INTRODUCTION

Myopia is considered a serious public health concern globally. Holden

predicted that 51% of Europeans would be myopic in the year 2050 by using simple regression analysis. In another study the author foretold that an average of -2.0 D would develop and the predicted prevalence of myopia is 63% in 2050

. Many population-based studies in children have shown that the prevalence of myopia is obviously higher in urbanized East Asian countries

. During the past decade, the prevalence of myopia and vision impairment was highly prevalent among Chinese school students, and increased with grade in a nonlinear manner; vision impairment was high in high school students who had a high prevalence of high myopia

.The rising prevalence of myopia is also accompanied by earlier onset, which in turn leads to an increased risk of high myopia. However, high myopia is a known risk factor for sight-threatening conditions such as retinal detachment,myopic macular degeneration and glaucoma later in life.Each additional 1 D of myopia progression associated with a 58%, 20%, 21%, and 30% increase in the risk of myopic maculopathy, open-angle glaucoma, posterior subcapsular cataract, and retinal detachment, respectively. The predicted years of visual impairment ranges from 4.42 in a person with myopia of -3.0 D to 9.56 in a person with myopia of -8.0 D,and 1.0 D reduction would lower these by 0.74 and 1.21y,respectively

. Therefore, myopia is a serious public health problem for the next few decades especially in China, and high myopia becomes a leading cause of blindness worldwide due to associated ocular illness

.

Several treatments to slow myopia progression have been investigated, including increase outdoor activity time,orthokeratology, peripheral defocus modifying contact lenses,and the topical use of low-concentration atropine eye drops.Previous review and Meta-analyses suggested that atropine eye drops conferred the best efficacy among all myopia prevention methods

. There have been many controlled clinical trials which indicate that low-concentration atropine eye drops can delay the occurrence and development of myopia. A review of 41 studies

and a meta-analysis of 16 interventions

for myopia showed that topical antimuscarinic drugs, such as 0.01%-1% atropine eye drops, were effective in slowing myopia progression and axial elongation in children. Moreover,1% atropine effectively inhibited myopia progression and promoted myopic rebound, although it was associated with adverse effects such as blurred near vision and hypersensitivity reactions

. Low-concentration (0.01%-0.5%) atropine eye drops can effectively prevent myopia progression

. Based on available evidence, 0.01% atropine eye drops are widely used for myopia control, with good efficacy and few side effects

.

In this study, 0.01% atropine sulphate ophthalmic gel was used to treat myopia in adolescent patients with a 6-month clinical application, and its effects on myopia control were evaluated by changes in spherical equivalent (SE) and axial length (AL).

Eye-drops are the most conventional dosage form of currently accessible ophthalmic formulations. Despite the excellent acceptance by patients, the major problems encountered are having low bioavailability profiles, rapid removal from the administration site, and thus ineffective delivery of drugs.However, eye gel has been investigated as a delivery system which is able to overcome some of these challenges

.Therefore, we developed a 0.01% atropine sulphate eye gel and evaluate its efficacy and safety on myopia progression.

SUBJECTS AND METHODS

Ethical Approval This prospective cohort study followed the tenets of the Helsinki Declaration on ethical principles for medical research involving human subjects and was approved by Xi’an No.1 Hospital Ethics Committee. Informed consent of the children and their guardians was obtained. The protocol of this study is registered in the ChiCTR Database(ChiCTR2000038218).

這些本來就積壓在我心中已久，如今在鄰居面前娓娓道來，我特別動情，有時說著說著眼淚就來了，不少鄰居很快就站到了我這一邊，說：“以前光聽你婆婆一面之詞了，她確實(shí)不應(yīng)該這么待你?！?/p>

Population The study recruited 185 children who had been diagnosed with myopia in Xi’an No.1 Hospital and Shaanxi Provincial Institute of Ophthalmology between February 2008 and October 2019. The inclusion criteria were as follows: age 6-12y, male or female, binocular myopia of 3.0 D or less, near visual acuity equal or greater than 1.0 in both eyes, and astigmatism of 2.0 D or less in both eyes. The exclusion criteria were as follows: other eye diseases such as strabismus, amblyopia, high intraocular pressure (intraocular pressure is higher than 21 mm Hg) or glaucoma, cataracts,fundus abnormalities, or corneal ocular surface diseases;allergy to atropine; systemic diseases such as heart or lung disease; contact lens use, or failure to provide signed written informed consent. Subjects who were lost to follow-up or took other drugs that affected the efficacy evaluation were also excluded. The termination criteria were as follows: allergy or a severe adverse reaction to the test drug or the appearance of inappropriate changes.

