Eyeworld

DECEMBER 2021 | EYEWORLD | 63 R Contact Tan: dt@ers.clinic Walsh: ewalsh@nyee.edu While atropine is approved by the FDA for cycloplegia, mydriasis, and amblyopia treat- ment, the lower doses that are now being used for pediatric patients for stemming myopia pro- gression are considered off label. It is obtained via a compounding pharmacy. Before starting atropine, Dr. Walsh said she begins screening for progression. During that time, she recommends environmental chang- es to parents. Several studies have associated indoor time and near work with increased risk of myopia development. However, the effect of outdoor time might only be helpful in prevent- ing myopia development as research has shown it doesn't slow the progression in established myopes. 6 The Shanghai Time Outside to Re- duce Myopia trial is currently taking place as a randomized controlled trial to investigate the protective effect of outdoor time of various lengths in the development of myopia. Dr. Walsh said longitudinal studies are being conducted to determine the ideal age to start taking a patient off atropine. When patients reach their late teens, Dr. Walsh said she stops atropine for 3–6 months, following up with them in this timeframe, seeing if it needs to be restarted or if the patient remains stable. Dr. Walsh said some physicians will treat for a couple of years and stop and monitor, while others will treat until they think it is a safe age (15–18) for myopia to slow down and taper. Dr. Tan also emphasized the need to doc- ument myopia progression before beginning a low-dose atropine use. He said screenings should begin earlier because research has shown younger ages for myopia onset are associated with greater myopia progression, leading to higher degrees of myopia in adulthood. Looking forward A literature and data review looked at efficacy of myopia control methods and reached several conclusions, including: Axial length rather than refractive error is the preferred metric for track- ing progression; there is a reduction in myopia treatment efficacy over time with a need for more information on why and whether there's a benefit to pulsing or changing treatment; and different treatments have "similar effect with some caveats." 7 "The clinician should choose the treatment based on numerous considerations such as their own skill set, preferences of parents and children, ability of the child to adapt to the treatment, as well as availability of product and regulatory considerations," Brennan et al. said. Dr. Tan said he hopes atropine will eventu- ally receive full regulatory approval as a form of myopia control for children. While Dr. Walsh thinks atropine is a great step forward in helping stem myopia progres- sion, there are still things she thinks could benefit patients. These include the ability to get atropine either over the counter or at a regular pharmacy (versus a compounding pharmacy). The cost, $40–45/month, can be significant to some families. On a grander scale, she said having some method for identifying patients who are likely to develop myopia before it even starts would be the "silver bullet" to helping stop it before it starts. She noted that there are some syndromes, systemic disorders, and genet- ic conditions where even atropine won't help the patient. Having treatments for those would be on her wish list as well. Dr. Walsh said physicians should counsel the patients they see on the importance of get- ting their children screened if there is a history of myopia in the family. "Edify your patients to come and see [pediatric specialists] sooner and start screening children early," she said. Dr. Tan said that studies using low-dose atropine are beginning to look at preventing myopia before it even starts, evaluating whether it can be prevented altogether or onset delayed. Until that time, he said his message to the ophthalmic community is that there is finally an approach to reducing progression that appears to be both safe and effective. Beyond medical therapy, he said myopia is a problem that needs to be solved at different levels. "It's not only going to be solved by a pediat- ric ophthalmologist. … It's going to be general ophthalmologists and other eyecare profession- als as well. We know that schools have a role to play in myopia," he said, noting that lifestyle changes across the board can help with this issue. References continued 5. Larkin GL, et al. Atropine 0.01% eye drops for myopia control in American children: A multiethnic sample across three US sites. Ophthalmol Ther. 2019;8:589–598. 6. Li SM, et al. Time outdoors and myopia progression over 2 years in Chinese children: The Anyang Childhood Eye Study. Invest Ophthalmol Vis Sci. 2015;56:4734–4740. 7. Brennan NA, et al. Efficacy in myopia control. Prog Retin Eye Res. 2021;83:100923 Relevant disclosures Tan: Eye-Lens, Santen Walsh: None

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