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Comment
. 2025 Nov 1;143(11):904-913.
doi: 10.1001/jamaophthalmol.2025.3243.

Atropine or Cyclopentolate to Diagnose Premyopia in Preschool Children

Haotian Wu  1   2 , Yanjiao Wang  1 , Qiuying Lu  1 , Kathryn A Rose  3 , Ian G Morgan  4 , Zihan Ni  1 , Kaidi Xiang  1   2   5 , Ziyi Qi  1   2 , Bo Zhang  1 , Jingjing Wang  1 , Jun Chen  1 , Xun Xu  1   2 , Xiangui He  1
Affiliations
Comment

Atropine or Cyclopentolate to Diagnose Premyopia in Preschool Children

Haotian Wu et al. JAMA Ophthalmol. .

Abstract

Importance: Sufficient cycloplegia is essential for reliable refraction in preschool children. The choice of cycloplegic agent may affect refraction and diagnosis outcomes.

Objective: To evaluate the objective refraction outcomes after cycloplegia in preschool children given either atropine or cyclopentolate.

Design, setting, and participants: This was a post hoc analysis of the 2024 Preschool Children Refractive Development Pattern and Influencing Factors Study (PRDP-IFS), in which children were given atropine, and the 2013 to 2014 Elaborative Shanghai Childhood Ocular Refractive Development Study (E-SCORDS), in which children were given cyclopentolate. These were population-based studies. Eyes in each group were included via propensity score matching. Study data were analyzed from December 2024 to July 2025.

Exposures: Cycloplegia induced by either 1% atropine (twice daily for 4 days with an additional dose on day 5) or 1% cyclopentolate (dual administration 5 minutes apart) eye drops.

Main outcomes and measures: Difference between the noncycloplegic and cycloplegic spherical equivalent (DSE) and the prevalence of refractive states were compared in the atropine and cyclopentolate groups. Refractive states (moderate to high hyperopia, low hyperopia, premyopia, and myopia) were determined by cycloplegic spherical equivalent (SE) using an autorefractor.

Results: A total of 1761 children and their 3048 eyes were included in this study. There were 773 children (1524 eyes) in the atropine group (mean [SD] age, 4.62 [0.92] years; 406 male [52.5%]) and 988 children (1524 eyes) in the cyclopentolate group (mean [SD] age, 4.62 [0.93] years; 530 male [53.6%]). There were a total of 1524 eyes in each group. The mean (SD) noncycloplegic SE was 0.30 (0.92) diopters (D) and 0.31 (0.76) D in the atropine and cyclopentolate groups, respectively (mean difference, -0.01 D; 95% CI, -0.07 to 0.05 D; P = .72). Mean (SD) DSE in the atropine group was 1.56 (0.72) D and in the cyclopentolate group was 0.97 (0.70) D. The mean difference in DSE between the 2 groups was 0.59 D (95% CI, 0.54-0.64 D; P < .001). The difference in the percentages of refractive states between the atropine and cycloplegic groups was as follows: moderate to high hyperopia (7.2% vs 2.7% = 4.5%; 95% CI, 2.9%-6.0%; P < .001), low hyperopia (82.8% vs 74.0% = 8.8%; 95% CI, 6.0%-11.8%; P < .001), premyopia (8.7% vs 21.6% = -12.9%; 95% CI, -15.4% to -10.4%; P < .001), and myopia (1.3% vs 1.8% = -0.5%; 95% CI, -1.3% to 0.4%; P = .30).

Conclusions and relevance: This study found that use of atropine for cycloplegia in preschool children was associated with less myopic refraction compared with cyclopentolate and may potentially avoid overestimation of premyopia prevalence; however, this investigation did not evaluate each cycloplegic agent in the same children.

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Conflict of interest statement

Conflict of Interest Disclosures: Dr J. Wang reported receiving a grant from the Shanghai Municipal Health and Health Commission. Dr He reported receiving grants from the Ministry of Science and Technology of China, National Natural Science Foundation of China, and Shanghai Science and Technology Commission during the conduct of the study. No other disclosures were reported.

Figures

Figure 1.
Figure 1.. Density Plots of Noncycloplegic Spherical Equivalent (SE), Cycloplegic SE, and Difference of Noncycloplegic and Cycloplegic SE (DSE) in the Atropine and Cyclopentolate Groups
Dashed lines indicate group means. The noncycloplegic SE was 0.30 (0.92) diopter (D) in the atropine group and 0.31 (0.76) D in the cyclopentolate group, with a mean difference of −0.01 D (95% CI, −0.07 to 0.05 D; P = .72). Cycloplegic SE was 1.86 (1.06) D in the atropine group and 1.28 (0.83) D in the cyclopentolate group (95% CI, 0.51-0.65 D; P < .001). DSE was 1.56 (0.72) D in the atropine group and 0.97 (0.70) D in the cyclopentolate group, with a mean difference of 0.59 D (95% CI, 0.54-0.64 D; P < .001).
Figure 2.
Figure 2.. Subgroup Analysis of the Difference of Noncycloplegic and Cycloplegic Spherical Equivalent (DSE) Between the Atropine and Cyclopentolate Groups
The DSE was calculated as cycloplegic SE minus noncycloplegic SE. The left half of the figures presented scatterplots, and the right half combined box plots and density curves. AL indicates axial length; D, diopter; NSE, noncycloplegic SE.
Figure 3.
Figure 3.. Subgroup Analysis of Difference in Prevalence of Refractive States Between the Atropine and Cyclopentolate Groups
Refractive states were determined based on cycloplegic spherical equivalent (SE) obtained using either atropine or cyclopentolate. AL indicates axial length; D, diopter; NSE, noncycloplegic SE.
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