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This article comes from the official account of Wechat: back to Park (ID:fanpu2019), author: Shuiyingbo

Parents often ask:

1) is low concentration atropine eye drops useful in the treatment of myopia in children?

2) are there any other magic drugs or artifacts that can be recommended for the treatment of myopia in children?

3) can myopia be cured?

Let's start with a simple answer:

1) low concentration atropine eye drops has a certain positive effect on delaying the development of myopia in children.

2) at present, there is no magic medicine or artifact to treat children's myopia.

3) once myopia is diagnosed, it cannot be cured, but doctors have ways to help improve myopia (surgical and non-surgical correction).

Written by By David Travis (Picture Source: Unsplash) | Shuiyingbo (Department of Ophthalmology and Visual Science, University of Washington School of Medicine, MD)

This article focuses on the progress of low concentration atropine eye drops in reducing / delaying myopia in children. Note that it is to delay the progression of myopia in children (Reduce Myopia Progression), not to cure myopia (Cure Myopia).

Children's myopia is a major concern and anxiety of parents. According to 2020 data from the CDC of the National Health Commission [1], the overall myopia rate of Chinese children and adolescents is as high as 52.7%. In fact, China is not the country with the most serious incidence of myopia. Singapore ranks first. According to the Singapore government health department report [2], the myopia rate of children in Singapore is as high as 65%, and the myopia rate of young people is as high as 83%. Preventing myopia and slowing down the progress of myopia is not only a top priority for parents, but also a major concern for health authorities all over the world, especially in Southeast Asia, where children have a high incidence of myopia.

Myopia is a common vision disorder. The typical symptom is that the patient sees what is near clearly, but blurs in the distance. This is because when parallel light is refracted through the refractive system of the eye, the image is focused in front of the retina rather than just on the retina. The cause of myopia is that the anterior and posterior axis of the eyeball is too long. When the baby is born, the anterior and posterior axis of the eyeball is short, generally in a state of hyperopia. Later, with the development of the body, the eyeball also grows, that is, the axis of the eye increases gradually, and the state of hyperopia decreases. This process of emmetropia from higher hypermetropia → to lower hyperopia → is also called emmetropization process of eyeball development (Emmetropinization). If this process is formed too early and the eyeball grows rapidly, the eye axis is too long and the image cannot be focused on the retina, that is, it develops into myopia. Myopia will deepen year by year in the stage of children's development and growth.

The cause of myopia is very complex, which is caused by many factors, such as heredity, development, nutrition, environment, eye habit and so on. There are some factors that we cannot overcome, such as heredity, and some factors can be improved through acquired efforts, such as obtaining balanced nutrition, adequate outdoor activities, scientific eye use, and so on. A healthy lifestyle and correct eye use can prevent myopia and slow down the progress of myopia to a certain extent. Current studies have shown that the role of drugs alone in the prevention and treatment of myopia is limited, so we should not expect too much of atropine eye drops, let alone as a panacea for myopia.

Atropine eye drops is an antique drug in ophthalmology. it is a non-selective muscarinic antagonist for paralysis of ciliary muscle, keratitis, iridocyclitis, cataract before and after cataract surgery and mydriasis optometry. Since 1989 when doctors in Taiwan first reported the results of a randomized controlled trial of 1% atropine to control myopia [3], atropine eye drops have been widely studied to prevent the deterioration of myopia in children. Of course, the relevant research results are mixed, some say it is effective, some say it is useless, and some media irresponsibly blow it as "magic medicine" or scold it as worthless, leaving parents at a loss as to what to do and who to trust.

