Paradox of atropine in myopia control: exploring dose-dependent efficacy, rebound effects, and optimal risk-benefit balance-a perspective.

The global surge in myopia prevalence, particularly the rising incidence of high myopia and its associated blinding complications-including myopic maculopathy, retinal detachment, and glaucoma-has transformed this condition into a pressing public health priority. Atropine, the most extensively studied pharmacological intervention for myopia control, now stands at a critical crossroads. The shift from high-concentration to low-concentration formulations has markedly improved tolerability, yet a fundamental paradox persists: the dose that minimizes side effects and rebound may be insufficient to halt axial elongation in children at greatest risk. This perspective article argues that atropine therapy faces an "impossible triangle" of dose-dependent efficacy, rebound magnitude, and tolerability, which precludes any single-concentration solution applicable to the entire pediatric population. We propose a redefinition of the risk-benefit assessment framework, moving beyond exclusive reliance on refractive error toward a multidimensional evaluation centered on axial length control, age at treatment initiation, and environmental factors such as outdoor activity. An integrated, stepped-titration strategy that combines pharmacological, optical, and behavioral interventions is advocated. Looking ahead, we call for the development of a multicentre, real-world evidence base with mandatory long-term washout data, which is essential to inform personalized, public-health-oriented myopia management aimed not at temporary dioptric stabilization but at the durable prevention of blindness.