Decision Tree Modeling to Predict Myopia Progression in Children Treated with Atropine: Toward Precision Ophthalmology.

: Myopia is a growing global health concern, especially among school-aged children in East Asia. Topical atropine is a key treatment for pediatric myopia control, but individual responses vary, with some children showing rapid progression despite higher doses. This retrospective observational study aims to develop an interpretable machine learning model to predict individualized treatment responses and support personalized clinical decisions, based on data collected over a 3-year period without a control group. : A total of 1545 pediatric eyes treated with topical atropine for myopia control at a single tertiary medical center are analyzed. Classification and regression tree (CART) is constructed to predict changes in spherical equivalent (SE) and identify influencing risk factors. These factors are mainly received treatments for myopia including atropine dosage records, treatment duration, and ophthalmic examinations. Furthermore, decision rules that closely resemble the clinical diagnosis process are provided to assist clinicians with more interpretable insights into personalized treatment decisions. The performance of CART is evaluated by comparing with the benchmark model of least absolute shrinkage and selection operator regression (Lasso) to confirm the practicality of CART usage. : Both the CART and Lasso models demonstrated comparable predictive performance. The CART model identified baseline SE as the primary determinant of myopia progression. Children with a baseline SE more negative than -3.125 D exhibited greater myopic progression, particularly those with prolonged treatment duration and higher cumulative atropine dosage. : Baseline SE has been identified as the key factor affecting SE difference. The generated decision rules from CART demonstrate the use of explainable machine learning in precision myopia management.