低浓度阿托品控制近视的临床研究进展

随着近视患病率的不断攀升,近视相关视力损害及其防控日益成为社会关注的焦点。目前主要的近视控制方法包括阿托品、角膜塑形镜、双焦角膜接触镜、多焦角膜接触镜和功能框架眼镜等。近年来,低浓度阿托品(0.01%、0.05%)成为有效控制近视发生和进展的一线用药。同时低浓度阿托品比高浓度阿托品疗效更加持久,副作用更少见,患者的接受度更高。现本文对低浓度阿托品延缓近视进展的临床研究作一综述,从有效性、安全性、使用时机、联合控制效果等方面进行归纳总结,以期为临床使用低浓度阿托品控制近视提供依据。     

阿托品控制近视增长的研究进展

近年来青少年近视发生率逐年上升,并且呈低龄化趋势。目前,用于治疗和控制近视增长的方法很多,如框架眼镜、角膜塑形镜、药物等,治疗和控制效果各异。其中,阿托品在控制近视增长方面效果显著,高浓度（1%、0.5%、0.1%）阿托品可以有效抑制近视屈光度和眼轴的增长,但同时伴有一些由药物本身药理作用引起的不良反应,如畏光、视近模糊等,而低浓度（0.01%）阿托品在保留近视控制作用的同时,不良反应相对较轻,患者接受度较高。现就阿托品在控制近视增长方面的一些研究进展做一综述。     

角膜塑形镜、低浓度阿托品与框架眼镜控制青少年近视的疗效比较

目的：对比观察角膜塑形镜、低浓度阿托品与框架眼镜控制青少年近视发展的疗效。

方法：选取2016-1/2016-07我科收治的青少年近视患者120例240眼,采取自愿原则分为3组：角膜塑形镜组40例80眼、低浓度阿托品组40例80眼、框架眼镜组40例80眼。随访18mo,对比分析三组患者的屈光度及眼轴变化情况。

结果：治疗18mo后,角膜塑形镜组、低浓度阿托品组的屈光度均低于框架眼镜组(P<0.05); 角膜塑形镜组、低浓度阿托品组治疗前后屈光度差值均低于框架眼镜组(P<0.05),但角膜塑形镜组与低浓度阿托品组比较,差异无统计学意义(P>0.05)。治疗18mo后,角膜塑形镜组、低浓度阿托品组眼轴均低于框架眼镜组(P<0.05); 角膜塑形镜组、低浓度阿托品组治疗前后眼轴差值均低于框架眼镜组(P<0.05),但角膜塑形镜组与低浓度阿托品组比较,差异无统计学意义(P>0.05)。

结论：角膜塑形镜与低浓度阿托品均可有效控制青少年近视患者屈光度和眼轴长度进展,其疗效均优于框架眼镜,但角膜塑形镜与低浓度阿托品控制近视的疗效无明显差异。     

三种不同干预方法对近视儿童调节参数及屈光度的影响

目的：通过观察低浓度阿托品、角膜塑形镜、框架眼镜对包头市近视儿童的控制效果,分析其近视相关调节参数的变化规律,为近视防控提供依据。

方法：选取2018-06/12在包头医学院第一附属医院眼科门诊就诊的8～14岁近视儿童120例240眼,分为低浓度阿托品组、角膜塑形镜组和框架眼镜组,并在1、3、6、12mo分别对调节滞后量、正相对调节、负相对调节及屈光度进行随访。

结果：随访3、6、12mo,低浓度阿托品组与角膜塑形镜调节滞后量有差异(P<0.05); 随访6、12mo时,角膜塑形镜组与框架眼镜组调节滞后量有差异(P<0.05)。随访3、6、12mo时,低浓度阿托品组与角膜塑形镜组、框架眼镜组负相对调节均有差异(P<0.05)。在各随访时间点角膜塑形镜组与低浓度阿托品组、框架眼镜组正相对调节均有差异(P<0.05)。随访6、12mo,低浓度阿托品组与框架眼镜组屈光度有差异(P<0.05); 随访12mo,角膜塑形镜组与框架眼镜组屈光度有差异(P<0.05)。

结论：角膜塑形镜可以通过降低调节滞后量,解决远视离焦的问题,同时还可以提高正相对调节,但需要长期坚持配戴。低浓度阿托品可以提高负相对调节,但可能有其他途径来控制近视的发展。相较其它组而言,框架眼镜对于各调节指标影响较小,对近视的控制效果并不显著。     

