Cochrane 2025 Review: Comparing Atropine and Optical Interventions for Myopia

Myopia management requires balancing treatment efficacy against tolerability across several distinct interventions evaluated in a Cochrane systematic review and meta-analysis published in 2025. Selecting an appropriate strategy depends heavily on the severity and progression of the condition, which clinicians measure by tracking the axial length of the eye and spherical equivalent alongside patient age and lifestyle demands like sports.

Atropine Drops and Brake Lenses Limit Axial Elongation

Atropine eye drops limit the axial elongation of the eye through multiple mechanisms of action, though only hospital preparations are currently available. Efficacy increases in a dose-dependent manner alongside side effects like photophobie, blurry near vision, hypersensitivity to sunlight, and a rebound effect upon cessation. Current literature suggests that atropine diluted to 0.05 percent provides the best compromise between efficacy and tolerability.

In contrast, brake lenses utilize peripheral myopic defocus. This method shifts the image that normally forms behind the retina in a myopic child to a position in front of it, which restrains myopia progression.

Orthokeratology and Soft Lenses Induce Peripheral Myopic Defocus

Orthokeratology relies on wearing rigid lenses overnight to remodel the cornea and impose peripheral myopic defocus. This approach suits young patients with mild or moderate myopia who maintain stable sleep patterns exceeding six hours, making it especially appropriate for athletes. The Société française des ophtalmologistes adaptateurs de lentilles de contact maintains a directory of practitioners.

Daytime soft brake lenses also induce peripheral myopic defocus but carry a higher risk of infectious keratitis than orthokeratology. Rigid daytime lenses are rarely used and typically reserved for high myopia. While less common, they offer better oxygen permeability and a lower infection risk than soft lenses.

Evidence Levels At Two Years

The 2025 Cochrane review established that the highest levels of evidence support high-dose atropine, orthokeratology, and soft lenses, while other methods hold lower evidentiary backing. Regarding axial length reduction at two years, orthokeratology yields the strongest results, followed by high-dose atropine at 0.5 percent or greater, moderate-dose atropine between 0.1 and 0.5 percent, combined orthokeratology and atropine, brake lenses, low-dose atropine under 0.1 percent, soft lenses, and rigid lenses.

For spherical equivalent improvement at two years, high-dose atropine achieves the top rank, succeeded by moderate-dose atropine, brake lenses, low-dose atropine, soft lenses, and rigid lenses. High-dose atropine delivers recognized efficacy but remains largely unused in routine practice due to poor patient tolerance.