Low-Dose Atropine for Pediatric Myopia: First-Year Progression as a Risk-Stratification and Management Signal.

PURPOSE: To determine whether first-year refractive progression predicts longer-term on-treatment myopia control and whether early progression guides escalation decisions and subsequent trajectories.

DESIGN

Retrospective cohort, single practice.

PARTICIPANTS

Five hundred fifty-five children (1107 eyes) treated with 0.01% (93.5%) or 0.02% (6.5%) atropine for ≥12 months.

METHODS

Spherical equivalent refraction (SER) progression was annualized (diopters [D]/year; positive = worse). At 12 months, eyes met or did not meet the ≤0.25 D/year threshold; children were categorized as responsive (both eyes), partially responsive (one eye), or unresponsive (neither eye). Progression was also modeled continuously (per 0.25 D/year). Escalation was defined as increasing the atropine concentration and/or adding optical therapy. Primary analyses associated 12-month response with on-treatment outcomes and progression before and after escalation. Eye-level models accounted for intereye correlation and baseline covariates. One-eye-per-subject sensitivity analyses were also performed.

MAIN OUTCOME MEASURES: Successful control (≤0.25 D/year over on-treatment course) and change in SER progression around escalation.

RESULTS

Baseline age was 9.8 ± 2.8 years and baseline SER -2.34 ± 2.37 D. 340 (61.3%) children were responsive, 99 (17.8%) partially responsive, and 116 (20.9%) unresponsive, with successful control rates of 70%, 28%, and 17%, respectively. 12-month status strongly predicted whole-course successful control in bilateral generalized estimating equations (odds ratio [OR]: 5.71; 95% confidence interval [CI]: 3.85-8.47) and one-eye sensitivity (OR: 10.90; 95% CI: 6.32-18.80) analyses and slower whole-course progression (β -0.27 D/year, 95% CI: -0.31 to -0.23). Each +0.25 D/year of first-year progression reduced success odds (OR: 0.55; 95% CI: 0.48-0.63). Post-12-month predictive value was attenuated relative to the whole-course analyses in both the bilateral generalized estimating equations (OR: 1.32; 95% CI: 0.94-1.86; P = 0.110) and one-eye sensitivity (OR: 1.92; 95% CI: 1.23-3.01; P = 0.004) analyses. Escalation occurred in 270 (48.6%) children, earlier among unresponsive children (log-rank P < 0.001). Event-time analyses showed marked slowing after first atropine escalation in initial failure eyes (0.71 → 0.28 D/year; Δ -0.43; P < 0.001) but minimal change in initial success eyes (0.189 → 0.193 D/year; Δ +0.004; P = 0.892). With atropine monotherapy, early response modestly predicted post-12-month success (OR: 1.57; 95% CI: 1.02-2.41).

CONCLUSIONS

Twelve-month response strongly stratifies overall on-treatment control as an early management signal, not a fixed treatment end point. Response-guided escalation slowed initial failures and attenuated post-12-month differences.

FINANCIAL DISCLOSURES: Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.