Myopia Control Was Not Sustained in the Long Term Following Atropine Treatment

Children who received atropine for myopia control did not have a dose-related benefit in the 20 years after treatment, and there was a trend toward a greater increase in myopic macular degeneration (MMD) with higher concentrations of low-dose atropine.

Study Design

The prospective, double-masked, observational Atropine Treatment Long-term Assessment Study (ATLAS) was a 20-year follow-up of adults who had participated in the Atropine for the Treatment of Myopia (ATOM1 and ATOM2) trials as children. ATOM1 compared atropine 1% vs placebo and ATOM2 compared atropine 0.01% vs 0.1% vs 0.5% (no placebo group); in both trials, treatment was given for 2–4 years. The goal of ATLAS was to evaluate the long-term safety and outcomes of topical atropine for myopia control with analysis of cycloplegic spherical equivalent (SE) with change in axial length (AL) elongation.

Outcomes

Eighteen percent of adult ATOM1 enrollees and 40% of adult ATOM2 enrollees participated in ATLAS. Results in both adult groups showed a rebound effect of atropine. In the ATOM1 group, SE and change in AL elongation were similar between the atropine-treated and placebo-treated eyes at the 20-year follow-up point. In the ATOM2 group, SE and change in AL elongation were similar for all 3 atropine-treated groups, at both the 10- and 20-year follow-up points. Therefore, patients from both ATOM studies continued to have myopic SE progression and AL elongation as adults. No differences in the incidence of MMD were seen between the atropine 1%–treated and the placebo-treated ATOM1 adults, whereas in the ATOM2 adults, there was an increase in MMD incidence that corresponded with higher concentrations of low-dose atropine from 0.01% to 0.1% to 0.5%.

Limitations

One limitation of the study was that only 25% of the original ATOM1 and ATOM2 participants were able to be analyzed as adults. In addition, differences in the instrumentation used for autorefraction and ocular biometry and variations in cycloplegic drop regimen between the current study and the original studies could have affected the comparisons of myopic SE progression and AL elongation following the cessation of atropine treatment.

Clinical Significance

For clinicians treating childhood myopia, these results leave us with more questions than answers. ATLAS is a valuable study because we need to ask ourselves these 5 questions related to our pediatric patients: (1) Is dilute topical atropine treatment ineffective at reducing myopia in certain populations? (2) Does the concentration of atropine matter if the treatment lasts <3 years? (3) Is the initial treatment age important? (4) What is the treatment duration needed to provide adults with the best long-term outcomes? (5) Should dilute atropine be used with other treatment modalities rather than as a singular treatment option? When we have conversations with parents of children with myopia, we will need to consider all of these questions, as well as the initial age of myopia presentation, family history, and the baseline SE and AL.

Financial Disclosures: Dr. Jennifer Galvin discloses no financial relationships.