Year : 2019 | Volume
: 31 | Issue : 1 | Page : 24--27
The use of atropine in childhood myopia: Experience in Indian eyes
Department of Ophthalmology, Little Flower Hospital, Angamaly; Vettam Eye Clinic, Mulanthuruthy, Ernakulam, Kerala, India
Vettam Eye Clinic, Mulanthuruthy, Ernakulam - 682 314, Kerala
This clinical query section discusses the use of topical atropine in childhood myopia among Indian children. Experts from across the country share their viewpoints, clinical experience, and concerns on the subject.
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Sathyan S. The use of atropine in childhood myopia: Experience in Indian eyes.Kerala J Ophthalmol 2019;31:24-27
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Sathyan S. The use of atropine in childhood myopia: Experience in Indian eyes. Kerala J Ophthalmol [serial online] 2019 [cited 2022 May 16 ];31:24-27
Available from: http://www.kjophthal.com/text.asp?2019/31/1/24/256272
Use of topical atropine for halting the progression of myopia has generated much interest among pediatric ophthalmologists worldwide. Atropine for the treatment of childhood myopia (ATOM) studies have provided solid evidence that atropine has a role in preventing the progression of myopia among East Asian children. However, further evidence regarding its mechanism of action, optimal duration of treatment, and effect in Indian eyes is awaited. This section involves leading pediatric ophthalmologists from across the country, sharing their clinical experience and concerns regarding the use of atropine in preventing the progression of myopia.
Dr. Ramesh Kekunnaya, Head, Child Sight Institute, Jasti V Ramanamma Children's Eye Care Center, Pediatric Ophthalmology, Adult Strabismus and Neuro-Ophthalmology, L V Prasad Eye Institute, HyderabadProf. Rohit Saxena MD, Ph.D. Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New DelhiDr. Jitendra Jethani, Director, Baroda Children Eye Care and Squint Clinic, GujaratDr. Sumita Agarkar, Pediatric Ophthalmology and Strabismus Services, Sankara Nethralaya, ChennaiJyoti Matalia, Pediatric Ophthalmology and Strabismus Services, Narayana Nethralaya, BengaluruDr. Muralidhar R, Department of Strabismus and Pediatric Ophthalmology, The Eye Foundation, Coimbatore.
1. What are your views on the use of low-dose atropine for preventing progression of myopia in children?
Ramesh Kekunnaya: Level I, II, and select level III trials suggest atropine is effective in slowing myopic progression. Atropine's antimuscarinic action helps in preventing axial elongation of the globe. ATOM (Atropine for the treatment of childhood myopia) studies have shown that low-dose atropine does prevent the progression of myopia in children. Recent ATOM study shows that 0.01% atropine prevents the progression of myopia close to 50%. Higher doses of atropine seem to have greater effect; however, rebound progression is greater. Atropine 0.01% appears the most reasonable approach to retard myopia progression with the least side effects. Atropine once started should be used at least for 2 years as maximum effect appears in the 2nd year. Rohit Saxena: I feel that the commercial availability of low-dose atropine has prevented rational discussion and research on the effect of the drug on Indian eyes. Currently, even in Singapore, it is not a company marketed product and is still not the Food and Drug Administration approved for this indication, but in India, numerous companies are marketing it.
While the drug has proven efficacy in East Asian eyes, in other populations, its efficacy, ideal dose (is 0.01% ideal for all races?), duration of treatment, and side effects are yet to be profiled.
Therefore, while I do offer this as a treatment option to parents of children with school-age myopia, I do so only after I have documented an increase of at least 0.5 D of myopia in the child and thorough discussion with the parents. Jitendra Jethani: Atropine eye drops are a wonderful way to prevent the progression of myopia. All the studies including my own work point that atropine does prevent the progression of myopia in children. There is a little bit of disagreement regarding what concentration is more important with some workers finding 1% as more effective than 0.01%, while others believe that they are comparable. My own work is mainly on comparison between 0.01% and no intervention. We found that 0.01% is definitely better and prevents myopic progression up to 60% compared to no intervention. In the initial years, we did use atropine 1% eye drops, but patient compliance was very poor and we had to discontinue its use in some patients and gave them bifocals also. Sumita Agarkar: Currently, atropine is the only drug proven to control the progression of myopia by a number of studies, especially the ATOM studies, with the low dose of 0.01% providing the best results with the least side effects. The Atropine in the Treatment of Myopia (ATOM) study found that low-dose atropine reduced the progression of myopia in the Asian population of Singapore. However, we do not have studies in the Indian population. We are currently a part of a multicentric randomized controlled trial conducted by the RP centre, AIIMS, Delhi. This should guide us in the usage of low-dose atropine among Indian children in the near future. Jyoti Matalia: Atom studies have eloquently demonstrated the effectiveness of low-dose atropine in retarding myopia progression. If we objectively look at evidence-based medicine, there is no reason to dispute the findings of researchers from Singapore as the studies are well designed with clear protocols. However, there are two unanswered questions: (1) whether racial differences will change the results in different populations and (2) what is the best strategy to deal with nonresponders?
