Optician India

Exacerbation of esotropia ( crossed eye ) is one of the potential factors with low dose atropine treatment , However on the other hand it’s now an effective therapy to slow down myopia progression .

An epidemic of myopia as its global prevalence continues to rise at an alarming rate . Mostly myopia is associated with excessive elongation of the eye that stretches the retina and choroid which increases the risk of ocular pathologies including glaucoma , retinal detachment and myopic maculopathy. 1(1)

Although many interventions such as myopia control spectacles ,orthokeratology and multifocal contact lens are available, low- dose atropine remains one of the most effective and widely used approaches for slowing myopia progression till date .

In recent years, 0.01% atropine eye drops—also known as low-dose atropine (LDA)—have become a go-to option for managing progressive myopia in children. But why is this tiny dose creating such a big impact? (2)

According to ( ATOM 1) , Atropine 1 % was commonly used for myopia controlling drops ,however Blurred vision and hypersensitivity reaction are common side effects of Atropine 1 % . Blurred vision was usually secondary to pupil dilation and temporary lack of accommodation . To avoid this side effect progressive addition photogray lens has to be prescribed . (3)

The popularity of LDA can be traced back to the groundbreaking ATOM (Atropine for the Treatment of Childhood Myopia) studies. These studies showed that even at a very low concentration, atropine significantly slowed down the worsening of nearsightedness by reducing the rate of refractive progression. (4)

Looking for the pro and cons for LDA . Low-dose atropine (LDA) typically causes a reduction in accommodation ranging from +3.00D to +6.00D, resulting in hypoaccommodation. In children, this mild decrease in accommodative ability is common and usually well tolerated. However, recent reports have highlighted the occurrence of convergence excess-type esodeviation associated with LDA use in patients who have preexisting fusional anomalies. (5)

Kothari et al . reported three children who developed convergence excess esotropia ( CEET ) associated with the use of LDA that improved or resolved after cessation of the drops . (6)

Possible Causes

1.Some hypotheses claim that partial cycloplegia induced by LDA causes incomplete paralysis of accommodation ,leading to resistance against relaxing accommodation .

2.Thereby , the eyes compensate with more innervational stimulation to accommodate results including reflex convergence .Thus , increasing convergence excess esotropia . (3) When LDA used for prolonged duration on a regular basis for retardation of myopia , may affect accommodation - convergence relationship resulting in the convergence excess esotropia . (1)

But ,if cycloplegia is complete ( 1% Atropine ) and present for an extended duration ,accommodative efforts are suspended causing complete abolition of an accommodative component of esotropia .

Clinical Considerations

• CEET as a side effect of LDA is rare, but clinicians should be aware, especially in patients with known accommodative issues or borderline binocular vision.
• Parents and patients should be advised to report any visual changes following LDA initiation.
• Monitoring binocular vision in myopia management programs is important.
• Mainly patients with high near work demands and borderline binocular vision parameters ,may put excessive strain on binocular vision systems that are already fragile. So, BSV function should be carefully considered while prescribing low dose atropine eye drops .

a. Myopic patient with LDA which induced esotropia in LE
b. An immediate resolution of esotropia with +3.00D in OPD .
c. Complete resolution after discontinuation of LDA . (7)

1.Kesarwani SS Mumbai Group of Paediatric Ophthalmologists and Strabismologists. Consensus statement and guidelines for use of dilute atropine sulphate in myopia control. Indian J Ophthalmol. 2019;67:461–3. doi: 10.4103/ijo.IJO_1457_18. [DOI] [PMC free article] [PubMed] [Google Scholar]

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4.Chia A, Lu QS, Tan D. Five-year clinical trial on atropine for the treatment of myopia

5: Myopia control with atropine 0.01% eye drops. Ophthalmology. 2016;123:391–9. doi: 10.1016/j.ophtha.2015.07.004. [DOI] [PubMed] [Google Scholar]

6.Flitcroft DI. The complex interactions of retinal, optical and environmental factors in myopia aetiology. Prog Retin Eye Res 2012; 31: 622–660. [DOI] [PubMed] [Google Scholar]

7. Myopia: Efficacy of 1% Atropine in Retarding Progression. Available from: https://www.researchgate.net/publication/353328556_Myopia_Efficacy_of_1_Atropine_in_Retar ding_Progression [accessed Jul 11 2025]. (Please add this to reference section)