Low-Dose Atropine and Other Interventions for Pediatric Myopia: A Systematic Review and Bayesian Network...

Although the comparative efficacy of interventions for pediatric myopia control has been explored, the trade-off between on-treatment efficacy and post-treatment rebound remains unclear. We evaluated the comparative efficacy and durability of effect of low-dose atropine (LDA, <0.1%) vs other interventions for pediatric myopia using Bayesian network meta-analysis (NMA).

Randomized controlled trials (RCTs) investigating the efficacy and safety of interventions for pediatric myopia were identified through a systematic review. Outcomes included change from baseline in spherical equivalent refraction (SER) and axial length (AL) after 1 or 2 years of treatment, and 12 months after treatment cessation. Evidence was synthesized in a hierarchical Bayesian NMA with a dose-response ordering constraint model to improve precision and interpretability for decision-making. Heterogeneity was explored in network meta-regressions (NMR).

The systematic review identified 117 RCTs evaluating 24 active interventions. Twenty-two RCTs and one study arm were excluded from quantitative synthesis because of missing outcomes or violation of the transitivity assumption. LDA concentrations ≥0.01% significantly slowed myopia progression compared with an inactive control over 2 years in a dose-dependent manner and showed numerically larger, though statistically non-significant, effects compared with optical interventions. Moderate‑to‑high dose atropine and repeated low‑intensity red‑light, alone or combined with orthokeratology, showed greater short‑term efficacy; however, 12 months post‑cessation, these interventions were associated with clinically meaningful rebound exceeding progression in untreated controls. In contrast, LDA was not associated with clinically meaningful rebound. Combining 0.01% atropine with orthokeratology improved efficacy relative to LDA monotherapy over 2 years, but post-treatment rebound data were unavailable. NMRs indicated baseline SER, baseline progression, geography, and race as effect modifiers, albeit with borderline significance.

These findings describe the comparative efficacy and rebound profiles of treatments for pediatric myopia. Within the current evidence base, atropine concentrations of 0.01% to 0.05% showed sustained on-treatment benefit with minimal post-treatment rebound.