There have been studies demonstrating that the use of atropine can slow the progression of myopia (Yam et al, 2022). There are studies that show we can slow myopia with soft multifocal lenses (Zhu et al, 2019). There are studies that show that orthokeratology can slow the progression of myopia (Cho et al, 2005). There is even evidence that using combination therapy can slow the progression even more than monotherapy. But, recently, the Bifocal & Atropine in Myopia (BAM) Study came out, showing that a combination of 0.01% atropine and soft multifocals did not have a dramatic effect on slowing the progression of myopia over using monotherapy (Jones et al, 2022). This has confused the message and clouded some of our thinking.

With myopia, how much therapy do we really want? Should we go all in, or take a graduated approach? It’s a debated topic.

My Take

In myopia management, every diopter matters, and, as myopia masters, we have an imperative to stop the progression of the disease as much as possible. Some people use the analogy of glaucoma to make the argument for a graduated approach. With glaucoma, therapies are added when a prior therapy is not as effective as desired.

If the goal is targeted IOP change, the patient might be examined using visual evoked potential/electroretinography (VEP/ERG), optical coherence tomography (OCT), or visual field test to determine the effect of the treatment. In most cases, this check-in takes place less than six months after therapy is initiated. These patients’ glaucoma progression may be very small and the additional of a medication is intended to further slow the progression of the disease, so the patients never even notice the vision loss; at least, that is the goal.

In myopia, every diopter matters to slow the progression and risk of disease. Testing a treatment on a young child for six months or even 12 months could result in the patient having 0.25D to 1.00D of change in refractive error or 0.01mm to 0.03mm of change in axial length before it is observed.

Once this progression has occurred, the risk of disease for this child will increase as he or she ages. While initiating additional treatment at this point would be ideal, why not start with additional treatment, establish a baseline, and then back off?

My take on multiple treatments is to start off by slowing things down as much as possible. In the BAM study, they used 0.01% atropine, which showed in the LAMP study to slow the progression the least compared to other concentrations. But the combo study with orthokeratology and atropine also used 0.01%. Could it be that we need a higher concentration with soft multifocals for an added effect to be seen, but a lower concentration in orthokeratology? Since most progression happens earlier, initiating multiple treatments at the start will do the most to slow things down, at least the evidence points to that in orthokeratology. As children age, monitor to see whether they have progressed; if they have not, explore reducing therapy and closely monitor to see whether they then begin to advance.

My Advice

At present, the negative effects of using low-dose atropine appear to be very small and, because of this, we are comfortable using it in most myopia management cases. In prac­tice, combine treatments often, and certainly with orthokeratology. Until it is proven to be ineffective, use combination treatment in soft multifocals, but with higher concentrations for children who continue to progress.

I’d challenge you to take a look at your myopia management approach and whether you want to be proactive or reactive in addressing the advancement of the disease. It’s still a debated topic, and I am grateful for our research colleagues, who are helping us get these answers. CLS

REFERENCES

1. Yam JC, Zhang XJ, Zhang Y, et al. Three-Year Clinical Trial of Low-Concentration Atropine for Myopia Progression (LAMP) Study: Continued Versus Washout: Phase 3 Report. Ophthalmology. 2022 Mar;129:308-321.
2. Zhu Q, Liu Y, Tighe S, et al. Retardation of Myopia Progression by Multifocal Soft Contact Lenses. Int J Med Sci. 2019 Jan 1;16:198-202.
3. Cho P, Cheung SW, Edwards M. The logitudnal orthokeratology research in children (LORIC) in Hong Kong: a pilot study on refractive changes and myopic control. Curr Eye Res. 2005 Jan;30:71-80.
4. 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;99:434-442.