1.2.2 錄像觀察法 通過對觀看第14屆世界健美操錦標(biāo)賽比賽錄像，進(jìn)行視頻的反復(fù)觀察與研究，從比賽成績、難度分值、難度類型、難度動作的運(yùn)用頻率等方面進(jìn)行統(tǒng)計研究。

Safety In this study, the 0.01% atropine sulphate eye gel was generally well tolerated. None of the participants developed dilated pupils, local toxicity reactions, irritation, allergic reactions or other clinical adverse reactions.

RESULTS

Demographics There were 125 effective cases in the atropine group, and 30 cases were excluded due to delayed drug review.The control group included 60 cases in accordance with the criteria during the same period. The demographics of the two groups are shown in Table 1.

Efficacy The initial SE and AL were not significantly different between the control group (-1.59±0.94 D, 24.06±0.77 mm)and the atropine group (-1.64±0.80 D, 24.13±0.76 mm;

＞0.05). After 6mo, the SE in the control group (-2.19±0.92 D)was significantly different than that in the atropine group(-1.91±0.87 D,

＜0.05), and the change in the SE was also significantly different (-0.60±0.35 and -0.27±0.33 D,respectively,

＜0.001). The relative reduction in myopia progression in this study was 55.0%. The increase in axial elongation was also significantly different (0.26±0.14

0.19±0.14 mm,

＜0.001). The relative reduction in AL in this study was 26.9% (Table 2).

Among the 120 eyes in the control group, 51.7% had myopic progression of less than or equal to 0.50 D, and the maximum degree of myopic progression was 1.75 D; 5 eyes had no change in the SE, accounting for 4.2%. Among the 250 eyes in the atropine group, 84.4% had myopic progression of less than or equal to 0.50 D, and the maximum degree of myopic progression was 1.50 D. The SE in 96 eyes remained unchanged, at 38.4%. Ten eyes (4%) recovered by 0.12-0.38 D in the atropine group (Figure 1).

Outcome Measures Efficacy in controlling myopia progression was evaluated by changes in the SE and AL in the eye. If the values in the atropine group were significantly less than those in the control group, the treatment was considered effective. Local toxicity, irritation, allergic reaction or other clinical adverse reactions were noted during the study period.Statistical Analysis All the data were analysed using SPSS version 15.0 (SPSS, Inc., Chicago, IL, USA). The Chi-square test was used for categorical data, and the independent

-test was used for measurement data. The efficacy of 0.01% atropine sulphate eye gel was statistically analysed by the number of eyes.

In this study, we explored short-term effect of 0.01% atropine sulphate eye gel on myopia progression in children in China.Our result revealed that a once-nightly dose of 0.01% atropine sulphate eye gel resulted in significant reductions in myopia progression and axial elongation. To our knowledge, this study is the first study to show the efficacy of 0.01% atropine sulphate eye gel on myopia progression in mainland of China.Eye gel, a viscous formulation, is more likely to adhere to the cornea and conjunctival surface after blinking, which can make the action time of the drug more durable, higher local bioavailability. When used as a myopia control drug, atropine is used in one drop per eye every night, so eye gel is a more suitable dosage form than eye drops for night application.

DISCUSSION

1.2.2 總體幸福感量表［3］ 美國國立衛(wèi)生統(tǒng)計中心制定的一種定式型測查工具。共有33個題項(xiàng)，前18題項(xiàng)包含6個因子，分別是對健康的擔(dān)心、精力、對生活的滿足和興趣、憂郁或愉快的心境、對情感和行為的控制、緊張與松弛。第18題以后的項(xiàng)目主要指向精神疾病方面，根據(jù)段建華［4］修訂，認(rèn)為前18個題目更符合國內(nèi)情況。因此，本研究計分為該量表前18項(xiàng)6因子分之和，滿分120分，得分在0～24分的被視為主觀幸福感低，25～48分為主觀幸福感較低，49～72分為有中等幸福感，73～96分為主觀幸福感較高，97～120分為主觀幸福感高。本量表內(nèi)部一致性系數(shù)在男性團(tuán)體中為 0.91，在女性團(tuán)體中為0.95。

