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Year : 2021  |  Volume : 1  |  Issue : 1  |  Page : 140-141

Treatment of 0.01% atropine eye drops induced convergence excess esotropia and rebound myopia managed with 1% atropine eye drops

Department of Binocular Vision Disorders, Jyotirmay Eye Clinic for Children and Adult Squint and Ocular Motility Laboratory, Thane, Maharashtra, India

Date of Submission18-Mar-2020
Date of Acceptance14-Jul-2020
Date of Web Publication31-Dec-2020

Correspondence Address:
Dr. Mihir Kothari
Jyotirmay Eye Clinic for Children and Adult Squint, Ocular Motility Lab and Pediatric Low Vision Center, 104, 105 Kaalika Tower, Kolbad Road, Khopat, Thane West 400 601, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijo.IJO_581_20

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We report a case of progressive childhood myopia who developed rebound myopia and convergence excess esotropia after switching from 1% atropine eye drops to 0.01% atropine eye drops. The esotropia recovered and myopia progression was arrested after stopping 0.01% atropine drops and resuming 1% atropine eye drops.

Keywords: Anticholinergic, atropine, convergence excess, esotropia, progressive myopia

How to cite this article:
Jahan S, Kothari M, Solanki M. Treatment of 0.01% atropine eye drops induced convergence excess esotropia and rebound myopia managed with 1% atropine eye drops. Indian J Ophthalmol Case Rep 2021;1:140-1

How to cite this URL:
Jahan S, Kothari M, Solanki M. Treatment of 0.01% atropine eye drops induced convergence excess esotropia and rebound myopia managed with 1% atropine eye drops. Indian J Ophthalmol Case Rep [serial online] 2021 [cited 2023 Jun 2];1:140-1. Available from: https://www.ijoreports.in/text.asp?2021/1/1/140/305529

A 10-year-old boy presented with the complaint of blurring of vision for distance since 1 month. He was using spectacle correction of –1.5DS (diopter sphere) since 8 months. His vision in both the eyes improved to 20/25 (0.1 logMAR) with –1.75DS –0.50DC (diopter cylinder) X180 in the right eye and –2.50DS in the left eye. On ocular examination, anterior segment and posterior segment of both the eyes were normal and he was orthotropic for near and distance in all cardinal positions of gaze. He was advised lifestyle modifications (outdoor physical activities in the daylight and break in the near activities) to slow the myopia progression. On his subsequent examinations [Figure 1], he was diagnosed with progressive myopia. His spectacle power increased to –3.75DS –0.75DCX10 in the right eye and –3.00DS –0.50DC X 165 in the left eye over 24 months. On his ocular examination, he was found to have flick esophoria for the near with the old refractive correction and after wearing full myopic correction.
Figure 1: Line chart showing the myopia progression

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For his myopia progression, he was advised 1% atropine eye drops (since low-dose atropine [LDA] was commercially unavailable in our country at that time) along with 90% photogrey progressive addition spectacles. 18 months following the use of 1% atropine eye drops, he developed photophobia and also complained of intolerable burning sensation. However, there was no clinical evidence of ocular allergy to atropine eye drops. On examination he was orthotropic for near and distance, his refractive error was also stable, and his anterior segment examination was normal. To treat his photophobia, 1% atropine drops were replaced with LDA (0.01% atropine) eye drops, once at bedtime, whereas the progressive addition photogrey lenses were continued.

At a 6-month follow-up, the patient had orthotropia for distance and poorly controlled esophoria (+16PD) for the near. The near esophoria was asymptomatic and relieved with +3.0DS addition to the distance vision correction. There was an increment of –0.50Ds in both the eyes. A diagnosis of worsening of near esodeviation (convergence excess esodeviation) and recurrence (rebound) myopia was made. The LDA was discontinued and the patient was followed up after 3 weeks. The accommodation, convergence, and esodeviation promptly normalized and the patient became orthotropic both for distance and near [Table 1].
Table 1: Orthoptic workup of the patient after cessation of 0.01% atropine eye drops

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To address his progressive myopia, 1% atropine eye drops at bedtime was started again. Three weeks following its usage, he had exophoria of –7PD for distance and –14PD for near and 9 months later, his myopia remained arrested and there was a well-controlled exophoria of -9PD for the near and distance. On the last follow-up visit, the patient had binocular sensory fusion on Bagolini striated glasses for near as well as distance, 200″ stereopsis on Lang test for the near and 1″ distance stereopsis on CP 690 projector chart system (Nidek, Japan).

