Round Tables

Roundtable: Pediatric ophthalmologists address difficulties of treating myopia progression with atropine

Myopia progression is a hot topic in pediatric ophthalmology, whether the treating physician uses atropine, surgical procedures or contact lenses.

The dilemma for pediatric ophthalmologists is whether to offer an off-label treatment, atropine drops, to inhibit axial lengthening when questions remain regarding the best way to use the treatment, how long to use it, whether certain populations benefit more, how to balance costs, and how best to present advice and counsel to patients.

The OSN Pediatrics/Strabismus Board Members, led by Section Editor Robert S. Gold, MD, tackled this debate in a roundtable discussion at the American Association for Pediatric Ophthalmology and Strabismus meeting in San Diego.

Roundtable Participants

  • Robert Gold
  • Moderator

  • Robert S. Gold
  • Kenneth P. Cheng
  • Kenneth P. Cheng
  • Douglas R. Frederick
  • Douglas R. Frederick
  • Courtney L. Kraus
  • Courtney L. Kraus
  • Erin D. Stahl
  • Erin D. Stahl
  • Rudolph S. Wagner
  • Rudolph S. Wagner
  • Roberto Warman
  • Roberto Warman
  • M. Edward Wilson
  • M. Edward Wilson

Roberto Warman, MD: I started prescribing atropine early, but I have since backed up a lot. The reason has nothing to do with results; it has to do with the practical issues and how you present it to the patient. No. 1, it is time consuming to explain to parents; you have to learn to present it fast. No. 2, patients are not keeping up with the treatment. It is a pain to put a drop in each eye every night for anybody, adults or children. We know this from experience with glaucoma treatment. Patients come back a year later without much progress because they stopped treatment halfway through. I have seen this happen multiple times. I am afraid that over multiple years, this will be an even worse problem. No. 3, we have the problem of getting the drops. You find a place where you can get the drops and then something happens and you cannot, so you have to interrupt treatment.

All those issues have made what is probably a good thing hard to implement.

Douglas R. Fredrick, MD: I do use atropine. I have been using it for many years, but the optimal dosage and duration of treatment have not been clearly established. We know that low-dose atropine will work with less rebound after discontinuation, but we also know that stronger atropine works better and faster. So, if I see a child who is 6 years old and is already –7 D, I will place that patient on high-dose 1% atropine, and I will give them photochromic transition lenses. For a younger child who is only maybe a –3 D, but they are 4 or 5 years old, I will start with a lower-dose atropine and no bifocal lens. So, I titrate the dose based on the individual as well as after a long conversation with the parent, which helps ensure compliance. The parents have to understand that the goals of therapy are not to prevent myopia but to decrease the magnitude of eventual myopia.

Rudolph S. Wagner, MD: My opinion has changed recently. I have reduced confidence in the preparation of these drops by some pharmacies because there is a lot of variability in their methods. Some pharmacies use injectable atropine and dilute it. Some use 1% bottle of atropine and dilute it. Some add a preservative. What I tell parents now is that there are three major studies going on. When results become available, what we are going to know is whether controlled preparation of low-dose atropine is effective in a diverse population. This is important because most of the studies have been limited to particular countries with uniform populations. That is how I handle it now.

Courtney L. Kraus, MD: I find that 90% of the discussion that parents want to have is about why their child is getting more myopic. Many of the children come to me wearing glasses that are not strong enough for them, sometimes from two refractions ago. I start the conversation by dispelling the notion that wearing a pair of glasses that is undercorrected is actually good for them. I think that sort of defocused image is in and of itself an impetus for myopia to get worse. So, we talk about that. We talk about near vision or near work. We talk about outdoor playtime and general “eye hygiene.” Then we talk about atropine and present it as an option if they are willing to commit.

Furthermore, not only do we not know whether it is effective as a daily kind of treatment, but we also do not know when it stops being a treatment that we should use. The struggle is not starting it; the struggle is knowing when to stop it. And so, before I start it, I like to let parents know that that’s kind of the big unknown. We don’t know what happens when you stop this drug.

Robert S. Gold, MD: What about alternatives such as orthokeratology or multifocal contacts?

Erin D. Stahl, MD: We have a myopia control clinic that is run by an optometrist in our practice. I find it ironic that as the ophthalmologist, I would be comfortable with ortho-k and our optometrists refuse to prescribe it. Multifocal contacts are an option, and we offer them. But I will mirror what everybody else has said: It is a lot of work in the room. It is a lot of conversation, and it takes a lot of dedication from the family, from the beginning, to partake in any of these options. If children are still progressing on low-dose atropine and they want to do something else, I think a discussion about contact lenses is a viable option. And, even though we do not offer orthokeratology, if used responsibly, it may be an option as well.

Kenneth P. Cheng, MD: I do not do vision exams, so myopic patients who have chosen to come to me are paying out of their pocket and are fairly demanding.

