Atropine in focus

Although not currently licensed for use in the UK, a multi-centre trial has investigated the safety and effectiveness of low-dose atropine (0.01%) for myopia management among UK children.

In September 2023, consultant ophthalmologist Imran Jawaid and colleagues published a narrative review for UK practitioners examining the evidence regarding the effectiveness and safety of low-concentration atropine for myopia management.

Jawaid qualified as an optometrist before undertaking further training to become an ophthalmologist. He specialises in paediatric ophthalmology and is currently practising at Moorfields Eye Hospital Dubai.

Jawaid spoke with OT about using atropine in practice and why he is excited about its potential to address the growing prevalence of myopia worldwide.

What are the advantages of atropine as an option for myopia management?

Atropine is a simple and straightforward modality – people are used to using eye drops. You administer the eye drops once daily before bed, and we know from the literature that this is safe and effective.

There is a significant amount of randomised control trial evidence that confirm the benefits of low-concentration atropine. It’s something that has minimal side effects and is well-tolerated. Atropine allows children to continue with their normal optical correction – whether that is daily contact lenses or spectacles.

The other advantage, from a clinical perspective, is that there’s a range of concentrations. When you’re reviewing patients, it allows you to escalate and de-escalate treatment.

Can you talk me through cost considerations when it comes to atropine?

Around the world, atropine is more popular than it is in the UK – primarily because it's cheap. When I've talked to colleagues across Europe, they’re prescribing atropine for less than €20 a month. In the UK, it’s closer to £80 a month, which is cost prohibitive.

Over the next few years, there will hopefully be a licensed product, and that will make it far more competitive as an option for myopia management.

Are there any drawbacks to atropine as a modality?

In the UK, cost is definitely a drawback at the moment – because it’s unlicensed there is little availability of atropine. This is a long-term treatment, which means that you need to counsel patients about the potential for a rebound effect if a treatment is stopped suddenly. The level of commitment to the treatment is something you need to discuss with the patient and their parent.

How long do patients continue taking atropine for?

If you look at the data from Caroline Klaver and colleagues in Rotterdam, they continued low concentration atropine until myopia progression slowed to 0.1mm of axial length growth per year. Then they would begin to taper the dose, stopping when axial length growth had slowed to 0.05mm per year. That would typically happen when the patients were 15 or 16. 

How do you use atropine within your toolkit of myopia management options at Moorfields Eye Hospital Dubai?

When children come to the clinic, as a baseline, they all have a cycloplegic refraction, pupil size, accommodation assessment and an axial length measurement. This happens alongside a complete eye health assessment. Then we will go through the range of myopia management options with them. They can either use an optical intervention – such as specialised spectacles or contact lenses – or they can use atropine. At the moment we have 0.01% atropine available. I am hoping that over the next year we will have a range of concentrations available.

It is something that could have a meaningful impact on the battle with myopia

At the moment, I would say that the split between patients choosing atropine and those selecting an optical modality is around 40% atropine, 60% optical. What tends to happen is that if the response to an optical intervention is sub-optimal, then we might deliver a combined treatment with atropine.

If the patient goes ahead with atropine, then we would commence treatment and undertake a review at six months where we would repeat the cycloplegic refraction and axial length measurement.

Why is this an area of research that you are interested in?

As an optometrist, and now an ophthalmologist, I am noticing increasing levels of myopia in children. If you look at the projections, that is going to cause a significant burden on eye departments around the world and society as a whole. You will have increasing numbers of retinal detachments and vision loss from conditions like myopic maculopathy.

From my point of view, these interventions are a really exciting opportunity to slow down this epidemic of myopia. As clinicians, and as people who are curious, we can look at what is happening around us and pose questions. Atropine holds potential because it is cheap and it is readily available. It is something that could have a meaningful impact on the battle with myopia.