Unlocking the Potential of Combination Strategies: Why H.A.L.T. Spectacles and Low-Dose Atropine Have a Synergistic Effect

Share

Tweet

Share

Share

Email

sponsored content

June 16, 2025

By Dr. Bryan Sim, Consultant Ophthalmologist, Myopia Service, Singapore National Eye Centre (SNEC)

Introduction: Addressing the Challenge of Progressive Myopia

The myopia pandemic is becoming a global and public health crisis, especially in East Asian children. In Singapore, myopia prevalence exceeds 80% in children and young adults, with 20-30% of the population^1,2 at risk of developing high myopia. These children will have an increased lifetime risk of complications like retinal detachment, glaucoma, myopic macular degeneration³ and irreversible visual impairment.⁴ This demands not only early intervention, but also more proactive and effective myopia management strategies. In cases of intractable rapidly progressing myopia, monotherapy (either pharmacologic or optical) often does not provide sufficient progression control. 

More ECPs are looking to combination therapy — especially in cases where monotherapy falls short — in particular the combined use of low-dose atropine (LDA) and the H.A.L.T. (Highly Aspherical Lenslet Target) spectacle lenses (Essilor Stellest lenses). Newly published evidence from a prospective clinical study conducted by the Singapore National Eye Centre (SNEC) provides support for this combination therapy approach,⁵ with the addition of H.A.L.T. spectacle lenses to children inadequately controlled with LDA monotherapy alone. This article explores the rationale, evidence and clinical application of this approach, based on our prospective clinical research conducted at the SNEC.

LDA and H.A.L.T. Mechanisms: Complementary and Synergistic

While both LDA and H.A.L.T. spectacle lenses have independently demonstrated efficacy, they differ in their mechanism, yet offer a potentially synergistic approach:

• Pharmacological treatment: Atropine is a non-specific muscarinic antagonist whose exact mechanism in slowing myopia remains uncertain, but it does not act by blocking accommodation as commonly believed. Instead, evidence from animal studies suggests that atropine influences biological processes in the retina and choroid to slow scleral remodelling and eye growth.
• H.A.L.T. spectacle lenses (also known as Essilor Stellest lenses): These lenses come with H.A.L.T. technology, which consists of a constellation of aspherical lenslets spread on 11 rings and was designed to create a volume of signal that slows down the elongation of the eye. The power on each ring has been ingeniously determined to guarantee a volume of signal always in front of the retina and following its shape,⁶ to achieve consistent myopia slowdown.

This dual-target strategy addresses both pharmacologic and optical pathways — making it particularly useful for children who continue progressing despite monotherapy.

The SNEC Study: Real-World Evidence of LDA and H.A.L.T.

Our team conducted the first global prospective study evaluating this combination approach in children who had documented progression despite LDA treatment. Fifty children aged 6–11 years (mean 8.9 years), all progressing ≥0.50D over the past six months on 0.01% or 0.025% atropine, were enrolled and continued their atropine regimen while initiating H.A.L.T. spectacle wear. 

Key findings over 12 months:

• Spherical equivalent (SE) progression reduced by 75%, from −0.60D to −0.15D.
• Axial elongation (AXL) reduced by 42%, from 0.24mm to 0.14mm.
• 24% showed axial length hyperopic shift, suggesting biological reversal or measurement stability.
• Combination therapy was very well-tolerated, with minimal visual distortion or compliance issues.

This study was the first of its kind globally—and the outcomes speak for themselves.

Clinical Application: Integrating Combination Therapy into Practice

From a clinical standpoint, this combination approach is both accessible and practical. Here are some key considerations for integration into clinical practice:

1. Identifying Candidates

Combination therapy can be beneficial for:

• Children still progressing on monotherapy
• Highly progressive myopia in a child with moderate to high myopia, for additional effect
• Early intervention in younger children with rapid progression and higher lifetime risk of high myopia
• Children or families preferring to avoid escalation to higher atropine doses due to potential side effects such a glare and/or near blur
• Cases where contact lens options (e.g., orthokeratology, multifocal soft contact lenses) are unsuitable or declined

2. Patient and Parent Education

• Talking with patients and managing parental expectations is key. Assess the myopia risk profile of their child. Discuss options including:
  • Pros and cons of each myopia treatment modality
  • Contraindications (e.g. concomitant ocular pathology)

• Likely management plan:
  • Inform that child may not always respond to treatment
  • Reinforce good eye care habits
  • Will need to monitor and customize treatment
  • Will need treatment until mid/late teens
• Explain the complementary effect of LDA and H.A.L.T. spectacle lenses. Reinforce the importance of:
  • Daily atropine compliance.
  • Full-time wear (12+ hours/day) of H.A.L.T. spectacle lenses for optimum efficacy.