In this study, 84.4% of the eyes in the 0.01% atropine group had myopic progression of less than or equal to 0.50 D at 6mo compared with 51.7% of the eyes in the control group. It should be noted that the spherical degree remained unchanged in 38.4% of the eyes in the atropine group at 6mo, while the spherical degree in the control group remained unchanged in only 4.2% of the eyes. Ten eyes (4%) recovered by 0.12-0.38 D in the atropine group. The LAMP study found that 43.8% of patients had myopia progression of less than 0.50 D in the 0.01% atropine group at 1y, and that in the study at Beijing Tongren Hospital was 48.7%

.

Several previous studies indicated that 0.01% atropine eye drops exhibited a varied relative reduction on myopia progression. A randomized, double-masked, placebo-controlled trial in Beijing evaluating the efficacy of atropine 0.01% eye drops revealed that the eye drops had 44.4% reduction at 6mo and 34.2% reduction at 1y

. In another study conducted in Europe, the relative reduction on myopia progression by 0.01%atropine eye drops was 50.5% at 1y

, and that was 24.1% at 1y in the LAMP study conducted in Hong Kong

; moreover,the relative reduction in a study in Japan was 14.86% at 2y

.In our study, the relative reduction in myopia progression, at 55.0%, was slightly greater than that in the European study and greater than that in case-control studies in Beijing, Hong Kong and Japan. This may be related to the use of a placebo as well as shortened periods of observation and differences in ethnicities, regions and learning and living habits among the observed subjects.

Atropine has a dose-related effect on myopia progression, with greater effects associated with more obvious side effects. Li

reported that younger age was associated with poor treatment response to low-concentration atropine. A 2-year clinical trial in the LAMP study showed that the efficacy of 0.05% atropine was double that of 0.01% atropine

. Fu

reported that 0.02% atropine eye drops had a better effect on myopia progression than 0.01% atropine eye drops,but 0.02% and 0.01% atropine showed similar effects on pupil diameter and accommodative amplitude after 12mo of treatment. In children for whom myopia is poorly controlled with 0.01% atropine, a slightly higher concentration of atropine in preparations can be considered.

Study Design This study comprised an atropine group and a control group. Patients in the atropine group received one drop of 0.01% atropine sulphate eye gel (prepared by Xi’an No.1 Hospital, which obtained approval for the clinical study of nosocomial preparations from the Shaanxi Medical Products Administration) in each eye before bedtime daily for 6mo.The control group comprised matched children without drug intervention during the same period.

學(xué)校員工的工作地位與其在學(xué)校的分工有關(guān)。機(jī)能實(shí)驗(yàn)技術(shù)人員的地位較低，具體表現(xiàn)為缺乏參加培訓(xùn)、進(jìn)修的機(jī)會，職業(yè)發(fā)展不明朗；較少有為學(xué)校政策出謀劃策的機(jī)會，自身訴求得不到傾聽；工作待遇較低；工作不受教師和學(xué)生的理解。

Axial elongation is the preferred endpoint for assessing myopic progression

. In our study, we found that the mean axial elongation values were 0.26±0.14 and 0.19±0.14 mm in the control and atropine groups at 6mo, respectively, with a reduction of 26.9% in axial elongation. The LAMP study in Hong Kong showed that the mean axial-length changes were 0.36±0.29 and 0.41±0.22 mm in the 0.01% atropine and placebo groups at 1y, respectively, with a reduction of 12%in axial elongation

. The changes in the Beijing Tongren Hospital study were 0.32±0.19 and 0.41±0.19 mm at 1y, with a reduction of 22.0% in axial elongation

.

