Atropine eye drops for myopia in children

| |

Key points

  • Atropine eye drops can slow myopia progression in children, but does not correct vision so spectacles or contact lenses are still required
  • Atropine has a ‘dose dependent’ effect, where stronger concentrations work more effectively to slow or control myopia progression
  • Side effects of atropine include enlarged pupils (light sensitivity) and blurred close-up vision. Currently, 0.05% atropine shows the best balance of myopia control with minimal side effects.

What is atropine?

Atropine is used in general medicine, and also as an eye medicine or eye drop. As an eye drop, atropine 1% has been used historically to dilate (enlarge) the pupil and stop the eye’s focusing mechanism, which has applications for testing the vision of very young children, treating amblyopia (lazy eye) and also for treating some eye diseases.1

The first studies using atropine eye drops to slow myopia progression in children used 1% atropine, but these had significant side effects – enlarged pupils made a child sensitive to light, and blurred their close-up vision.2 Studies in the last 10 years have instead investigated lower concentrations, which have minimal side effects. The drops are used once per day, at night time.

It is not certain how atropine slows myopia progression in children. Scientists are still exploring the mechanism, which is likely how the atropine eye drops influence how chemical signals are conducted in the retina, the light sensitive layer at the back of the eye.3

Why are atropine eye drops used for children with myopia?

Once a child becomes short-sighted (also called near-sighted or myopic), their blurred long-distance vision tends to get worse over time. However there are ways to slow down this worsening, called myopia control or myopia management. Read more about this in what is myopia control for children and why it’s important.

When your child is myopic, we have to firstly think about correcting their blurred distance vision, which we can do with spectacles or contact lenses. You can read more about spectacle lens options, contact lens options and the safety of contact lenses in children via the links. There are special types of myopia control spectacles and contact lenses which can both correct blurred vision and slow myopia progression. Standard types of spectacles and contact lenses, called single vision, only correct blurred vision and do not control myopia progression.

Not all types of myopia control spectacles and contact lenses are available in every country, and sometimes they may not be suitable to your child. Atropine eye drops are an excellent alternative option in these cases.

Information

Your eye care practitioner may recommend atropine eye drops, which are used in combination with either spectacles or contact lenses. Atropine eye drops are especially favoured by ophthalmologists (medical doctor eye surgeons) around the world. Optometrists (non-medical doctor eye care practitioners) in Australia, New Zealand and the USA can also prescribe atropine eye drops.

Here’s some information about atropine eye drops, so you can ensure the right choice is made for your child between yourself and their eye care practitioner (optometrist and/or ophthalmologist).

What is the best atropine concentration?

The concentration of atropine eye drops which have been researched for myopia control vary from 0.01% right up to 1%. The stronger the concentration, the more likelihood of side effects.

Side effects of stronger atropine concentrations (0.1% up to 1%) include sensitivity to light due to enlarged (dilated) pupils, and problems with close up reading vision due to reducing the eye’s focusing mechanism. These side effects can be managed with spectacle lenses which darken when outside (called photochromatic) and that also incorporate a stronger power in the lens to support reading (a bifocal or progressive addition spectacle lens).

Lower dosages of atropine – 0.01% to 0.05% – have been shown to have minimal effects on pupil size and close up reading vision, making them more attractive options to prescribe for myopia control. The well known ATOM2 atropine study4 seemed to indicate that 0.01% had the least side effects and the best effectiveness for myopia control, however the newer LAMP atropine study5 has shown that there is a dose dependent effect and that 0.01% actually has minimal influence on slowing down the speedy eye growth which is a feature of childhood myopia. Slowing down eye growth is important, as longer eyes have been shown to have higher risks of myopia-associated eye diseases and vision impairment in adulthood.6 Low dose atropine of 0.025% slowed eye growth by about 30% (about one-third) and 0.05% by about 50% (about half) in the LAMP study. Over three years, the LAMP study showed that 0.05% was the most effective.7

Newer studies are underway investigating low dose atropine in various formulations – it may be that more stable chemical formulations of 0.01% atropine show better research results for myopia control.

Important

Currently, in most countries low dose atropine has to be compounded – specially made by a pharmacist – and in this form, it appears that 0.01% shouldn’t be the first choice for your child’s myopia management, until research shows us stronger data. Concentrations of at least 0.025% are more evidence based, and 0.05% is currently indicated to be the best balance of being effective to slow myopia progression, with minimal side effects.