3. Monitoring and Follow-Up

• Initially, children should be followed at three- to six-month intervals to monitor for both SE and AXL changes. Watch for: 
  • Continued progression.
  • Signs of poor compliance to atropine (e.g., reported by parent/patient, pupil reactivity may indicate poor atropine absorption).
  • At each visit, visual acuity, compliance, and presence/absence of side effects should be checked
  • Refraction and axial length should also be measured.
  • When control reaches steady state, then follow-up could be extended to six to 12 months.
  • In most cases, treatment is continued into the early to mid teens (13 to 15 years old), when myopia progression starts to plateau

• When to stop: Taper or stop one agent then the other.

4. Optimizing Outcomes

• Consider maintaining the same atropine dose initially when adding H.A.L.T. spectacle lenses.
• If progression persists, re-assess compliance and consider modestly increasing atropine concentration—but keep H.A.L.T. spectacle lenses in place.

The Impact of LDA and HA.L.T.: Better Outcomes for Children 

The goal of myopia management is not only to slow progression, but also to reduce the lifelong risk of vision-threatening complications and to mitigate the quality-of-life impacts associated with high myopia, even before those complications occur. Combination therapy offers a proactive, personalized solution that can significantly shift a child’s myopia trajectory. Compared to LDA or H.A.L.T. monotherapy studies, combination therapy yielded better SE stabilization and AL control, including in younger children. Notably, younger age and smaller pupil size (a possible compliance proxy) were associated with continued progression—highlighting the importance of early intervention and adherence.

Our study showed that this combined approach can stabilize or significantly slow progression in children otherwise potentially destined for high myopia. This not only reduces the potential for future vision-threatening complications but also delays or avoids the need for more invasive interventions.

In clinical practice, combination therapy has consistently demonstrated favorable outcomes. Two illustrative cases include:

Case 1: Avoiding Atropine Frequency Increase with H.A.L.T. spectacle lenses

A 7-year-old myopic girl continued to progress despite being on nightly 0.01% atropine drops. She was advised to increase to twice daily 0.01% atropine drops but could not manage the morning dose due to school. Instead, H.A.L.T. spectacles were added, and she maintained her nightly 0.01% atropine drops which yielded myopia SE and AXL stabilization thereafter.

Case 2: Reversing the Trend

 

An 8-year-old avid reader showed persistent myopic SE and axial elongation whilst on LDA. Upon adding H.A.L.T. spectacle lenses, not only was progression halted, but there was also a mild reversal in AXL observed—an encouraging outcome that underlines the potential of optical synergy.

These real-world cases underscore the individualized and sustainable impact of combination therapy, particularly when tailored to the child’s risk profile and preferences. As ECPs, we now have the tools—and growing evidence base—to move beyond one-size-fits-all approaches. By tailoring strategies to each child’s response and risk profile, we can deliver more effective, patient-centered, bespoke care with tangible, long-lasting benefits.

The Role of H.A.L.T. Spectacles in Combination Myopia Management

While atropine plays a crucial role, H.A.L.T. technology spectacle lenses provide the essential optical signal needed to reinforce myopia progression control when pharmacologic measures plateau. In our clinical experience, they offer excellent adaptation and cosmetic acceptability, even for younger children. Their non-invasive nature also makes them ideal for children with eye allergies, lid conditions, or those who simply prefer to avoid eye drops or contact lenses. 

In addition, the clinical evidence supporting H.A.L.T. spectacle lenses continue to support the efficacy of the lenses. A two-year randomized controlled clinical trial initiated in 2018 at the Eye Hospital of Wenzhou Medical University in Wenzhou, China, evaluated children aged between 8-13 years. The two-year findings showed that the lenses slowed myopia progression by 0.80D and axial elongation by 0.35mm, on average, compared to single-vision lenses.⁷ Among full-time wearers, the efficacy was even greater—with 0.99D less myopia progression and 0.41mm less axial elongation, on average, over two years.^*7

This year, long-term six-year data has reaffirmed the sustained efficacy of the lenses in controlling myopia progression and axial elongation over six years.⁸ Over six years, the lenses demonstrated up to 1.95D less myopia progression^†8 and 0.81mm slower axial elongation on average, compared to the extrapolated control group.^‡8  These extended findings provide ECPs with further confidence that the treatment effect remains reliable over time.