The author believes in science. Let the facts speak for themselves. Singapore leads the world in the study of low concentration atropine in the control of myopia. The National Ophthalmology Research Institute of Singapore has conducted a large number of clinical studies on children. Since 2006, it has reported a randomized double-blind clinical study of atropine in the treatment of myopia and follow-up, including myopic rebound after drug withdrawal. After comparing the efficacy and safety of different concentrations (1.0%, 0.5%, 0.1% and 0.01%) of atropine eye drops, they found that 0.01% atropine had the best treatment index for Singaporean children, while the relative side effects were mild. These findings are published in the world's top ophthalmology journal, which has been strictly reviewed by the peers. [4-8]

However, this article focuses on the latest report of the Chinese University of Hong Kong ophthalmology study on the prevention and treatment of myopia with low concentration of atropine (LAMP), because their subjects are Chinese children. From 2019 to 2022, the Chinese University of Hong Kong published five high-quality papers in the professional ophthalmology magazine Ophthalmology. The main contents are as follows:

1. The first year of the study: 438 children aged 4 to 12 years with at least 100 degrees of myopia (- 1.0D) were recruited to use 0.05%, 0.025% and 0.01% atropine eye drops. The results showed that 0.05% atropine had the best effect on controlling myopia progression and delaying the growth of axial eye axis (AL) within 1 year. [9]

two。 The second year study: 383 children continued to participate in the study. It was found that 0.05% atropine was twice as effective in alleviating myopia as 0.01% atropine. Compared with the concentrations of other atropine eye drops (0.025% and 0.01%), 0.05% was the best concentration to slow down the progression of myopia. [10] Note: the Singapore study promotes 0.01% atropine eye drops, which is different from the results of the Hong Kong study.

3. The third year of the study: 326 children continued to be treated with atropine eye drops. It was found that all different concentrations of atropine eye drops could achieve good results. Among them, 0.05% of atropine is still in the lead in the 3-year treatment of children, and the rebound rate of myopia is very small. [11]

4. The study found that the main mechanism of low concentration atropine against myopia is to reduce the elongation of eye axis (AL), thus reducing the risk of subsequent myopic complications; atropine eye drops do not change corneal or lens diopter. [12]

5. A continuous follow-up study found a pattern: the younger the myopia begins, the higher the concentration of atropine, that is, 0.05% atropine is better than 0.025% and 0.01%. Older children use lower concentrations (0.025% and 0.01%) to achieve an effect similar to that of atropine eye drops at 0.05% concentration for younger children. The main reason may be that the younger the age, the faster the progress of myopia, and the intensity of medication needs to be moderately strengthened. [13]

6. Each of these studies reported the side effects of atropine eye drops, the most important being ① photophobia and some requiring sunglasses in outdoor sunlight. ② has poor eyesight, and children complain that they can't read the words in books clearly, so they need to take them a little further before they can read them. ③ allergic conjunctivitis. Most children can tolerate these side effects, and a few can not tolerate them. The side effects can be eliminated quickly after drug withdrawal.

In addition, clinical studies related to low concentrations of atropine are also in full swing in Chinese mainland regions. the interim results of some studies have been published [14-15], which once again confirm that low concentration atropine eye drops have a certain effect on preventing the progression of myopia. We look forward to more studies to be published in the near future.

After comparing a large number of independent clinical research data from various countries in the world, and making a cross-comparison, the ophthalmology circle has reached a more unified opinion at present: low concentration atropine eye drops has a certain exact effect in delaying myopia and axial growth in children, but it is not a "magic medicine" to cure myopia.

It should be noted that governments have made different progress in approving low concentrations of atropine for myopia in children. Singapore's Department of Health (HSA) has approved 0.01 per cent of atropine to be legally prescribed by doctors for children aged 6 and 12 to slow the progression of myopia. China's State Drug Administration (NMPA) and the US Food and Drug Administration (FDA) have not yet formally approved low concentrations of atropine eye drops to delay myopia in children, only allowing clinical studies of the drug in children with myopia. This may be one of the reasons why it is not easy to obtain low concentration atropine eye drops in China. With the completion of the clinical phase III study, it is believed that this dilemma will be gradually solved in the near future.

In addition to the simple use of low concentration atropine for the prevention and treatment of myopia in children, some clinical studies on combined treatment are being carried out in the ophthalmology community at the same time. For example, low concentration atropine combined with keratoplasty (Ortho-K,OK lens) [16-19], binocular visual function (BVF) balance training combined with virtual reality (VR) [20], combined with peripheral defocus double concentric circles to design soft contact lenses [21], and so on. At present, the research on the prevention and treatment of myopia is changing with each passing day, and whether the new method is effective is still being explored, which can not be enumerated in this paper.

