Purpose: To examine the hypothesis that the spatial frequency spectra of urban and indoor environments differ from the natural environment in ways that may promote the development of myopia. Methods: A total of 814 images were analyzed from three datasets; University of California Berkeley (UCB), University of Texas (UT), and Botswana (UPenn). Images were processed in Matlab (Mathworks Inc) to map the camera color characteristics to human cone sensitivities. From the photopic luminance images generated, two-dimensional spatial frequency (SF) spectra were calculated and converted to one-dimensional spectra by rotational averaging. The spatial filtering profile of a 0.4 Bangerter foil, which has been shown to induce myopia experimentally, was also determined. Results: The SF slope for natural scenes followed the recognized 1/f^α relationship with mean slopes of −1.08, −0.90, and −1.04 for the UCB, UT and UPenn image sets, respectively. Indoor scenes had a significantly steeper slope (−1.48, UCB; −1.52, UT; P < 0.0001). Urban environments showed an intermediate slope (−1.29, UCB; −1.22, UT) that was significantly different from the slopes derived from the natural scenes (P < 0.0001). The change in SF content between natural outdoor scenes and indoors was comparable to that induced by a 0.4 Bangerter foil, which reduced the SF slope of a natural scene from −0.88 to −1.47. Conclusions: Compared to natural outdoor images, man-made outdoor and indoor environments have spatial frequency characteristics similar to those known to induce form-deprivation myopia in animal models. The spatial properties of the man-made environment may be one of the missing drivers of the human myopia epidemic.

Background: To test the hypothesis that 0.01% atropine eyedrops are a safe and effective myopia‐control approach in Australian children.Methods: Children (6–16 years; 49% Europeans, 18% East Asian, 22% South Asian, and 12% other/mixed ancestry) with documented myopia progression were enrolled into this single‐centre randomised, parallel, double‐masked, placebo‐controlled trial and randomised to receive 0.01% atropine (n = 104) or placebo (n = 49) eyedrops (2:1 ratio) instilled nightly over 24 months (mean index age = 12.2 ± 2.5 and 11.2 ± 2.8 years, respectively). Outcome measures were the changes in spherical equivalent (SE) and axial length (AL) from baseline.Results: At 12 months, the mean SE and AL change from baseline were −0.31D (95% confidence interval [CI] = −0.39 to −0.22) and 0.16 mm (95%CI = 0.13–0.20) in the atropine group and −0.53D (95%CI = −0.66 to −0.40) and 0.25 mm (95%CI = 0.20–0.30) in the placebo group (group difference p ≤ 0.01). At 24 months, the mean SE and AL change from baseline was −0.64D (95%CI = −0.73 to −0.56) and 0.34 mm (95%CI = 0.30–0.37) in the atropine group, and −0.78D (95%CI = −0.91 to −0.65) and 0.38 mm (95%CI = 0.33–0.43) in the placebo group. Group difference at 24 months was not statistically significant (p = 0.10). At 24 months, the atropine group had reduced accommodative amplitude and pupillary light response compared to the placebo group.Conclusions: In Australian children, 0.01% atropine eyedrops were safe, well‐tolerated, and had a modest myopia‐control effect, although there was an apparent decrease in efficacy between 18 and 24 months, which is likely driven by a higher dropout rate in the placebo group.

Purpose: The Myopia Outcome Study of Atropine in Children (MOSAIC) is an investigator‐led, double‐masked, randomized controlled trial investigating the efficacy and safety of 0.01% atropine eye drops for managing myopia progression in a predominantly White, European population.Methods: Children aged 6–16 years with myopia were randomly allocated 2:1 to nightly 0.01% atropine or placebo eye drops in both eyes for 2 years. The primary outcome was cycloplegic spherical equivalent (SE) progression at 24 months. Secondary outcomes included axial length (AL) change, safety and acceptability. Linear mixed models with random intercepts were used for statistical analyses.Results: Of 250 participants enrolled, 204 (81.6%) completed the 24‐month visit (136 (81.4%) treatment, 68 (81.9%) placebo). Baseline characteristics, drop‐out and adverse event rates were similar between treatment and control groups. At 24 months, SE change was not significantly different between 0.01% atropine and placebo groups (effect = 0.10 D, p = 0.07), but AL growth was lower in the 0.01% atropine group, compared to the placebo group (−0.07 mm, p = 0.007). Significant treatment effects on SE (0.14 D, p = 0.049) and AL (−0.11 mm, p = 0.002) were observed in children of White, but not non‐White (SE = 0.05 D, p = 0.89; AL = 0.008 mm, p = 0.93), ethnicity at 24 months. A larger treatment effect was observed in subjects least affected by COVID‐19 restrictions (SE difference = 0.37 D, p = 0.005; AL difference = −0.17 mm, p = 0.001).Conclusions: Atropine 0.01% was safe, well‐tolerated and effective in slowing axial elongation in this European population. Treatment efficacy varied by ethnicity and eye colour, and potentially by degree of COVID‐19 public health restriction exposure during trial participation.