Broader Implications for Myopia Management

As global myopia prevalence grows, combination strategies represent a significant paradigm shift — that demands more than monotherapy. They offer ECPs greater flexibility and effectiveness. The combined use of LDA and H.A.L.T. spectacle lenses:

• Can enhance clinical outcomes.
• Can reduce reliance on high-dose atropine (HDA) and its associated side effects.
• Supports a more personalized and holistic approach to care.

Looking ahead, further longitudinal studies and randomized trials will continue to strengthen the evidence base. But already, the message is clear: combination therapy is not only safe and effective—it’s becoming essential. They offer ECPs a more robust, multifaceted toolkit to combat the myopia epidemic. 

Conclusion: The Future is in Personalized, Combination Strategies 

Combination therapy is shifting the paradigm in pediatric myopia care—from reactive monotherapy to proactive, personalized treatment. Our study shows that the addition of H.A.L.T. spectacle lenses to LDA can significantly alter the trajectory of high-risk children, reducing the risk of lifelong visual impairment. For ECPs, this combination offers a practical, scalable strategy to enhance outcomes.

This dual approach is paving the way toward a more comprehensive and individualized standard of care in myopia management. We’ve seen it work, not just in data, but in the eyes of the children who now face a brighter visual future.

As the evidence grows, the message is clear: combination therapy is not just an option—it may be essential.

 

Dr. Bryan Sim is a Consultant Ophthalmologist of the Myopia Service at the Singapore National Eye Centre (SNEC). As a multi-gold medalist at the specialist exit examinations, he is passionate about medical education and has received numerous teaching awards and actively contributes to undergraduate and postgraduate ophthalmology training as well as optometry education, where he serves as the co-lead for Optometry Education at SNEC. He is also the principal investigator (PI) of multiple clinical trials on myopia control with a special interest in combination therapy.

 

Disclaimers 

Essilor Stellest lenses are currently not available in all countries, including in the U.S.

H.A.L.T. – Highly Aspherical Lenslet Target 

Essilor Stellest lenses are based on the optical design of spectacle lenses with highly aspherical lenslets (HAL) and are designed with H.A.L.T. technology

*Two-year prospective, controlled, randomized, double-masked clinical trial results on 54 myopic children wearing Essilor Stellest lenses compared to 50 myopic children wearing single vision lenses in Wenzhou China. Results based on 32 children from the Test Group wearing Essilor Stellest lenses at least 12 hours per day every day for two consecutive years. 

†Compared to the 72-month progression of the extrapolated control group (predicted average annual decrease in SER by 9.7% based on the initial two-year control group, Smotherman C, et al. IOVS 2023;64:ARVO E-Abstract 811) . 

‡Compared to the 72-month progression of the extrapolated control group (predicted average annual decrease in AL by 15% based on the initial two-year control group, Shamp W, et al. IOVS 2022;63:ARVO E-Abstract A0111).

References

1. Chow YC, Dhillon B, Chew PT, Chew SJ. Refractive errors in Singapore medical students. Singapore medical journal. 1990 Oct 1;31(5):472-3.
2. Saw SM. A synopsis of the prevalence rates and environmental risk factors for myopia. Clinical and Experimental Optometry. 2003 Sep 1;86(5):289-94.
3. Flitcroft DI. The complex interactions of retinal, optical and environmental factors in myopia aetiology. Progress in retinal and eye research. 2012 Nov 1;31(6):622-60.
4. Haarman AEG, Enthoven CA, Tideman JWL, Tedja MS, Verhoeven VJM, Klaver CCW. The Complications of Myopia: A Review and Meta-Analysis. Invest Ophthalmol Vis Sci. 2020;61(4):49. doi:10.1167/iovs.61.4.49
5. Xiangrong BS, Lyn LK, Htoon HM, Sri Y, Balakrishnan M, Lin PC, Hui RS, Wen CL, Lin AC. Additive effect of Highly Aspherical Lenslet Target (HALT) spectacles to children inadequately controlled by Atropine monotherapy. Ophthalmology Science. 2025 Feb 26:100753.
6. Atchison DA. Optical models for human myopic eyes. Vision Res. 2006;46:2236–50.
7. Bao J, Huang Y, Li X, Yang A, Zhou F, Wu J, Wang C, Li Y, Lim EW, Spiegel DP, Drobe B. Spectacle lenses with aspherical lenslets for myopia control vs single-vision spectacle lenses: a randomized clinical trial. JAMA ophthalmology. 2022 May 1;140(5):472-8.
8. EssilorLuxottica data on file 2025. Myopia control efficacy of spectacle lenses with highly aspherical lenslets: results of a 6-year follow-up study.