Long-Term Outcomes and Predictors of Stepwise Atropine Concentration Adjustment in Paediatric Myopia Management

To evaluate long-term real-world treatment responses and baseline factors in children who received low-dose atropine for myopia control and required stepwise concentration adjustments.

This retrospective study included 651 of 1032 children (651 right eyes) aged 5-12 years at initiation, treated with daily atropine for at least 5 years (mean follow-up, 6.1 years). All began with 0.025% atropine, with escalation to 0.05%, 0.05% plus 0.025% in the late afternoon and finally to 0.125% at bedtime plus 0.025% in the late afternoon if the spherical equivalent (SE) showed a myopic shift ≥0.50 D over 6 months. Baseline characteristics were summarised across stepwise treatment pathways. A baseline-only Cox model was used to evaluate predictors of time to first escalation from 0.025 to 0.05%. Multivariable linear regression identified factors associated with annual SE change.

Mean age at baseline was 7.9 years, with annual SE and axial length (AL) changes of -0.41 D and 0.23 mm, respectively. Escalation from 0.025 to 0.05% occurred in 91.1%; of these, 70.8% required an additional 0.025% afternoon dose and 57.6% escalated to 0.125% plus 0.025% in the afternoon. Across stepwise comparisons, children requiring higher-intensity regimens tended to be younger and were less likely to show AL reduction at 3 months. In the baseline-only Cox model, younger age at initiation was independently associated with earlier escalation to 0.05% (p < 0.001). In multivariable regression, faster progression was most strongly associated with greater annual AL elongation (p < 0.001) and was also associated with younger age at initiation and SE ≤ -3.00 D at age 7-8 years (all p ≤ 0.02).

Most children required escalation beyond 0.025%, and many progressed despite using 0.05% atropine. The mean annual SE change of -0.41 D suggests acceptable long-term myopia control under stepwise atropine adjustment, highlighting the need for early risk stratification and tailored strategies.