Study: Could atropine delay or prevent myopia in children?

Nightly doses of atropine in young children may have the potential to delay or prevent the onset of myopia in children, say the authors of a new study.

The study was published Feb. 14 in JAMA online. The objective of the study was “to evaluate the efficacy of low-concentration atropine sulfate eyedrops at 0.05% and 0.01% concentration for delaying the onset of myopia” in children. The randomized trial was placebo-controlled, double-masked and included 474 nonmyopic children ages 4 through 9 with cycloplegic spherical equivalent between +1.00 D to 0.00 D and astigmatism of less than −1.00 D. The first treatment was administered in July 2017, with the final follow-up session in 2022. Over a two-year period, eyedrops were applied once nightly to both eyes of participants in each group (0.05%, 0.01% and placebo).

Per the findings:

• The two-year, cumulative incidence of myopia in the 0.05% atropine, 0.01% atropine, and placebo groups were 28.4%, 45.9% and 53%, respectively, and the percentages of participants with fast myopic shift at two years were 25.0%, 45.1%, and 53.9%.
• Compared with the placebo group, the 0.05% atropine group had significantly lower cumulative myopia incidence.
• Compared with the 0.01% atropine group, the 0.05% atropine group had significantly lower cumulative myopia incidence.
• The 0.01% atropine and placebo groups were not significantly different in cumulative myopia incidence or percentage.

“Among children aged 4 to 9 years without myopia, nightly use of 0.05% atropine eyedrops compared to those given the placebo doses showed a significantly lower incidence of myopia and lower percentage of participants with fast myopic shift at 2 years,” conclude the study’s authors who primarily were affiliated with The Chinese University of Hong Kong. “There was no significant difference between 0.01% atropine and placebo. Further research is needed to replicate the findings, to understand whether this represents a delay or prevention of myopia, and to assess longer-term safety.”

They add: “Prevention or delay of myopia onset may have the potential to improve long-term visual outcomes.”

Myopia: A public health threat

The incidence of myopia (nearsightedness) is growing at an alarming rate—with the study’s authors calling it a “worldwide public health threat.” Myopia, which is irreversible once it begins about age 8, is expected to affect 50% of the world’s population by 2050.

“Prescribing a treatment to those children most at risk before the onset of myopia may have a greater effect than slowing myopia progression after onset because it provides earlier intervention when eye growth and progression are fastest,” say David Berntsen, O.D., Ph.D., clinical sciences department chair, University of Houston College of Optometry, and Jeffrey Walline, O.D., Ph.D., associate dean for research at The Ohio State University. Drs. Berntsen and Walline co-authored an editorial, “Delaying the Onset of Nearsightedness,” that accompanies the JAMA article.

Toward that end, the LAMP2 study does increase understanding of the use of low concentrations of atropine to delay the onset of myopia, say Drs. Berntsen and Walline, who note in their editorial the risks associated with myopia—greater risk of sight-threatening complications and the nation’s financial burden due to treating myopia.

LAMP2 is the “first large-scale, 2-year randomized clinical trial to investigate the effects of nightly administration of 0.05% or 0.01% atropine eyedrops vs. placebo eyedrops in children without myopia,” the two doctors of optometry say in the editorial. It also builds on three previous studies that have focused on nightly administrations of atropine.

But there remain plenty of unknowns. For instance, can it delay myopia progression in adults or prevent myopia in children? What about a further look at side effects—the most common being photophobia reported by 15 study participants? Additional research will shed light, and that will take time.

“The LAMP2 study provides the strongest evidence to date that daily administration of 0.05% atropine delays the onset of myopia and meaningfully adds to the evidence that refractive error change and eye growth can be slowed, even before myopia onset,” they say. “However, the evidence presented does not yet warrant a change in the standard care of children because we do not yet know the long-term effects of delaying the onset of myopia with low-concentration atropine.

“Additionally, identifying whom to consider for treatment is a challenge because children who are not yet myopic do not routinely have their eyes examined by an eye care specialist unless they fail a routine vision screening test,” they add. “Ultimately, the implementation of vision screenings that include determining a child’s prescription will likely be needed to identify children most likely to become myopic who may benefit from low-concentration atropine. Additional randomized studies are needed to replicate these findings and to answer questions regarding the long-term outcomes.”

The study does hold promise.

“Delaying the onset of myopia is a novel way to potentially reduce the amount of myopia someone develops and possibly the risk of associated sight-threatening eye diseases in adulthood,” Drs. Berntsen and Walline say. “Delaying myopia onset also has the added benefit of additional time that young children do not have to wear vision correction. It is noteworthy that the nightly administration of low-concentration (0.05%) atropine eye drops over two years in the LAMP2 Study resulted in few side effects and a potentially meaningful benefit.

“This study provides doctors with evidence to support a new tool in the management of myopia by providing a way to potentially delay myopia onset for children most likely to become myopic,” they add. “However, pre-myopic children don’t typically receive eye examinations, so we need to change how we manage children at risk of myopia in order to identify and educate those who are most likely to benefit from this new treatment strategy. The LAMP2 Study, which enrolled children in China, found a benefit. Additional randomized studies also are needed to determine if the results are the same in other populations of children.”

Children’s vision resources

The AOA provides a number of resources that doctors of optometry can use in caring for children. Access these AOA members-only resources:

• View several children’s vision tools.
• Read Clinical Report: Myopia Management (2021) developed by the AOA Evidence-based Optometry Committee.