I do believe that it is part of our responsibility to talk to them about atropine. I do not think it is a medicolegal responsibility because it is not FDA approved and its use is off label, but the patients who come to us are seeking advice and counsel. It becomes a long discussion: The studies are varied by genetic population, sunlight exposure may be a factor, the FDA has not approved atropine treatment, insurance companies do not reimburse for the treatment, obtaining the drug is challenging, and there are unknown factors such as rebound and length of treatment. The discussion could go on and on and on.

Stahl: Another thing about myopia control is the financial aspect. We monitor these patients with axial length and refractions three to four times in the first year, but insurance claims are denied because you cannot see a child with a diagnosis of myopia multiple times a year, so that becomes a big challenge for us and our system.

I recommend that people have an out-of-pocket cost for myopia control and that it is a manageable price. An axial length measurement has a $700 facility charge that goes along with it. It is not fair to have patients saddled with that expense without knowing about it upfront.

Cheng: So, the issue becomes, how often do you need to see these patients?

Fredrick: I see them in 3 months, especially if I am starting with low-dose atropine, because if they are progressing on low dose, then I increase the dose. I tell them they will get axial length measured because I think it is a better indicator of efficacy than refraction.

Gold: If you are involved in any formal studies, you have to see patients back for compliance, usually within a 3-month period and for complete exams within a 6-month period, depending on how the studies are set up.

Cheng: Isn’t there information that shows that the rebound effect with the higher doses is much worse than a low dose?

Fredrick: I think most people titrate the dose. If you are using a higher concentration of atropine, you do not stop cold turkey. You would not go right from 1% to 0%. You go to maybe every other day therapy or from 1% to 0.5% to 0.05%, decreasing the concentration slowly to make certain you do not get rebound axial elongation.

Gold: If the pediatric ophthalmologist is not doing that, then they are not doing their service to the patient and the family. In other words, they have to be diligent following up of these children.

Cheng: Is it wrong to see them again in 8 months to a year?

M. Edward Wilson, MD: I do not think so.

Kraus: I think it is better than not offering the treatment.

Gold: I think you have to feel comfortable with how you are doing it. If they are having a problem, they should call you.

Stahl: The downfall is, if they progress quickly, then you might have started them on a different concentration.

Wilson: Another problem is that this therapy does not have absolute results. You are slowing progression, but the expectation of the parent may be that you stop progression. So, when the myopia gets a little worse, you are happy that it did not get a lot worse, but the parent thinks the treatment stopped working because the glasses prescription changed. That is also difficult to deal with.

Disclosures: Fredrick reports he is an uncompensated member of the scientific advisory board of Eyenovia. Stahl reports she is a consultant for Treehouse Health and a consultant for and shareholder in Nevakar. The other roundtable participants report no relevant financial disclosures.

Myopia progression is a hot topic in pediatric ophthalmology, whether the treating physician uses atropine, surgical procedures or contact lenses.

The dilemma for pediatric ophthalmologists is whether to offer an off-label treatment, atropine drops, to inhibit axial lengthening when questions remain regarding the best way to use the treatment, how long to use it, whether certain populations benefit more, how to balance costs, and how best to present advice and counsel to patients.

The OSN Pediatrics/Strabismus Board Members, led by Section Editor Robert S. Gold, MD, tackled this debate in a roundtable discussion at the American Association for Pediatric Ophthalmology and Strabismus meeting in San Diego.

Roundtable Participants

  • Robert Gold
  • Moderator

  • Robert S. Gold
  • Kenneth P. Cheng
  • Kenneth P. Cheng
  • Douglas R. Frederick
  • Douglas R. Frederick
  • Courtney L. Kraus
  • Courtney L. Kraus
  • Erin D. Stahl
  • Erin D. Stahl
  • Rudolph S. Wagner
  • Rudolph S. Wagner
  • Roberto Warman
  • Roberto Warman
  • M. Edward Wilson
  • M. Edward Wilson

Roberto Warman, MD: I started prescribing atropine early, but I have since backed up a lot. The reason has nothing to do with results; it has to do with the practical issues and how you present it to the patient. No. 1, it is time consuming to explain to parents; you have to learn to present it fast. No. 2, patients are not keeping up with the treatment. It is a pain to put a drop in each eye every night for anybody, adults or children. We know this from experience with glaucoma treatment. Patients come back a year later without much progress because they stopped treatment halfway through. I have seen this happen multiple times. I am afraid that over multiple years, this will be an even worse problem. No. 3, we have the problem of getting the drops. You find a place where you can get the drops and then something happens and you cannot, so you have to interrupt treatment.

All those issues have made what is probably a good thing hard to implement.

Douglas R. Fredrick, MD: I do use atropine. I have been using it for many years, but the optimal dosage and duration of treatment have not been clearly established. We know that low-dose atropine will work with less rebound after discontinuation, but we also know that stronger atropine works better and faster. So, if I see a child who is 6 years old and is already –7 D, I will place that patient on high-dose 1% atropine, and I will give them photochromic transition lenses. For a younger child who is only maybe a –3 D, but they are 4 or 5 years old, I will start with a lower-dose atropine and no bifocal lens. So, I titrate the dose based on the individual as well as after a long conversation with the parent, which helps ensure compliance. The parents have to understand that the goals of therapy are not to prevent myopia but to decrease the magnitude of eventual myopia.