Various studies have shown that scleral extracellular matrix (ECM) remodelling plays a critical role in myopia development

. Hypoxia is a key modulator for scleral ECM remodelling during myopia development. It is plausible that changes in choroidal thickness in myopia might result from reduced choroidal blood perfusion, which in turn may lead to scleral hypoxia. This condition could in turn trigger downstream receptor-linked signalling pathways events that induce responses promoting myopia progression. Atropine is an antimuscarinic agent that causes pupil dilation and loss of accommodation, even in concentrations as low as 0.01%

. In addition, atropine also has the effect of dilating blood vessels. It is suggest that the choroid may be the target site for atropine

. Although the above studies have provided some evidence for the mechanism of atropine, the detailed pharmacological mechanism, by which atropine can slow myopia progression and axial elongation, need further research.

湖北華貴銷售的產(chǎn)品以藕帶為主、其他蓮藕制品及水生蔬菜為輔，目前藕帶銷售占比為80%。因藕帶為加工制品，存放時間較長，線上銷售量變化不大，不受季節(jié)因素影響，線上年推廣投入費(fèi)用約為300萬；線下銷售量受節(jié)日因素影響，在年底需求量較大。公司的運(yùn)營成本主要包括人工成本、原材料采集成本、物流成本以及推廣成本，加上目前企業(yè)還沒有專項(xiàng)物流，完全依靠與各大物流公司合作完成，年物流成本約為360萬。

The advantage of this experiment was the use of a novel atropine eye gel rather than eye drops and proved its efficacy on controlling myopia progression and axial elongation. Eye gel has several advantages over eye drops in dosage form.Atropine is used as a prevention and control drug to slow the myopia progression. It does not mean that myopia does not increase after atropine application but delays the increase of myopia degree. In this study, we also noted that 38.4% of the eyes in the atropine group remained unchanged at 6mo, while only 4.2% of those in the control group remained unchanged.However, this study has some limitations. First, this study evaluated the efficacy of this preparation for the control of myopia (change of less than -3.0 D) only in the children aged 6-12y with binocular myopia. Second, a follow-up period of 6mo may not be long enough for evaluating the efficacy of an atropine treatment regime. Third, 19% of subjects in the experimental group were lost to follow-up, which may affect the deviation of the experimental result. Fourth, although all parents are told to administrate the drug before bed every night, it is difficult to guarantee that they will fully adhere to the doctor’s advice. Fifth, risk factors for myopia, such as outdoor activities time, near work time, and hereditary factor are not considered in this study. Importantly, as adolescents are a special study population, a placebo control group is a recognized potential weakness in studies on the efficacy and safety of atropine at low concentrations.

總之，柳樹因其外在形象和對生存環(huán)境的適應(yīng)能力，引發(fā)了人們的聯(lián)想，成為堅韌、友誼、離愁、相思、女性等多元意象的集合，成為中華兒女普遍情感的寄托，并經(jīng)過千百年的積淀，文化意蘊(yùn)愈加豐富。

本研究通過對兩組生存質(zhì)量量表指標(biāo)比較發(fā)現(xiàn)，觀察組在改善癥狀感覺、心理狀態(tài)及自我總評分均優(yōu)于對照組。其可能與以下兩方面有關(guān)：一方面，十一味參芪片配合化療能夠有效改善患者的臨床癥狀，取得一定的療效，增強(qiáng)了患者對抗疾病的信心；另一方面，祖國醫(yī)學(xué)認(rèn)為“脾胃為氣血生化之源”“脾胃為后天之本”以及“腎為先天之本”，長期口服十一味參芪片能維護(hù)人體正氣、改善脾腎功能從而提高患者免疫功能，也有益于改善患者的精神狀態(tài)。

In this study, no dilated pupils, local toxicity reactions,irritation, allergic reactions or other clinical adverse reactions were observed during the study. Similar to other studies with low concentration of atropine eye drops, our study suggest that 0.01% atropine sulphate eye gel can slow myopia progression and axial elongation in children during a shortterm administration. Therefore, low concentration atropine eye drops may be a novel choice that can be used in clinical practice to retard myopia. However, long-term prevention effects and adverse events of 0.01% atropine sulphate eye gel on myopia progression, as well as its detailed pharmacological mechanism need further investigation.

ACKNOWLEDGEMENTS

Supported by Shaanxi Province Social Development and Technology of Research Project (No.2020SF-274; No.2014K11-03-07-05); Xi’an Science and Technology Project (No.20YXYJ0008-6).

Conflicts of Interest: Pan SY, None; Wang YZ, None; Li J, None; Zhang XH, None; Wang J, None; Zhu XP, None;Xiao XH, None; Liu JT, None.