This paper only focuses on the research progress of low concentration atropine combined with keratoplasty (Ortho-K,OK mirror). OK lens is a kind of specially designed, reverse geometric, breathable contact lenses, which is used to temporarily change and reshape corneal surface curvature in order to correct refractive errors. Wear OK lens at night, flatten the central cornea to reduce daytime myopia, the short-term effect is obvious. Since the cornea will return to its original state (rebound) after stopping wearing lenses, it is necessary to wear lenses for a long time to correct refractive effect. In 2004, FDA approved OK lenses for adults to wear at night. Although this approval does not include children, FDA gives ophthalmologists the discretion to use OK lenses in children. As soon as this opening is opened, in recent years, more and more people use OK mirror alone or in combination with low concentration atropine for the prevention and treatment of myopia in children.

The comprehensive analysis of Taiwan scholars [16] makes a detailed comparison of recent studies on keratoplasty (Ortho-K,OK lens), atropine eye drops, and the combined application of atropine and OK lens.

1) in 19 good quality independent randomized controlled trials (a total of 3435 patients), atropine (0.01% 0.1%) could significantly slow down the progression of myopia, and the dose was proportional to the effect, that is, the higher the concentration, the more obvious the effect. This is consistent with our known research results.

2) very low concentration of atropine (0.01%) combined with OK mirror has a certain synergistic effect, and the curative effect is similar to that of high-dose atropine alone.

3) there are many problems in using OK lens alone, for example, the sample size of many studies is too small, the high drop-out rate (dropout rate) of children participating in the study due to safety problems such as corneal injury, and the lack of follow-up after discontinuation and cost problems, the results are different, some are reported to be effective, but others are difficult to determine the effect of OK lens.

The 2019 special report of the American Academy of Ophthalmology concluded that the use of keratoplasty (Ortho-K,OK lens) to prevent myopia in children may slow the progression of myopia in children and adolescents. However, because the wearing of contact lenses may increase the risk of keratitis caused by blind microorganisms, safety is still a big problem. In other words, both benefits and risks exist, and there are different opinions on how to choose. Generally speaking, ophthalmologists are more at ease about the use of low concentrations of atropine for children, while they are more cautious about OK lenses.

At this point, you may find that apart from low concentration atropine eye drops, this article does not introduce any other products that slow the progression of myopia. Frankly speaking, there are too few reliable products to prevent myopia, and doctors cannot make bricks without rice. With the innovative development of science, some other effective anti-myopia products may be born in the near future. However, before seeing the formal research report after peer review, I will not recommend and dare not recommend some of the so-called myopic devices on the market. It is hoped that colleagues in the industry will be science-based and not irresponsibly recommend or promote some products with high prices and uncertain efficacy, or even only immature products in the research to their parents for the sake of economic benefits. Writing down this paragraph may offend some people or companies. Please take it easy, welcome to come up with excellent research results-- rather than advertising words-- to convince me and my colleagues in ophthalmology.

It is hoped that researchers from various countries will make joint efforts to enable ophthalmologists to have more and better ways to help children overcome the problem of myopia and give children a future that can see clearly.

Emphasize again:

The National Health and Family Planning Commission and other six departments jointly issued a document to make it clear that misleading expressions such as "myopia cure" should not be publicized in myopia correction. Myopia can be corrected, prevented, controlled and slowed down, but it can not be cured under the current medical technical conditions.

reference

[1] the overall myopia rate of children and adolescents in China in 2020 is 52.7%. The problem of low age of myopia is still prominent. Source: Xinhua News Agency. 2021-07-13 20:07 http://www.gov.cn/ xinwen / 2021-07 Universe 13 / content_5624709.htm

Speech by Dr. Lin Binmin, Senior Minister of Health of Singapore at the opening ceremony of Singapore National Eye Center myopia Center. 2019 08 16. Https://www.moh.gov.sg/ news-highlights / details / speech-by-dr-lam-pin-min-senior-minister-of-state-for-health-at-the-opening-of-the-singapore-national-eye-centre-s-myopia-centre-16-august-2019

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