Editorial: Children with myopia and the evidence-based ophthalmologist

With top medical school graduates routinely entering our profession after many years of science classes and lectures, it is no wonder that ophthalmologists embrace scientific data and use them to ensure that we provide the best possible care to our patients.

The evidence-based ophthalmologist takes notice when a study published in the prestigious British Journal of Ophthalmology reports that 361 European children who were randomly assigned to 0.01% atropine eye drops at bedtime or nothing in their right eyes, and who were followed for 5 years, showed that atropine slowed the progression of myopia (–0.63 0.42 diopter [D] vs –0.92 ± 0.56 D) and the increase in axial length (0.26 0.28 mm vs 0.49 ± 0.34 mm). According to the authors, “atropine 0.01% is effective in slowing myopia progression in a European population. There were no [adverse] effects.”¹ The ophthalmologist ponders how to counsel the worried parents of a young patient with myopia who want everything possible to be done to limit myopic progression in their child. Why not use this dilute atropine therapy that is reportedly so effective and free of adverse effects?

But then in July of this year, our data-driven ophthalmologist reads online in the prestigious JAMA Ophthalmology that an extended study of 187 US children found the opposite: “atropine eye drops at a concentration of 0.01% did not outperform placebo drops in slowing either myopia progression or elongation of the eye.”²

What is our ophthalmologist, who worships at the altar of biomedical science, to make of these conflicting data? Although both studies used the same active treatment (0.01% atropine), they differed in several ways (the ethnicity of the children enrolled, whether placebo drops were used in the control eye, the length of follow-up).

The second study’s lead coauthor, Michael X. Repka, MD, noted that some studies performed in Asia support a therapeutic benefit from atropine, but pointed out that his “study enrolled fewer Asian children, whose myopia progresses more quickly, and included Black children, whose myopia progresses less quickly compared with other races.” Katherine K. Weise, OD, the other lead coauthor, said “it will take a real convergence of eye research to solve the environmental, genetic, and structural mystery of myopia.”

What should our evidence-based ophthalmologist do in their office when confronted with a child with myopia and anxious parents? Should the parents leave with a prescription of atropine, or not? I agree with Weise that the phenomenon of myopic progression and its treatment remain a mystery.

References:

1. Moriche-Carretero M, Revilla-Amores R, Gutiérrez-Blanco A, et al. Five-year results of atropine 0.01% efficacy in the myopia control in a European population. Br J Ophthalmol. Published online June 2, 2023. doi:10.1136/bjo-2022-322808

2. Michael X. Repka, MD, MBA; Katherine K. Weise, OD, MBA; Danielle L. Chandler, MSPH. Low-Dose 0.01% Atropine Eye Drops vs Placebo for Myopia Control: A Randomized Clinical Trial. JAMA Ophthalmol. Published July 13, 2023. Accessed July 15, 2023; doi: 10.1001/jamaophthalmol.2023.2855