Abstract
We conducted a narrative review of peer-reviewed randomized controlled trials (RCTs) investigating low-concentration atropine for myopia management. Studies were identified using the terms "myopia" AND "atropine" and supplemented through reference searches. Key data on spherical equivalent refraction (SER), axial length (AL) progression, participant demographics, and ethnicity were extracted and qualitatively compared across trials. In addition, observed AL progression was contextualized against expected age-matched myopic axial elongation and physiological emmetropic eye growth derived from previously published normative models. Evidence from pivotal trials such as ATOM and LAMP, mainly conducted in Asian populations, demonstrated dose-dependent efficacy of atropine, with 0.05% showing superior outcomes compared with 0.01%. However, more recent studies in non-Asian populations, including STAR, MOSAIC, WA-ATOM, and MTS, have reported more modest treatment effects with 0.01% atropine. Differences in efficacy appear influenced by factors including age, ethnicity, baseline progression rates, environmental exposures, and placebo-group axial elongation rates. The coronavirus disease 2019 (COVID-19) pandemic also impacted outcomes in several trials, highlighting environmental influences on myopia progression. In addition, off-protocol use of myopia-control interventions in studies such as CHAMP further complicates interpretation of atropine efficacy. While low-concentration atropine remains a promising option for myopia management, rebound progression after cessation remains a concern. Emerging evidence suggests that future research should look at higher atropine concentrations, individualized treatment strategies, and comparisons against normative ocular growth trajectories rather than placebo alone. Licensed atropine formulations, particularly within Europe, are anticipated to improve treatment standardization, support regulatory oversight, and help refine future clinical guidelines for myopia management.