Does 0.01% atropine work equally for every child? Ethnicity and the low-dose debate

Jagrut Lallu — BOptom (Hons), MSc Specialty Lenses (Hons), FIAOMC. Therapeutic Optometrist & Contact Lens Specialist. Founder, New Zealand Eye Research Centre; Partner, Rose Optometry; WCO Asia-Pacific Myopia Ambassador; International Myopia Institute NZ Ambassador; Clinical Senior Lecturer, Deakin School of Optometry; Honorary Teaching Fellow, University of Auckland.

Low-dose 0.01% atropine has been one of the most debated myopia-control treatments of the past decade. Trials have disagreed about how well it works. A systematic review and meta-analysis published in the British Journal of Ophthalmology in 2026 asks whether part of that disagreement comes down to ethnicity. Its headline is that South Asian children appear to respond most strongly. The detail tells a more nuanced story.

What the review did

The authors searched six sources, including two trial registries, up to August 2025 and included 25 randomised controlled trials (RCTs) involving 4374 children aged 4 to 18 years. Each trial had to compare 0.01% atropine with a control for at least 12 months. The review was registered on PROSPERO and pooled results with random-effects models.

Trials were grouped at study level as East Asian (13 studies, 2116 children), white (7 studies, 1619 children) or South Asian (4 studies, 373 children, from India and Bangladesh). One multiethnic Australian trial was left out of the ethnic comparison.

Two effect measures were used. The ratio of means (RoM) divides the yearly progression on atropine by the yearly progression in the control group, giving a relative percentage reduction. The mean difference (MD) is the absolute difference in dioptres (D) or millimetres per year.

The headline results

Overall, 0.01% atropine was associated with a 37% reduction in annual refraction (spherical equivalent, SER) progression (RoM 0.63; 95% CI 0.54 to 0.74), equivalent to 0.21 D per year (95% CI 0.15 to 0.27). By ethnic group, the relative reductions were:

• South Asian: 66% (RoM 0.34; 95% CI 0.27 to 0.42)
• East Asian: 35% (RoM 0.65; 95% CI 0.54 to 0.78)
• White: 28% (RoM 0.72; 95% CI 0.59 to 0.86)

A 95% confidence interval (CI) is the range of true effects reasonably compatible with the pooled data; a narrower interval means a more precise estimate. The difference between the subgroups was statistically significant (p<0.0001), meaning it would be unlikely to arise by chance alone if the true effects were identical. The Discussion gives slightly different percentages for white children than the Results; we have used the Results figures.

Relative versus absolute: the key to this paper

Look at the absolute benefit instead. On the MD scale, atropine slowed progression by 0.29 D per year in South Asian children (95% CI 0.22 to 0.36) and 0.26 D per year in East Asian children (95% CI 0.16 to 0.36). These are very similar. White children gained less, 0.12 D per year (95% CI 0.05 to 0.19).

So why does the South Asian relative reduction look so much larger than the East Asian one (66% versus 35%)? The answer lies in the control groups. Pooled control-arm progression was −0.74 D per year in East Asian trials, but −0.43 D per year in South Asian trials and −0.41 D per year in white trials. When the control group progresses slowly, a similar absolute benefit becomes a much bigger percentage.

In other words, the "greatest efficacy" in South Asian children depends heavily on which scale you use. On the absolute scale, South Asian and East Asian children benefit by much the same amount. For white children, the 28% relative figure translates into only 0.12 D per year.

Refraction versus axial length

Refraction can be influenced by atropine's effects on focusing as well as by eye growth. Axial length (AL), the physical length of the eye, is the more objective structural measure. On AL, the overall effect was smaller: a 27% reduction per year (RoM 0.73; 95% CI 0.66 to 0.81). East Asian and white children both showed 27%, while South Asian children showed 48% (RoM 0.52; 95% CI 0.36 to 0.77). That wide interval reflects only four small trials. Several placebo-controlled trials in Japan, Hong Kong, Australia, Denmark and the USA found no significant axial benefit from 0.01% atropine, which fits with the dose-response questions we discussed in our review of the atropine dose-response meta-analysis.

The review also found a larger relative effect in children older than 9 (46%; RoM 0.54) than in those aged 9 or younger (22%; RoM 0.78). This may partly reflect slower natural eye growth in older children.

Limitations of this evidence

• Ethnicity is tangled up with country and trial. Groups were assigned by study population, which largely followed geography, not individual ethnicity. Differences could reflect trial design, drug formulation, comparator type, age, baseline myopia, outdoor time or risk of bias, not biology.
• Not all controls were placebo. The authors counted placebo drops, no intervention and single-vision spectacles as controls. Trials without a placebo may overstate effects.
• A small South Asian evidence base. Four trials and 373 children underpin the headline finding.
• Mostly short-term data. Only three trials ran beyond two years.
• Incomplete reporting. Six of 25 trials had risk-of-bias concerns in at least one domain. No GRADE certainty rating, formal publication-bias test or pooled safety analysis was reported, and heterogeneity statistics were not given in the main text. Some data were estimated from medians or read from graphs.
• Author involvement. Funding was from public Hong Kong sources and no competing interests were declared, but several authors belong to the LAMP trial group, and LAMP is one of the included trials.
• No Māori or Pacific data. There were no Māori, Pacific, African, Hispanic or Middle Eastern subgroups, and no New Zealand trial.

What this means for children in Hamilton and across New Zealand

New Zealand's children come from many backgrounds, and this review cannot tell us how 0.01% atropine performs for Māori or Pacific tamariki; applying its findings to them would be extrapolation. What it does show is how easily a relative percentage can mislead when control groups progress at different rates. When you read any atropine study, it is worth asking how fast the untreated children progressed and what the absolute difference was. Our article on the MARS trial of 0.02% and 0.04% atropine looks at the evidence for higher concentrations.

Any decision about atropine or other options should follow a professional assessment of a child's age, prescription, axial length and family history. Our optometrists, including Jagrut Lallu and Jacqueline Rowe, provide myopia control at Rose Optometry in Hamilton. If you would like to discuss the evidence first, book a free Myopia Chat with Jagrut.

References

• Zhang XJ, et al. Efficacy of 0.01% atropine eye drops for myopia control in children of different ethnicities: a systematic review and meta-analysis. British Journal of Ophthalmology. 2026;110(10):1108. PMID: 41876209. DOI: 10.1136/bjo-2025-328942