1 Holden BA, Fricke TR, Wilson DA, Jong M, Naidoo KS, Sankaridurg P, Wong TY, Naduvilath TJ, Resnikoff S. Global prevalence of myopia and high myopia and temporal trends from 2000 through 2050.

2016;123(5):1036-1042.

2 Medina A. The cause of myopia development and progression: Theory,evidence, and treatment.

2022;67(2):488-509.

3 Matsumura S, Ching-Yu C, Saw SM.

. Singapore: Springer Singapore, 2019:27-51.

4 Wang J, Ying GS, Fu X, Zhang R, Meng J, Gu F, Li J. Prevalence of myopia and vision impairment in school students in Eastern China.

2020;20(1):2.

5 Chen M, Wu A, Zhang L, Wang W, Chen X, Yu X, Wang K. The increasing prevalence of myopia and high myopia among high school students in Fenghua City, Eastern China: a 15-year population-based survey.

2018;18(1):159.

6 Li Y, Liu J, Qi P. The increasing prevalence of myopia in junior high school students in the Haidian District of Beijing, China: a 10-year population-based survey.

2017;17(1):88.

7 Bullimore MA, Ritchey ER, Shah S, Leveziel N, Bourne RRA,Flitcroft DI. The risks and benefits of myopia control.

2021;128(11):1561-1579.

8 Mérida S, Villar VM, Navea A, Desco C, Sancho-Tello M, Peris C,Bosch-Morell F. Imbalance between oxidative stress and growth factors in human high myopia.

2020;11:463.

9 Huang J, Wen D, Wang Q, McAlinden C, Flitcroft I, Chen H, Saw SM, Chen H, Bao F, Zhao Y, Hu L, Li X, Gao R, Lu W, Du Y, Jinag Z, Yu A, Lian H, Qu J. Efficacy comparison of 16 interventions for myopia control in children: a network meta-analysis.

2016;123(4):697-708.

10 Walline JJ, Lindsley KB, Vedula SS, Cotter SA, Mutti DO, Ng SM,Twelker JD. Interventions to slow progression of myopia in children.

2020;1:CD004916.

11 Gong Q, Janowski M, Luo M, Wei H, Chen B, Yang G, Liu L. Efficacy and adverse effects of atropine in childhood myopia: a meta-analysis.

2017;135(6):624-630.

12 Zhu Q, Tang Y, Guo L, Tighe S, Zhou Y, Zhang X, Zhang J, Zhu Y,Hu M. Efficacy and safety of 1% atropine on retardation of moderate myopia progression in Chinese school children.

2020;17(2):176-181.

13 Prousali E, Haidich AB, Fontalis A, Ziakas N, Brazitikos P, Mataftsi A.Efficacy and safety of interventions to control myopia progression in children: an overview of systematic reviews and meta-analyses.

2019;19(1):106.

14 Chia A, Chua WH, Wen L, Fong A, Goon YY, Tan D. Atropine for the treatment of childhood myopia: changes after stopping atropine 0.01%,0.1% and 0.5%.

2014;157(2):451-457.e1.

15 Yam JC, Jiang Y, Tang SM, Law AKP, Chan JJ, Wong E, Ko ST,Young AL, Tham CC, Chen LJ, Pang CP. Low-concentration atropine for myopia progression (LAMP) study: a randomized, double-blinded,placebo-controlled trial of 0.05%, 0.025%, and 0.01% atropine eye drops in myopia control.

2019;126(1):113-124.

16 Sacchi M, Serafino M, Villani E, Tagliabue E, Luccarelli S,Bonsignore F, Nucci P. Efficacy of atropine 0.01% for the treatment of childhood myopia in European patients.

2019;97(8):e1136-e1140.

17 Joachimsen L, B?hringer D, Gross NJ, Reich M, Stifter J, Reinhard T,Lagrèze WA. A pilot study on the efficacy and safety of 0.01% atropine in German schoolchildren with progressive myopia.

2019;8(3):427-433.

18 Brennan NA, Toubouti YM, Cheng X, Bullimore MA. Efficacy in myopia control.

2021;83:100923.