加强我国儿童青少年近视的科学预防与控制

我国儿童青少年近视率居高不下,近视低龄化、重度化日益严重,已成为重要的公共卫生问题,儿童青少年近视防控也已上升为国家战略。目前,近视的病因尚未明确。因此,仍需深入探讨遗传和环境因素对近视的影响,进一步明确户外活动、角膜塑形镜、多焦点隐形眼镜、框架眼镜、阿托品滴眼液、重复低强度红光照射治疗等措施的优势及可能存在的局限性,综合考虑和应用现有的近视防控措施,制定科学有效的干预策略,加强我国儿童青少年近视的科学预防与控制。     

阿托品近视防控的临床与实验室研究进展

随着近视人口的逐年增长,近视已经成为全球关注的热点问题。如何预防近视、控制近视进展、减少病理性近视的发生、减少近视的成本投入是临床工作及科学研究的主要目的。阿托品是目前防控近视的主要药物方法,实验室研究及临床试验均已证实其显著的近视防控效果。美国眼科学会推荐使用0.01%低浓度阿托品,目前报道其近视防控效果为50%～53%。本文汇总了近年来近视防控相关的临床与实验室研究,对阿托品近视防控效果、其相关影响因素(如浓度、个体差异、生物利用度等)以及作用机制等方面的研究进展进行归纳综述,并分析了阿托品用于临床儿童近视防控工作存在的困难与挑战。     

低浓度阿托品与角膜塑形镜控制近视疗效对比

目的:对比分析低浓度阿托品与角膜塑形镜对青少年近视发展控制的疗效.方法:选取我院门诊青少年近视患者150例,随机分为3组,A组50例为应用低浓度阿托品组,B组50例为验配角膜塑形镜组,C组50例为验配框架眼镜组.三组患者治疗前屈光度及眼轴长度差异无统计学意义.随访1a后通过统计学分析三组屈光度、眼轴长度变化.结果:随访1a后各组屈光度治疗前后均有统计学意义(P<0.01).各组间屈光度比较结果如下:低浓度阿托品组与角膜塑形镜组比较,差异无统计学意义(P>0.05);低浓度阿托品组与框架眼镜组比较,差异有统计学意义(P<0.05);角膜塑形镜组与框架眼镜组比较,差异有统计学意义(P<0.05).随访1a后各组眼轴变化治疗前后均有统计学意义(P<0.01).随访1a后各组间眼轴变化比较结果如下:低浓度阿托品组与角膜塑形镜组比较,差异无统计学意义(P>0.05);低浓度阿托品组与框架眼镜组比较,差异有统计学意义(P<0.05);角膜塑形镜组与框架眼镜组比较差异有统计学意义(P<0.05).结论:低浓度阿托品和角膜塑形镜在控制青少年近视度数增长,眼轴增长方面无明显差异,且两者控制青少年近视疗效均优于框架眼镜.     

儿童近视进展的机制及其干预

近年来,针对近视发生和发展的可能机制,学者们从遗传、调节滞后、远视性离焦等多个方面进行了大量的动物研究和临床试验.目前延缓近视发展的主要措施有渐进多焦点眼镜、双光眼镜、角膜塑形镜等.此外,学者们在阿托品等药物防控近视方面也进行了有益的探索.     

低浓度阿托品治疗近视的临床研究进展

阿托品是毒蕈碱受体抑制剂,1％浓度滴眼可以抑制近视的发展及眼轴的增长,但是畏光、视近模糊等常见的副作用限制了其临床应用.近期研究者逐渐将兴趣转向低浓度阿托品（小于1％浓度）的临床研究,发现低浓度阿托品滴眼可以有效延缓近视发展,比1％浓度的阿托品副作用更小,疗效也更持久稳定.     

缓减近视发展药物的新进展

迄今的研究表明，利用药物疗法可望减缓青少年近视的发展。其中已应用的主要药物有睫状肌麻痹剂、降眼压药物、多巴胺等。已经证实胆碱能受体阻断剂能够显著地减缓近视发展，阿托品是代表性的药物，但其不可避免的副作用限制了它的使用。派伦西平作为选择性的M1受体阻断剂表现出引人关注的发展前景。寻找有效减缓近视发展、应用方便、毒副作用轻微的药物或方法，已成为近视研究的热点     