  Discussion Top

0.01% atropine eye drops or LDA has become a popular first-line treatment to retard the progression of childhood myopia.[1],[2] Modest reduction in accommodation in children using LDA is common and generally well tolerated.[2],[3],[4],[5],[6] However, convergence excess type of esodeviation associated with the use of LDA in patients with preexisting fusional abnormalities is recently reported.[7]

In that report, Kothari et al.[7] reported three children who developed convergence excess esotropia (CEET) associated with the use of LDA that improved or resolved after cessation of the drops. However, all of them were previously operated for an exotropia and developed monofixation syndrome postoperatively. It was hypothesized that partial cycloplegia induced by LDA causes resistance to partially retained accommodative effort, and a reflex convergence is induced by excessive innervational stimulation of accommodation, thus causing increasing convergence excess esodeviation. When used for prolonged duration on a regular basis as used for retardation of myopia, LDA may affect accommodation––convergence relationship resulting in the convergence excess esotropia. Conversely, complete cycloplegia for a longer duration causes abolition of the accommodative efforts as is seen with the use of 1% atropine drops in this patient and in the patients with fully refractive accommodative esotropia.[8]

Akin to this patient, in the authors' past experience, use of progressive addition lenses was futile to treat convergence excess esodeviation induced with the use of LDA. We hypothesize that use of PAL in children using LDA may not reliably relax the accommodation because children often continue to use the upper segment of their spectacles even during the period of their near activity.

Similar to our findings, in a previous study, Lyu et al.[9] reported that partial cycloplegia was associated with a median increase of +10PD in 38% children who had a pre-existing esodeviation. A maximum increase of +25PD was reported, which recovered after the effect of cycloplegia subsided.

  Conclusion Top

We recommend close monitoring of the children with near esophoria who are using LDA for myopia control and any worsening of the esodeviation should prompt cessation/shifting to 1% atropine. However, more such cases should be observed and larger series might help understand the management of these patients better.

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Conflicts of interest

There are no conflicts of interest.

  References Top

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.  Back to cited text no. 1
[PUBMED]  [Full text]  
Chia A, Chua WH, Cheung YB, Wong WL, Lingham A, Fong A, et al. Atropine for treatment of childhood myopia: Safety and efficacy of 0.5%, 0.1% and 0.01% doses. Ophthalmology 2012;119:347-54.  Back to cited text no. 2
Cooper J, Eisenberg N, Schulman E, Wang FM. Maximum atropine dose without clinical signs or symptoms. Optom Vis Sci 2013;90:1467-72.  Back to cited text no. 3
Chia A, Lu QS, Tan D. Five-year clinical trial on atropine for the treatment of myopia 2: Myopia control with atropine 0.01% eye drops. Ophthalmology 2016;123:391-9.  Back to cited text no. 4
Nishiyama Y, Moriyama M, Fukamachi M, Uchida A, Miyaushiro H, Kurata A, et al. [Side effects of low dose atropine] Nippon Ganka Gakkai Zasshi 2015;119:812-16.  Back to cited text no. 5
Loughman J, Flitcroft DI. The acceptability and visual impact of 0.01% atropine in a Caucasian population. Br J Ophthalmol 2016;100:1525-9.  Back to cited text no. 6
Kothari M, Modak M, Khan H, Jahan S, Solanki M, Rathod V. Convergence excess consecutive esotropia associated with 0.01% atropine eye drops usage in patients operated for intermittent exotropia. Indian J Ophthalmol 2020;68:653-6.  Back to cited text no. 7
[PUBMED]  [Full text]  
Kothari M, Manurung F, Paralkar S. Use of atropine to predict the accommodative component in esotropia with hypermetropia. Indian J Ophthalmol 2011;59:487-90.  Back to cited text no. 8
[PUBMED]  [Full text]  
Lyu IJ, Park KA, Oh SY. Increase in esodeviation under cycloplegia with 0.5% tropicamide and 0.5% phenylephrine mixed eye drops in patients with hyperopia and esotropia. BMC Ophthalmol 2017;17:247.  Back to cited text no. 9


  [Figure 1]

  [Table 1]


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