Side effects can also include stinging of the eye drop on instillation, and sensitivity reactions. It is important to ensure that your child tolerates the eye drops – and in fact any myopia control treatment – so make sure to ask about side effects and report any concerns you may have. Atropine eye drops are usually used once daily, at night time.

Combining atropine with other treatments for myopia

While atropine 0.01% may not be the first choice for a front-line myopia management option, it is showing promise as a combination with Orthokeratology (OrthoK), special overnight wear contact lenses. Atropine 0.01% plus OrthoK appears to work better than just OrthoK alone, when used together for the first 6-12 months.8 If your child’s vision continues to progress in OrthoK wear or your eye care practitioner feels they’re at higher risk of fast progression, this may be prescribed.

By contrast, a three-year study combining atropine 0.01% with multifocal soft contact lenses did not show a beneficial effect of the two treatments used together.9 There is no research published yet on combining atropine with other myopia control treatments, like special types of spectacles.

What can you do?

Your eye care practitioner will be the best guide of which myopia control option is most suitable for your child, as it can depend on their level of myopia, age and other factors. If your eye care practitioner is recommending 0.01% atropine as their only treatment (not in combination with special myopia control spectacles or contact lenses), then it’s important to ask if a stronger concentration would be better, such as 0.025% or 0.05%.

Here are some other questions you can ask your child’s eye care practitioner regarding atropine eye drops.

  1. When the atropine eye drops should be used (usually once a day, at bedtime)
  2. How to properly apply eye drops – see our How-To Video Guides for help
  3. What type of spectacles or contact lenses your child also needs, to correct their blurred vision
  4. What signs of side effects you should watch for, and when your child’s next eye examination should be.

Finally, with any myopia control treatment, it’s also important for you to also understand the influence of your child’s visual environment – outdoor time and screen time – on successfully managing their myopia.

References

  1. McLendon K, Preuss CV. Atropine. [Updated 2021 Sep 12]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: (link)
  2. Chua WH, Balakrishnan V, Chan YH, Tong L, Ling Y, Quah BL, Tan D. Atropine for the treatment of childhood myopia. Ophthalmology. 2006 Dec;113(12):2285-91. (link)
  3. McBrien NA, Stell WK, Carr B. How does atropine exert its anti-myopia effects? Ophthalmic Physiol Opt. 2013 May;33(3):373-8. (link)
  4. Chia A, Lu QS, Tan D. Five-Year Clinical Trial on Atropine for the Treatment of Myopia 2: Myopia Control with Atropine 0.01% Eyedrops. Ophthalmology. 2016 Feb;123(2):391-399. (link)
  5. Yam JC, Jiang Y, Tang SM, Law AKP, Chan JJ, Wong E, et al. (LAMP) Low-Concentration Atropine for Myopia Progression Study: A Randomized, Double-Blinded, Placebo-Controlled Trial of 0.05%, 0.025%, and 0.01% Atropine Eye Drops in Myopia Control. Ophthalmol. 2019;126(1):113-24.2. (link)
  6. Tideman JW, Snabel MC, Tedja MS, van Rijn GA, Wong KT, Kuijpers RW, Vingerling JR, Hofman A, Buitendijk GH, Keunen JE, Boon CJ, Geerards AJ, Luyten GP, Verhoeven VJ, Klaver CC. Association of Axial Length With Risk of Uncorrectable Visual Impairment for Europeans With Myopia. JAMA Ophthalmol. 2016 Dec 1;134(12):1355-1363. (link)
  7. Yam JC, Zhang XJ, Zhang Y, Wang YM, Tang SM, Li FF, Kam KW, Ko ST, Yip BHK, Young AL, Tham CC, Chen LJ, Pang CP. Three-Year Clinical Trial of Low-Concentration Atropine for Myopia Progression (LAMP) Study: Continued Versus Washout: Phase 3 Report. Ophthalmology. 2022 Mar;129(3):308-321. (link)
  8. Tan Q, Ng AL, Cheng GP, Woo VC, Cho P. Combined 0.01% atropine with orthokeratology in childhood myopia control (AOK) study: A 2-year randomized clinical trial. Cont Lens Anterior Eye. 2022 May 30:101723.  (link)
  9. Jones JH, Mutti DO, Jones-Jordan LA, Walline JJ. Effect of Combining 0.01% Atropine with Soft Multifocal Contact Lenses on Myopia Progression in Children. Optom Vis Sci. 2022 May 1;99(5):434-442.  (link)
Previous

Myopia Myths and treatments for short sightedness