PAGE BREAK

Rudolph S. Wagner, MD: My opinion has changed recently. I have reduced confidence in the preparation of these drops by some pharmacies because there is a lot of variability in their methods. Some pharmacies use injectable atropine and dilute it. Some use 1% bottle of atropine and dilute it. Some add a preservative. What I tell parents now is that there are three major studies going on. When results become available, what we are going to know is whether controlled preparation of low-dose atropine is effective in a diverse population. This is important because most of the studies have been limited to particular countries with uniform populations. That is how I handle it now.

Courtney L. Kraus, MD: I find that 90% of the discussion that parents want to have is about why their child is getting more myopic. Many of the children come to me wearing glasses that are not strong enough for them, sometimes from two refractions ago. I start the conversation by dispelling the notion that wearing a pair of glasses that is undercorrected is actually good for them. I think that sort of defocused image is in and of itself an impetus for myopia to get worse. So, we talk about that. We talk about near vision or near work. We talk about outdoor playtime and general “eye hygiene.” Then we talk about atropine and present it as an option if they are willing to commit.

Furthermore, not only do we not know whether it is effective as a daily kind of treatment, but we also do not know when it stops being a treatment that we should use. The struggle is not starting it; the struggle is knowing when to stop it. And so, before I start it, I like to let parents know that that’s kind of the big unknown. We don’t know what happens when you stop this drug.

Robert S. Gold, MD: What about alternatives such as orthokeratology or multifocal contacts?

Erin D. Stahl, MD: We have a myopia control clinic that is run by an optometrist in our practice. I find it ironic that as the ophthalmologist, I would be comfortable with ortho-k and our optometrists refuse to prescribe it. Multifocal contacts are an option, and we offer them. But I will mirror what everybody else has said: It is a lot of work in the room. It is a lot of conversation, and it takes a lot of dedication from the family, from the beginning, to partake in any of these options. If children are still progressing on low-dose atropine and they want to do something else, I think a discussion about contact lenses is a viable option. And, even though we do not offer orthokeratology, if used responsibly, it may be an option as well.

PAGE BREAK

Kenneth P. Cheng, MD: I do not do vision exams, so myopic patients who have chosen to come to me are paying out of their pocket and are fairly demanding.

I do believe that it is part of our responsibility to talk to them about atropine. I do not think it is a medicolegal responsibility because it is not FDA approved and its use is off label, but the patients who come to us are seeking advice and counsel. It becomes a long discussion: The studies are varied by genetic population, sunlight exposure may be a factor, the FDA has not approved atropine treatment, insurance companies do not reimburse for the treatment, obtaining the drug is challenging, and there are unknown factors such as rebound and length of treatment. The discussion could go on and on and on.

Stahl: Another thing about myopia control is the financial aspect. We monitor these patients with axial length and refractions three to four times in the first year, but insurance claims are denied because you cannot see a child with a diagnosis of myopia multiple times a year, so that becomes a big challenge for us and our system.

I recommend that people have an out-of-pocket cost for myopia control and that it is a manageable price. An axial length measurement has a $700 facility charge that goes along with it. It is not fair to have patients saddled with that expense without knowing about it upfront.

Cheng: So, the issue becomes, how often do you need to see these patients?

Fredrick: I see them in 3 months, especially if I am starting with low-dose atropine, because if they are progressing on low dose, then I increase the dose. I tell them they will get axial length measured because I think it is a better indicator of efficacy than refraction.

Gold: If you are involved in any formal studies, you have to see patients back for compliance, usually within a 3-month period and for complete exams within a 6-month period, depending on how the studies are set up.

Cheng: Isn’t there information that shows that the rebound effect with the higher doses is much worse than a low dose?

Fredrick: I think most people titrate the dose. If you are using a higher concentration of atropine, you do not stop cold turkey. You would not go right from 1% to 0%. You go to maybe every other day therapy or from 1% to 0.5% to 0.05%, decreasing the concentration slowly to make certain you do not get rebound axial elongation.

PAGE BREAK

Gold: If the pediatric ophthalmologist is not doing that, then they are not doing their service to the patient and the family. In other words, they have to be diligent following up of these children.

Cheng: Is it wrong to see them again in 8 months to a year?

M. Edward Wilson, MD: I do not think so.

Kraus: I think it is better than not offering the treatment.

Gold: I think you have to feel comfortable with how you are doing it. If they are having a problem, they should call you.

Stahl: The downfall is, if they progress quickly, then you might have started them on a different concentration.

Wilson: Another problem is that this therapy does not have absolute results. You are slowing progression, but the expectation of the parent may be that you stop progression. So, when the myopia gets a little worse, you are happy that it did not get a lot worse, but the parent thinks the treatment stopped working because the glasses prescription changed. That is also difficult to deal with.

Disclosures: Fredrick reports he is an uncompensated member of the scientific advisory board of Eyenovia. Stahl reports she is a consultant for Treehouse Health and a consultant for and shareholder in Nevakar. The other roundtable participants report no relevant financial disclosures.