| Increased dose N = 32 | Decreased dose N = 26 | Same dose N = 31 | Allergy stopb N = 9 | Adverse eventsc N = 17 | Lost to follow-up N = 9 | |
| Median age (year) myopia onset (IQR) | 6.0 (3) | 7.0 (4) | 6.0 (4) | 6.0 (5) | 6.0 (5) | 7.0 (6) |
| Median age (year) at baseline (IQR) | 8.5 (3) | 11.0 (4) | 9.0 (3) | 9.0 (4) | 11.0 (5) | 12.0 (6) |
| Median spherical equivalent (SE) in D | ||||||
| 1 year prior to treatment | −4.5 (4.9) | −2.9 (3.9) | −3.8 (3.1) | −3.6 (6.4) | −4.3 (4.5) | −4.8 (4.1) |
| Baseline | −5.8 (3.5) | −4.4 (2.8) | −4.9 (2.8) | −5.4 (4.9) | −5.3 (4.0) | −5.4 (3.0) |
| 1st year | −6.0 (3.6) | −4.2 (3.5) | −4.8 (2.5) | −7.5 (6.7) | −5.6 (3.7) | – |
| 2nd year | −6.9 (4.7) | −4.6 (2.8) | −5.2 (2.6) | −8.0 (5.5) | −6.8 (3.3) | – |
| 3rd year | −7.5 (5.2) | −4.8 (2.6) | −5.6 (2.6) | −8.1 (6.0) | −7.8 (3.7) | – |
| Median progression rate of SE in D/year | ||||||
| 1 year before treatment | −1.0 (1.3) | −1.3 (1.0) | −1.0 (1.2) | −1.1 (2.1) | −0.8 (1.1) | −0.4 (1.0) |
| 1st year | −0.4 (0.6) | +0.2 (0.7) | +0.1 (0.5) | −0.4 (0.7) | −0.7 (1.1) | – |
| 2nd year | −0.6 (0.7) | −0.3 (0.4) | −0.3 (0.6) | −0.9 (1.3) | −0.8 (0.9) | – |
| 3rd year | −0.5 (0.8) | −0.3 (0.3) | −0.3 (0.5) | −0.4 (1.4) | −0.9 (1.1) | – |
| Median axial length (AL) in mma | ||||||
| Baseline | 25.2 (1.3) | 24.7 (1.3) | 25.4 (1.6) | 25.2 (2.8) | 24.8 (1.2) | 25.9 (2.5) |
| 1st year | 25.5 (1.7) | 24.5 (1.5) | 25.3 (1.6) | 25.4 (1.5) | 25.1 (1.3) | – |
| 2nd year | 25.8 (1.4) | 24.7 (1.3) | 25.3 (1.6) | – | – | – |
| 3rd year | 25.9 (2.3) | 24.8 (1.5) | 25.4 (1.5) | – | – | – |
| Median progression rate AL in mm/yeara | ||||||
| 1st year | 0.3 (0.2) | 0.0 (0.2) | 0.0 (0.1) | 0.2 (0.3) | 0.3 (1.0) | – |
| 2nd year | 0.3 (0.3) | 0.1 (0.1) | 0.1 (0.2) | – | – | – |
| 3rd year | 0.2 (0.3) | 0.1 (0.1) | 0.1 (0.1) | – | – | – |
Table 2. Progression of spherical equivalent and axial length for children receiving atropine 0.5% as a starting dose.
aAL was not included in the standard ophthalmological examination 1 year prior to start of therapy and was not included in the children who stopped atropine treatment.
bAllergies developed after 1 year. First-year data are on treatment, 2nd and 3rd year were without treatment.
cAdverse events included photophobia, reading difficulties, nightmares, and deterioration of behavioral problems in a child with diagnosis of ADHD.
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Background: Atropine is the most powerful treatment for progressive myopia in childhood. This study explores the 3-year effectiveness of atropine in a clinical setting.
Methods: In this prospective clinical effectiveness study, children with progressive myopia ≥ 1D/year or myopia ≤ −2.5D were prescribed atropine 0.5%. Examination, including cycloplegic refraction and axial length (AL), was performed at baseline, and follow-up. Outcome measures were spherical equivalent (SER) and AL; annual progression of SER on treatment was compared with that prior to treatment. Adjustments to the dose were made after 1 year in case of low (AL ≥ 0.3 mm/year) or high response (AL < 0.1 mm/year) of AL.
Results: A total of 124 patients were enrolled in the study (median age: 9.5, range: 5–16 years). At baseline, median SER was −5.03D (interquartile range (IQR): 3.08); median AL was 25.14 mm (IQR: 1.30). N = 89 (71.8%) children were persistent to therapy throughout the 3-year follow-up. Median annual progression of SER for these children was −0.25D (IQR: 0.44); of AL 0.11 mm (IQR: 0.18). Of these, N = 32 (36.0%) had insufficient response and were assigned to atropine 1%; N = 26 (29.2%) showed good response and underwent tapering in dose. Rebound of AL progression was not observed. Of the children who ceased therapy, N = 9 were lost to follow-up; N = 9 developed an allergic reaction; and N = 17 (19.1%) stopped due to adverse events.
Conclusion: In children with or at risk of developing high myopia, a starting dose of atropine 0.5% was associated with decreased progression in European children during a 3-year treatment regimen. Our study supports high-dose atropine as a treatment option for children at risk of developing high myopia in adulthood.
The prevalence of myopia is increasing all over the world, and has reached the highest frequencies in young adults in South Korea (96.5%), but has also increased significantly in Europe (49.2%).[1,2] The trait is determined by several optical components, of which increased axial length (AL) is the most important.[3] High myopia, i.e. refractive errors −6D or more, has increased from 4.2 to 21.6% in East-Asians and from 1.4 to 5.3% in Europeans.[2,4] Countries which presently have a low prevalence will follow these trends, as myopia prevalence is driven by lifestyle changes such as less time outdoors and increased near work activities.[5] Myopia carries a significant risk of retinal detachment, glaucoma, and myopic macular degeneration, which is most prominent for severe refractive errors.[6] Of those with high myopia, one in three develops bilateral severe visual impairment or blindness with age.[7] This highlights the need for myopia control strategies in children with progressive myopia, in particular progression to high myopia.[5,8,9]
During the last 10 years, many intervention studies for myopia progression have emerged.[10–12] Although lifestyle adjustments and optical solutions can be effective, pharmacological interventions targeting muscarinic receptors have shown the highest efficacy on reduction of eye growth.[13,14] Atropine is a nonselective muscarinic receptor antagonist which has been tested for progressive myopia in several dosages.[10] High dosages, 0.5 and 1%, are the most effective in reducing eye growth, but have drawbacks as pupil dilatation, loss of accommodation, and potential rebound of spherical equivalent of refraction (SER) after stopping.[15] The lowest dose of atropine, 0.01%, has become popular because it has minimal side effects and virtually no rebound after stopping, but reduction on AL progression is also minimal.[16–18]
In an earlier study, we reported 1 year results of intervention with atropine 0.5% for progressive myopia in a clinical setting in Europe. In children with already severe myopic refractive errors (mean SER, −6.6D) and progression of myopia 1D/year or more, we showed that atropine 0.5% reduced myopia progression to 0.1D/year. Despite the side effects, persistence to therapy was 78%.[19] We extended this study, and now report 3-year follow-up after the starting dose of atropine 0.5%. We addressed the photophobia and accommodation problems by prescribing photochromic multifocal spectacles.