Muralidhar R: The medication is a very valuable addition to our therapeutic armamentarium. Atropine was tried because it was thought to stall accommodation and prevent myopia progression. This explanation for its therapeutic action is not true and we are not clear about the exact mechanism of action. We, however, know that low concentration atropine (0.01%) works based on the data from the ATOM studies and is safe to use with minimal side effects. Limited data on Indian patients have also come in from some of my friends and colleagues in practice which vouches for its efficacy in retarding myopia progression.
2. Can you share your personal experience in terms of the efficacy, patient acceptance, and side effects of atropine in myopia?
Ramesh Kekunnaya: I prescribe low-dose atropine for children (more than 5 years of age) who have progressive myopia. I exclude children with anisometropia, astigmatism more than 1.50 D, syndromic children with myopia, retinopathy of prematurity kids with myopia, and myopic shift seen in children after pediatric cataract surgery. I start the low dose 0.01% (once daily at bedtime) in children who have progressive myopia (>0.50 D per 6 months). I get axial length done at every visit and monitor for any side effects. I follow them up every 3–4 months. During every visit, we do cycloplegic refraction and axial length measurement. So far, it is working well, though I cannot give statistical details. Majority of the parents are very happy with idea of starting these eye drops, especially when they know that there are no side effects. No side effects have been noted in our cohort of children. Rohit Saxena: We have a double-blinded multicentric (R P Centre, Sankara Netralaya Chennai, and Narayana Netralaya, Bengaluru) trial ongoing and hence I hope to get accurate results within a year. Anecdotal experience is that it is effective in a vast majority of patients, but some may need higher doses as they do show significant progression even on 0.01%. A careful patient selection and good follow-up are essential. I have not observed any significant side effects. Jitendra Jethani: I have been using atropine eye drops (0.01%) since 2012, and the patient acceptance is quite good. Very few patients complain of accommodation problems and photophobia. Apart from these minimal side effects, we did not come across any other problem in a patient pool of almost 550 children between the age group of 5 and 16 years. There is enough evidence that this therapy works. In our own trial which was presented at All India Ophthalmology Conference, Coimbatore, we found that this therapy is definitely effective compared to no intervention in a long term for up to 3 years. Sumita Agarkar: Yes, I have adopted low-dose atropine in my clinical practice. In terms of efficacy, it maybe too early to comment on it as we advise both lifestyle modifications as well as 0.01% atropine drops. However, we do not exactly know which among them is working. However, our randomized trial would throw more light on this question.
Side effects of low-dose atropine have been very minimal. Only about <1% in my practice have complained of difficulty with near work after 1–2 weeks of use of the low-dose atropine. This of course can be easily managed with the use of bifocals or progressive lenses and parents need to be explained regarding the need for temporary near glasses before prescribing the atropine drops. Jyoti Matalia: Yes, we have adopted low-dose atropine in our practice only after commercial preparation has become available in the last November. I do not have patients with enough follow-up to comment on its effectiveness in Indian children. There is a prospective multicentric study led by the All India Institute of Medical Sciences which hopefully will shed light on how atropine affects myopia progression in Indian children. It will provide the evidence to adopt atropine more universally. Muralidhar R: Yes, I have been using atropine 0.01% for over a year now. Some of my patients are younger than 6 years and have a baseline myopia of <2D. I recommend 0.01% atropine at nighttime when there is a documented progression of >0.5 D over the past 6 months. I also get a baseline axial length and keratometry done before instituting the drug. The ATOM studies had tried 0.01% atropine when the astigmatism was <1.5 D and I generally stick to this recommendation. None of my patients have reported any side effects (difficulty in reading, problems with bright light, irritation, etc.) and almost all my patients have been very compliant with treatment. I must admit, however, that the number of my patients is small and the follow-up short. We know from the ATOM studies that the effect peaks in the 2nd year of use. There has not been a significant increase in myopia in any of my patients, but it is too early to comment.
