Ocular Alignment and Strabismus-Related Findings Associated with Low-Dose Atropine for Myopia Control in Children: A Structured Narrative Review

Background/Objectives: Low-dose atropine eye drops are widely used to slow myopia progression in children, but by reducing accommodation they may affect near ocular alignment and binocular visual function. Evidence on ocular alignment and strabismus-related findings remains insufficiently synthesized. This review examined low-dose atropine for pediatric myopia control in relation to ocular alignment and strabismus-related findings. Methods: PubMed/MEDLINE and Web of Science Core Collection were searched from inception to 16 April 2026. English-language studies addressing low-dose atropine, myopia control, ocular alignment, strabismus, binocular vision, accommodation, and vergence were screened. Of 247 records, 166 underwent screening after duplicate removal. Twenty-three database-derived and four manually identified full-text articles were reviewed. Eleven studies were included. Results: Of eleven included studies, six were clinical or interventional studies and five were case reports or case series. Case-based reports described near-predominant esodeviation, convergence excess-type deviation, elevated accommodative convergence/accommodation (AC/A) ratios, diplopia, reduced fusion, and acquired esotropia during fixed low-dose or escalating atropine use; most fixed low-dose cases improved after discontinuation or treatment modification. Clinical and interventional studies did not show consistent worsening of ocular alignment, near point of convergence (NPC), fusional vergence, or binocular vision. More consistent changes included pupil dilation, receded near point of accommodation (NPA), reduced accommodative amplitude and facility, selected fusional vergence changes, and short-term binocular or accommodative fluctuations. Conclusions: Low-dose atropine appears to be useful for pediatric myopia control and is generally well tolerated. However, selected cases may be temporally associated with ocular alignment abnormalities or strabismus-related findings. Careful monitoring may be warranted in children with unstable binocular systems and during dose escalation.