Center-distance multifocal and orthokeratology contact lenses are well-accepted myopia management options that decrease progression by about 50% (Walline, 2016). In addition to contact lenses, topical ophthalmic atropine also decreases myopic progression (Yam et al, 2019; Chua et al, 2012). High-dose (1% weight per volume [w/v]) atropine decreased refractive and axial progression by 85% and 100%, respectively (Chua et al, 2006).

Due to unwanted side effects of 1% atropine, several studies including the Low-Concentration Atropine for Myopia Progression (LAMP) Study examined 0.05%, 0.025%, and 0.01% atropine for myopia management (Yam et al, 2019; Chua et al, 2012; Chia et al, 2014). This large and well-controlled study demonstrated that refractive progression was reduced by 66%, 43%, and 27%, and axial length progression was reduced by 59%, 21%, and 12%, by the 0.05%, 0.025%, and 0.01% atropine doses, respectively (Yam et al, 2019). While not as efficacious as 1% atropine, the 0.05% dose evinced a good balance between treatment effect and side effects and has become the standard dose in clinical practice.

The mechanisms by which topical atropine reduces myopic progression are likely distinct from those modulated by contact lens treatment. Thus, a synergistic effect may be realized by combining soft lenses with topical atropine. The Bifocal & Atropine in Myopia Study demonstrated that the combination of 0.01% atropine and center-distance soft bifocal lens wear was well tolerated by children (Huang et al, 2019) but did not have a greater efficacy in decreasing progression than bifocal lenses alone (Jones et al, 2022).

Considering the results of the LAMP study, these results are unsurprising and encourage the use of higher atropine doses (0.025% or 0.05%) in combination therapies (Walline, 2016; Yam et al, 2019). Therefore, an effective strategy may be to have young children start on atropine and then continue with contact lenses as soon as they are able.

Case in Point

A 10-year-old Korean male with a history of progressive myopia was started on 0.01% atropine at age 8 for myopia management in Malaysia. According to his mother, his prescription increased by 1.75D in both eyes within 18 months. After this increase in refraction, his mother asked for a combination contact lens and atropine treatment. The provider at the time was not comfortable prescribing both modalities because there was “not much research on it.” Thus, atropine was discontinued, and orthokeratology lens treatment was initiated. Due to poor handling and inadequate comfort, the patient discontinued orthokeratology wear. In its place, the previous provider prescribed a relatively high dose of 0.125% atropine for nightly use.

During the visit to my clinic, the patient and his mother wanted to continue atropine treatment but also to start combination contact lens treatment. He presented with 20/20 acuity corrected with a –5.50D spectacle prescription in each eye. Although his pupils were fully dilated, he did not relate any visual discomfort on the 0.125% atropine dosage.

At this visit, he was prescribed soft daily center-distance multifocal lenses and his atropine dose was decreased to 0.1% nightly. Since the patient’s pupils remained dilated at 0.1% atropine after several months, his mother agreed to switch to a lower dose of 0.05% atropine. After a further six weeks of combined treatment, the patient relayed good vision, comfort, and cosmesis.

Summary

Separately, atropine and contact lenses have proven effective at limiting myopic progression. Atropine only begins to be effective above 0.025% and can nearly abolish myopic progression at 1%, however, unwanted side effects of atropine exist at higher doses. A dose of 0.05% atropine appears to best balance the side effects with the treatment effect.

While combination treatments are not contraindicated, studies demonstrating synergistic effects using an effective dose of atropine are rare. To treat myopia as early and as aggressively as possible, initiate 0.05% atropine in young myopes and add in, or switch to, contact lenses later. CLS

REFERENCES

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3. Chia A, Chua W-H, Cheung Y-B, et al. Atropine for the treatment of childhood myopia: safety and efficacy of 0.5%, 0.1%, and 0.01% doses (Atropine for the Treatment of Myopia 2). Ophthalmology. 2012 Feb;119:347-354.
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7. Jones JH, Mutti DO, Jones-Jordan LA, Walling JJ. Effect of Combining 0.01% Atropine with Soft Multifocal Contact Lenses on Myopia Progression in Children. Optom Vis Sci. 2022 May1;99:434-442.