1%阿托品眼膏控制近视性散光青少年近视进展的一年疗效

目的 研究1%阿托品眼膏控制近视性散光青少年近视进展的一年疗效。设计 病例对照研究。研究对象 选择2013年2-9月在宁波市眼科医院视光门诊诊治的120例（240眼）6~9岁近视性散光患者（近视性散光≥-1.50 D,等效球镜在-1.00~ -4.00 D,弱视已治愈）。方法 采用随机数字表法将患者分为A、B、C三组,每组均为40例80眼,A组戴框架眼镜,B组戴框架眼镜联合0.5%复方托吡卡胺滴眼液1次/晚,C组戴框架眼镜联合1%阿托品眼膏1次/周五晚。随访12个月,每个月复查最佳矫正视力、屈光状态、眼压及眼轴变化。主要指标 视力、屈光度及眼轴。结果 随访12个月时,A组、B组和C组患者近视屈光度进展分别为（-1.22±0.38）D、（-1.07±0.31）D和（-0.38±0.25）D,各组之间比较差异有统计学意义（F=58.031, P<0.001）;眼轴增长分别为（0.48±0.21）mm、（0.39±0.15）mm和（0.15±0.09）mm,各组之间比较差异有统计学意义（F=24.612, P<0.001）;散光屈光度变化分别为（+0.33±0.12）D、（+0.21±0.18）D和（+0.26±0.13）D,各组之间比较差异无统计学意义（F=0.253, P=0.901）;各组患者均无明显不适主诉及高眼压等眼部并发症。结论 随访一年的结果表明,戴框架眼镜联合1%阿托品眼膏每周五晚1次能安全、有效地控制近视性散光青少年近视的进展,适宜基层医院推广。（眼科, 2016, 25： 298-301）     

An intervention trial on efficacy of atropine and multi-focal glasses in controlling myopic progression

PURPOSE: This randomized clinical trial assessed the treatment effects of atropine and/or multi-focal lenses in decreasing the progression rate of myopia in children. METHODS: Two hundred and twenty-seven schoolchildren with myopia, aged from 6 to 13 years, who were stratified based on gender, age and the initial amount of myopia were randomly assigned to three treatment groups: 0.5% atropine with multi-focal glasses, multi-focal glasses, and single vision spectacles. Each subject was followed for at least eighteen months. These results report on the 188 patients available for the follow-up. RESULTS: The mean progression of myopia in atropine with multi-focal glasses group (0.41 D) was significantly less than the multi-focal (1.19 D) and single vision group (1.40 D) (p < 0.0001). But no significant difference was noted between the last two groups (p = 0.44). The progression of myopia was significantly correlated with the increases of axial length (r = 0.65, p = 0.0001), but not with the changes of corneal power (r=-0.09), anterior chamber depth (r = -0.023), lens thickness (r = -0.08), or intra-ocular pressure (r = -0.008). CONCLUSION: The 0.5% atropine with multi-focal lenses can slow down the progression rate of myopia. However, multi-focal lenses alone showed no difference in effect compared to control.     

Attempts to reduce the progression of myopia and spectacle prescriptions during childhood: a survey of eye specialists

Purpose

To determine methods tried in clinical trials to reduce the progression of myopia in children, and spectacle prescribing patterns of hospital ophthalmologists.

Methods

A multi-sectioned survey composed of Likert items relating to the methods of reducing myopia progression (orthokeratology lenses [O-K lenses], undercorrected glasses, and topical atropine) and the patterns of prescribing spectacles for children (including two cases involving a 5-year-old girl and an 8-year-old boy) were distributed to members of the Korean Ophthalmological Society, and the collected data was statistically analyzed.

Results

A total of 78 out of 130 ophthalmologists returned the survey. On a scale of 1 to 5, the mean rates of whether the ophthalmologists think O-K lenses arrest myopia progression, and whether they recommend their patients to wear O-K lenses if indicative, were 3.06 and 2.75, respectively. Moreover, the mean rates of whether they consider that wearing glasses which are undercorrected would slow down the progression of the myopia, or if they think topical atropine helps in arresting myopia progression in children, were 2.34 and 1.27, respectively. In response to the case studies, the majority of practitioners preferred to prescribe the full amount found in cycloplegic refraction to pediatric patients with myopia.

Conclusions

Ophthalmologists in clinical practice encouraged children to wear O-K lenses more than undercorrected glasses as a way to retard myopia progression. However, the application of atropine is rarely tried in clinical trials. In managing pediatric patients with myopia (case specific), the majority of the practitioners chose to prescribe glasses with full cycloplegic correction.     

Who needs myopia control?

Myopia has become a major visual disorder among school-aged children in East Asia due to its rising prevalence over the past few decades and will continue to be a leading health issue with an annual incidence as high as 20%-30%. Although various interventions have been proposed for myopia control, consensus in treatment strategies has yet to be fully developed. Atropine and orthokeratology stand out for their effectiveness in myopia progression control, but children with rapid progression of myopia require treatment with higher concentrations of atropine that are associated with increased rates of side effects, or with orthokeratology that carries risk of significant complication. Therefore, improved risk assessment for myopia onset and progression in children is critical in clinical decision-making. Besides traditional prediction models based on genetic effects and environmental exposures within populations, individualized prediction using machine learning and data based on age-specific refraction is promising. Although emerging treatments for myopia are promising and some have been incorporated into clinical practice, identifying populations who require and benefit from intervention remains the most important initial step for clinical practice.     