19 Larkin GL, Tahir A, Epley KD, Beauchamp CL, Tong JT, Clark RA. Atropine 0.01% eye drops for myopia control in American children: a multiethnic sample across three US sites.

2019;8(4):589-598.

20 Zhao Y, Feng K, Liu RB, Pan JH, Zhang LL, Xu ZP, Lu XJ. Atropine 0.01% eye drops slow myopia progression: a systematic review and Meta-analysis.

2019;12(8):1337-1343.

21 Guo L, Fan L, Tao J, Hua R, Yang Q, Gu H, Yu S, Li L, Zhao X. Use of topical 0.01% atropine for controlling near work-induced transient myopia: a randomized, double-masked, placebo-controlled study.

2020;36(2):97-101.

22 Lynch CR, Kondiah PPD, Choonara YE, du Toit LC, Ally N, Pillay V.Hydrogel biomaterials for application in ocular drug delivery.

2020;8:228.

23 Wei S, Li SM, An W, Du J, Liang X, Sun Y, Zhang D, Tian J, Wang N.Safety and efficacy of low-dose atropine eyedrops for the treatment of myopia progression in Chinese children: a randomized clinical trial.

2020;138(11):1178-1184.

24 Hieda O, Hiraoka T, Fujikado T, Ishiko S, Hasebe S, Torii H, Takahashi H, Nakamura Y, Sotozono C, Oshika T, Morimoto T, Nishida K,Nishikawa N, Song YS, Tokutake T, Nishi Y, Shigeno Y, Kurihara T,Negishi K, Tsubota K, Ono M, Nakai T, Tan D, Tanaka S, Kinoshita S, Group AJS. Efficacy and safety of 0.01% atropine for prevention of childhood myopia in a 2-year randomized placebo-controlled study.

2021;65(3):315-325.

25 Li FF, Zhang Y, Zhang X, Yip BHK, Tang SM, Kam KW, Young AL, Chen LJ, Tham CC, Pang CP, Yam JC. Age effect on treatment responses to 0.05%, 0.025%, and 0.01% atropine: lowconcentration atropine for myopia progression study.

2021;128(8):1180-1187.

26 Yam JC, Li FF, Zhang X, Tang SM, Yip BHK, Kam KW, Ko ST,Young AL, Tham CC, Chen LJ, Pang CP. Two-year clinical trial of the low-concentration atropine for myopia progression (LAMP) study:phase 2 report.

2020;127(7):910-919.

27 Fu A, Stapleton F, Wei L, Wang W, Zhao B, Watt K, Ji N, Lyu Y.Effect of low-dose atropine on myopia progression, pupil diameter and accommodative amplitude: low-dose atropine and myopia progression.

2020;104(11):1535-1541.

28 Li FF, Kam KW, Zhang Y, Tang SM, Young AL, Chen LJ, Tham CC,Pang CP, Yam JC. Differential effects on ocular biometrics by 0.05%,0.025%, and 0.01% atropine: low-concentration atropine for myopia progression study.

2020;127(12):1603-1611.

29 McBrien NA. Regulation of scleral metabolism in myopia and the role of transforming growth factor-beta.

2013;114:128-140.

30 Zhao W, Li Z, Hu Y, Jiang J, Long W, Cui D, Chen W, Yang X. Shortterm effects of atropine combined with orthokeratology (ACO) on choroidal thickness.

2021;44(3):101348.

31 Zhou X, Zhang S, Zhang G, Chen Y, Lei Y, Xiang J, Xu R, Qu J, Zhou X. Increased choroidal blood perfusion can inhibit form deprivation myopia in Guinea pigs.

2020;61(13):25.

32 Ye L, Li S, Shi Y, Yin Y, He J, Zhu J, Xu X. Comparisons of atropine versus cyclopentolate cycloplegia in myopic children.

2021;104(2):143-150.

33 Jiang Y, Zhang Z, Wu Z, Sun S, Fu Y, Ke B. Change and recovery of choroid thickness after short-term application of 1% atropine gel and its influencing factors in 6-7-year-old children.

2021;46(8):1171-1177.

34 Zhou X, Ye C, Wang X, Zhou W, Reinach P, Qu J. Choroidal blood perfusion as a potential “rapid predictive index” for myopia development and progression.

(

) 2021;8(1):1.