August 24, 2026
By Ashley Tucker, OD, FAAO, FSLS
Study Purpose
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Li, Yi and Liu published a 2026 systematic review and meta-analysis evaluating whether orthokeratology combined with atropine provides greater myopia control than orthokeratology alone in children. In addition to axial elongation, the authors evaluated visual acuity, tear-film measures, pupil diameter, accommodative amplitude and corneal curvature.
Study Design
- 18 randomized controlled trials
- 1,669 children with myopia
- 834 received orthokeratology + atropine
- 835 received orthokeratology alone
- 17 of 18 studies used 0.01% atropine; one study used 1% atropine
- Follow-up ranged from one to 24 months
- Studies were predominantly conducted in China, with additional trials from Australia and Japan
This represents a substantially larger evidence base than previous meta-analyses evaluating combination therapy.
Key Results
The most clinically important finding involved axial elongation. Eleven studies reported axial length outcomes, and combination therapy resulted in significantly less axial elongation than orthokeratology alone:
- SMD: −0.66
- 95% CI: −0.80 to −0.53
- p<0.001
- Benefit was demonstrated with follow-up both < one year and ≥ one year.
One important distinction: −0.66 is a standardized mean difference (SMD), not 0.66 mm of reduced axial elongation. The authors reference earlier meta-analyses that found approximately 0.09 mm less axial elongation with combination therapy compared with OrthoK alone, which may be a more clinically intuitive estimate of the additive effect.
Other findings included:
- Uncorrected visual acuity: No significant difference
- Tear-film lipid layer thickness: No significant difference
- Tear break-up time: Longer with combination therapy
- Pupil diameter: Increased with combination therapy
- Accommodative amplitude: Decreased with combination therapy
Strengths
This analysis included more children and more randomized trials than previous meta-analyses. The authors also performed sensitivity analyses and assessed publication bias for axial elongation, with no significant publication bias identified.
Limitations
Several limitations are important when interpreting the results:
- Significant heterogeneity existed across several outcomes.
- Orthokeratology lens designs, treatment protocols and measurement techniques varied.
- Age-specific analyses were limited, particularly for younger children.
- Maximum follow-up was only two years.
- Long-term efficacy, rebound, optimal duration and withdrawal strategies remain unclear.
- Adverse effects were inadequately reported, preventing a reliable overall safety assessment.
Clinical Takeaway
This meta-analysis strengthens the evidence that adding atropine to OrthoK can provide additional control of axial elongation. However, it does not establish that every child wearing OrthoK should automatically receive atropine.
Combination therapy may be particularly valuable for children who continue to progress faster than desired despite successful OrthoK treatment. The evidence increasingly answers whether combination therapy can work. The bigger unanswered questions are which patients need it, when atropine should be added, what concentration should be used and how long combination therapy should continue.
Abstract
Efficacy of Orthokeratology Combined with Atropine Versus Orthokeratology Alone for Myopia Control in Children: A Meta-Analysis
Yuchan Li, Meichao Yi, Bing Liu
Objective
To systematically evaluate the efficacy of orthokeratology combined with atropine versus orthokeratology alone in treating myopia in children.
Methods
Randomized controlled trials (RCTs) comparing the efficacy of orthokeratology combined with atropine versus orthokeratology alone for pediatric myopia were retrieved from databases including CNKI, Wanfang, VIP, CBM, PubMed, Cochrane Library, Embase, and Web of Science from inception to April 2025. Data were analyzed using RevMan 5.2 software.
Results
A total of 18 randomized controlled trials involving 1,669 myopic children were included. The analysis showed that the intervention group had greater improvements in axial elongation (SMD = -0.66, 95% CI = -0.80 to -0.53, p < 0.001), tear film break-up time (SMD = 0.48, 95% CI = 0.33 to 0.63, p < 0.001), and corneal curvature (SMD = -2.47, 95% CI = -4.21 to -0.73, p = 0.005) compared to the control group. However, no statistically significant differences were found between the two groups in uncorrected visual acuity (SMD = 0.49, 95% CI = -0.27 to 1.24, p = 0.21) or tear film lipid layer thickness (SMD = -0.00, 95% CI = -1.09 to 1.09, p = 1.00). In addition, increased pupil diameter (SMD = 0.37, 95% CI = 0.09 to 0.64, p < 0.001) and reduced accommodative amplitude (SMD = -1.50, 95% CI = -2.58 to -0.43, p = 0.006) reflected the side effects associated with combined atropine treatment.
Conclusion
Compared with orthokeratology alone, orthokeratology combined with atropine treatment reduces axial elongation, tear film break-up time, and corneal curvature in myopic children, but shows no significant advantage in uncorrected visual acuity or tear film lipid layer thickness, while incurring side effects of increased pupil diameter and reduced accommodative amplitude.
DOI: 10.3389/fmed.2026.1786718
