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• W4200162014 abstract "We thank Yam et al for their valuable comments and suggestions. We agree with the authors that Indian children are at a lower risk of myopia incidence and progression than their Chinese counterparts. The reported annual incidence of childhood myopia (5–15 years) per the North India Myopia study is 3.4%1Saxena R. Vashist P. Tandon R. et al.Incidence and progression of myopia and associated factors in urban school children in Delhi: the North India Myopia Study (NIM Study).PLoS One. 2017; 12e0189774Crossref PubMed Scopus (73) Google Scholar and the prevalence is 13%,2Saxena R. Vashist P. Tandon R. et al.Prevalence of myopia and its risk factors in urban school children in Delhi: the North India Myopia Study (NIM Study).PLoS One. 2015; 10e0117349Crossref PubMed Scopus (106) Google Scholar which is much lower than those reported in East Asia, but comparable with White children. Mean myopia progression of –0.27 ± 0.42 diopters (D) per year reported in this cohort is also less compared with their Chinese counterparts.1Saxena R. Vashist P. Tandon R. et al.Incidence and progression of myopia and associated factors in urban school children in Delhi: the North India Myopia Study (NIM Study).PLoS One. 2017; 12e0189774Crossref PubMed Scopus (73) Google Scholar Inherent ethnic and lifestyle variations could account for this difference. Despite lower incidence and progression rates, myopia shows a rising trend in the last 4 decades in India, encroaching into even the rural settings of the country (reference 1 in the original article). Recent studies have shown factors like age and baseline myopia are known to influence myopia progression and response to atropine therapy. We evaluated the association between these parameters (age, baseline myopia, and gender) with myopia progression in the cohort of the I-ATOM study. Younger age is related to higher myopia progression and poor treatment response with various concentrations of atropine as seen in Chinese and Singaporean populations in the Low-Concentration Atropine for Myopia Progression study (LAMP) (0.05%, 0.025%, 0.01%) and ATOM-1 (1%), respectively.3Yam J.C. Li F.F. Zhang X. et al.Two-year clinical trial of the Low-Concentration Atropine for Myopia Progression (LAMP) study: phase 2 report.Ophthalmology. 2020; 127: 910-919Abstract Full Text Full Text PDF PubMed Scopus (105) Google Scholar,4Chua W.H. Balakrishnan V. Chan Y.H. et al.Atropine for the treatment of childhood myopia.Ophthalmology. 2006; 113: 2285-2291Abstract Full Text Full Text PDF PubMed Scopus (367) Google Scholar In our study, younger age was associated with higher myopia progression in the placebo group. In contrast with the findings of LAMP and ATOM-1, treatment response with 0.01% atropine was better in younger children. This finding is possibly because the effect of atropine is more evident during the years of maximal eye growth (Table 1, Fig 1).Table 1Comparison of Myopia Progression∗The change in spherical equivalent refractive error represented as mean ± standard deviation. According to Age and Baseline Refractive Error in 2 Study GroupsAtropine Group (n)Placebo Group (n)P ValueAge, years 6–0.17 ± 0.52 (4)–0.75 (1)0.39 7–0.12 ± 0.14 (2)–0.46 (1)0.26 8–0.16 ± 0.59 (4)–0.4 ± 0.52 (3)0.77 9–0.12 ± 0.00 (2)–0.32 ± 0.43 (7)0.42 10–0.08 ± 0.19 (10)–0.34 ± 0.22 (4)0.57 11–0.14 ± 0.44 (8)–0.28 ± 0.39 (10)0.16 12–0.24 ± 0.22 (8)–0.31 ± 0.36 (7)0.69 13–0.23 ± 0.21 (7)–0.28 ± 0.34 (7)0.36 14–0.3 ± 0.24 (2)–0.34 ± 0.35 (5)0.49Baseline refractive error <–2 D–0.01 ± 0.01 (2)–0.5 ± 0.45 (2)0.23 –2 to –2.99 D–0.06 ± 0.31 (19)–0.43 ± 0.4 (16)0.01 –3 to –3.99 D–0.19 ± 0.29 (12)–0.33 ± 0.42 (9)0.27 –4 to –4.99 D–0.27 ± 0.32 (9)–0.3 ± 0.37 (10)0.19 –5 to –5.99 D–0.34 ± 0.22 (2)–0.35 ± 0.48 (5)0.45 6 D and more–0.38 ± 0.56 (3)–0.39 ± 0.2 (3)0.63∗ The change in spherical equivalent refractive error represented as mean ± standard deviation. Open table in a new tab Higher baseline myopia was associated with a decreasing response to atropine therapy (i.e., greater progression of spherical equivalent refractive error) in the current study (Table 1, Fig 1), which corroborates the previous studies. However, this association was not noted in the LAMP study.5Li F.F. Zhang Y. Zhang X. et al.Age effect on treatment responses to 0.05%, 0.025%, and 0.01% atropine: Low-Concentration Atropine for Myopia Progression Study.Ophthalmology. 2021; 128: 180-1187Abstract Full Text Full Text PDF Scopus (21) Google Scholar Regarding gender, mean myopia progression in females was greater (–0.47 ± 0.46 D) than males (–0.27 ± 0.34 D) in the placebo group, although the difference did not reach statistical significance (P = 0.19). In the treatment group, however, males showed a significantly better response with a mean progression of –0.03 ± 0.32 D that was significantly less than in females (–0.34 ± 0.39 D) (P = 0.004) (Fig 2). Female gender has been identified as a risk factor for natural myopia progression in the North India Myopia1Saxena R. Vashist P. Tandon R. et al.Incidence and progression of myopia and associated factors in urban school children in Delhi: the North India Myopia Study (NIM Study).PLoS One. 2017; 12e0189774Crossref PubMed Scopus (73) Google Scholar and LAMP5Li F.F. Zhang Y. Zhang X. et al.Age effect on treatment responses to 0.05%, 0.025%, and 0.01% atropine: Low-Concentration Atropine for Myopia Progression Study.Ophthalmology. 2021; 128: 180-1187Abstract Full Text Full Text PDF Scopus (21) Google Scholar studies and has been attributed to preferred indoor activities in females. Its effect on response to atropine therapy has not been reported before. These findings suggest that younger age, lower baseline myopia, and male gender are associated with better response to atropine therapy in Indian children. Therefore, early intervention should be considered in progressive childhood myopia. Lastly, LAMP (phase II)5Li F.F. Zhang Y. Zhang X. et al.Age effect on treatment responses to 0.05%, 0.025%, and 0.01% atropine: Low-Concentration Atropine for Myopia Progression Study.Ophthalmology. 2021; 128: 180-1187Abstract Full Text Full Text PDF Scopus (21) Google Scholar and ATOM-2 (reference 2 in the original article) report better efficacy of 0.01% atropine during the second year of therapy. Based on these results, the treatment response in our cohort is expected to improve further by extending the duration of therapy to 2 years. Therefore, the approach of starting the treatment with 0.01% atropine in progressive childhood myopia and stepping up to higher concentrations in case of nonresponders seems to be acceptable in Indian children. However, larger Indian studies using varying atropine concentrations and longer follow-up are needed to confirm the outcomes. Re: Saxena et al.: Atropine for treatment of childhood myopia in India: multicentric randomized trial (Ophthalmology. 2021;128:1367-1369)OphthalmologyVol. 128Issue 12PreviewSaxena et al1 conducted a multicenter, double-masked, placebo-controlled randomized clinical trial in India and reported 1-year data proving efficacy of 0.01% atropine drops in decreasing myopia progression. We congratulate the authors for a careful trial with important results. Full-Text PDF" @default.
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