Role of Cycloplegics in Progressive Myopia

Atropine sulfate 1% was instilled in both eyes of 86 children (172 eyes) on a daily basis for a period of two to eight years. No untoward changes in intraocular pressure, pupillary response, accommodation, or appearance of the ocular fundi were noted. A comparison with a similar group of children having only glasses prescribed during a similar time span revealed that atropine is effective in reducing the progression of myopia in children; a permanent reduction in the degree of myopia may be achieved. Relaxation of accommodation by means of cycloplegic drugs may be a safe and effective treatment of myopia.     

Myopia and orthokeratology for myopia control

The prevalence of myopia in children is increasing worldwide and is viewed as a major public health concern. This increase has driven interest in research into myopia prevention and control in children. Although there is still uncertainty in the risk factors underlying differences in myopia prevalence between ethnic groups, rates in children of East Asian descent are typically higher regardless of where they live. Mounting evidence also suggests that myopia prevalence in children increases with age. Earlier commencement and more rigorous education systems in these countries, resulting in more time spent on near‐work activities and less time on outdoor activities, may be responsible for the earlier age of myopia onset. However, to date, the mechanisms regulating myopia onset and progression are still poorly understood. Findings from several studies have shown orthokeratology to be effective in slowing axial elongation and it is a well‐accepted treatment, particularly in East Asian regions. While our understanding of this treatment has increased in the last decade, more work is required to answer questions, including: How long should the treatment be continued? Is there a rebound effect? Should the amount of myopia control be increased? To whom and when should the treatment be offered? Practitioners are now faced with the need to carefully guide and advise parents on whether and when to undertake a long somewhat complex intervention, which is costly, both in time and money. In the near future, a greater demand for effective prophylaxis against childhood myopia is envisaged. Other than orthokeratology, atropine therapy has been shown to be effective in slowing myopia progression. While its mechanism of control is also not fully understood, it is likely that it acts via a different mechanism from orthokeratology. Thus, a combined treatment of orthokeratology and atropine may have great potential to maximise the effectiveness of myopia control interventions.     

Juvenile myopia progression,risk factors and interventions

The development and progression of early onset myopia is actively being investigated. While myopia is often considered a benign condition it should be considered a public health problem for its visual, quality of life, and economic consequences. Nearly half of the visually impaired population in the world has uncorrected refractive errors, with myopia a high percent of that group. Uncorrected visual acuity should be screened for and treated in order to improve academic performance, career opportunities and socio-economic status.Genetic and environmental factors contribute to the onset and progression of myopia. Twin studies have supported genetic factors and research continues to identify myopia genetic loci. While multiple myopia genetic loci have been identified establishing myopia as a common complex disorder, there is not yet a genetic model explaining myopia progression in populations.Environmental factors include near work, education levels, urban compared to rural location, and time spent outdoors. In this field of study where there continues to be etiology controversies, there is recent agreement that children who spend more time outdoors are less likely to become myopic.Worldwide population studies, some completed and some in progress, with a common protocol are gathering both genetic and environmental cohort data of great value. There have been rapid population changes in prevalence rates supporting an environmental influence.Interventions to prevent juvenile myopia progression include pharmacologic agents, glasses and contact lenses. Pharmacological interventions over 1–2 year trials have shown benefits. Peripheral vision defocus has been found to affect the emmetropization process and may be affected by wearing glasses or contacts. Accommodation accuracy also has been implicated in myopia progression.Further research will aim to assess both the role and interaction of environmental influences and genetic factors.     

Effects of different concentrations of atropine on controlling myopia in myopic children.

Although 1% atropine effectively slows myopia progression, it is associated with adverse effects, including photophobia, blurred near vision, and poor compliance. We investigated whether lower doses of atropine would control myopia progression. One hundred and eighty-six children, from 6 to 13 years of age, were treated each night with different concentrations of atropine eye drops or a control treatment for up to 2 years. The mean myopic progression in each of the groups was 0.04 +/-0.63 diopter per year (D/Y) in the 0.5% atropine group, 0.45+/-0.55 D/Y in the 0.25% atropine group, and 0.47+/-0.91 D/Y in the 0.1% atropine group. All atropine groups showed significantly less myopic progression than the control group (1.06+/-0.61 D/Y) (p<0.01). Our study also showed that 61% of students in the 0.5% atropine group, 49% in the 0.25% atropine group and 42% in the 0.1% atropine group had no myopic progression. However, 4% of children in the 0.5% atropine group, 17% in the 0.25% atropine group, and 33% in the 0.1% atropine group still had fast myopic progression (>-1.0 D/Y). In contrast, only 8% of the control group showed no myopic progression and 44% had fast myopic progression. These results suggest that all three concentrations of atropine had significant effects on controlling myopia; however, treatment with 0.5% atropine was the most effective.