3. A few studies have found association of myopia with increasing near work demands, reduction in outdoor activities, and the use of electronic devices. In the light of current evidence and your clinical experience, what are your suggestions to the parents/teachers/children to fight the myopia epidemic?
Ramesh Kekunnaya: There is association of near work and myopia. However, definite temporal relationships for exposure (near work) and disease (myopia) cannot be established. Outdoor activities and exposure to sunlight are protective against myopia. We recommend very less or no screen time, more outdoor games for all growing children. This is very healthy habit in so many ways for child's overall health including behavioral health. Rohit Saxena: In our studies, we have found near activity having a strong association with prevalence and progression of myopia in school-going children.
Saxena R, Vashist P, Tandon R, Pandey RM, Bhardawaj A, Menon V, et al. Prevalence of myopia and its risk factors in urban school children in Delhi: The North India myopia study (NIM study). PLoS One 2015;10:e0117349.Saxena R, Vashist P, Tandon R, Pandey RM, Bhardawaj A, Gupta V, et al. Incidence and progression of myopia and associated factors in urban school children in Delhi: The North India myopia study (NIM study). PLoS One 2017;12:e0189774.
More than 2 h of outdoor activity (not necessarily sports) was strongly protective which was independent of near activity, i.e. less outdoor was not just due to higher near activity. Therefore, while I do recommend moderation (not >1–2 h/day) in the use of electronic devices for recreation, I insist on at least 2 h every day of outdoor activity. Jitendra Jethani: A load of literature has suggested that near work and reduced outdoor activities would cause a higher progression of myopia compared to children who go outdoors. With the current evidence, it is pretty clear that progression is a multifactorial thing. I do suggest the parents to make sure that they tell the children to read and write in good lighting, stay outdoors, develop a hobby, start playing more outdoor games, and reduce electronic device time and playing video games. Sumita Agarkar: A number of studies have associated myopia progression with increased near work and use of electronic devices. I recommend a screen time of <1 h and a minimum of 2 h of outdoor activities in sunlight every day. Furthermore, taking frequent breaks during near activities and following 20-20-20 rule helps reduce eyestrain which may contribute to further progression of myopia. In addition, I also advise the parents to encourage the child to perform near work at a minimum distance of 30 cm under good illumination.
Parents and teachers must try and include more and more outdoor games as a part of their recreational activities. Furthermore, having sports and outdoor activities as a part of schooling every day may eventually help us to restore the balance of indoor–outdoor activities. Jyoti Matalia: There is enough circumstantial evidence in favor of limiting hand-held gadgets in children younger than 12 years of age. It makes sense to keep that smartphone away, and this message should go down unequivocally to parents/teachers and caregivers. Similarly, there are studies outlining the benefits of daylight outdoor activity. This will not only keep myopia epidemic at bay but also will promote fitness and take care of Vitamin D deficiency. I advise parents to encourage at least 40 min of outdoor activity every day. Muralidhar R: I quote the World Society of Paediatric Ophthalmology and Strabismus consensus statements here (http://wspos.org/world-society-of-paediatric-ophthalmology-strabismus-consensus-statements). Outdoor activity has been shown to reduce myopia progression and I encourage parents of my patients with refractive error to ensure at least 1 h of outdoor activity per day. Recent evidence suggests that prolonged near work at closer distances (<33 cm) may be more damaging. Encouraging a healthy working distance, good posture, and lighting while reading may also help retard myopia progression.
Atropine has been adopted into clinical practice for preventing the progression of childhood myopia by all the members of our panel, and all of them use 0.01% atropine in children with documented progression of myopia. Although long-term follow-ups are lacking, anecdotal evidence does not show any significant side effects in their patients started on atropine. However, the effects of topical atropine in Indian children are yet to be established through well-designed studies. Furthermore, the discussion highlights the importance of sunlight exposure, outdoor activities, and judicial use of electronic gadgets in children, in light of current evidence-based studies.
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