June 1, 2026
By Dr. Dzung Tran
Photo Credit: Getty Images
When it comes to managing myopia, we are now more proactive than ever, with combination therapy at the forefront for patients who continue to progress despite monotherapy. Pairings typically include an optical appliance and low-dose atropine. Low level red light therapy (RLRL) is also showing promising results; however, given its relatively recent introduction, further long term data is required.
Orthokeratology and Atropine
The effectiveness of combining orthokeratology and atropine has been replicated by numerous trials, most agreeing that their effect in combination is superior to each alone. A recent systematic review collected data from eight studies on combination therapy, six on OrthoK alone and five on atropine monotherapy. The combination therapy studies assessed dual use with 0.01% atropine and found that these studies showed a mean change in axial length (AL) of 0.0963mm. This represents a far superior outcome compared to the studies which assessed atropine and OrthoK alone.
Similarly, a retrospective cohort study found that the addition of atropine to children that were still progressing beyond 0.15mm over six months despite being managed with OrthoK, showed a marked reduction in the mean axial elongation. The effect was concentration dependent, with additive 0.05% atropine showing the greatest reduction at almost 40% and 0.01% atropine showing 28.4% reduction.
Atropine and DIMS spectacle lenses
A 12-month randomized controlled trial (RCT) conducted in Europe with a group of multiethnic children showed the benefit of additive 0.025% atropine to Defocus Incorporated Multiple Segment (DIMS) spectacle lenses, recording a mean AL change of 0.07mm compared to 0.18mm for children on 0.025% atropine with single vision correction. The authors concluded that the addition of DIMS to atropine allowed for AL growth to become similar to their emmetropic peers.
A Taiwanese retrospective cohort study also agreed on the benefits of combination therapy, assessing the additive effect of atropine to DIMS compared to the sole use of DIMS. Interestingly, they concluded that additive 0.01% and 0.125% atropine yielded similar myopia control effects. The combined effects of the higher concentration atropine and DIMS perhaps showed slightly better myopia control in younger children, aged between 6 to 10, who were more likely to progress at a faster rate. This suggests that lower dose atropine in combination with other modalities may be beneficial for a majority of children and higher concentrations should be reserved for younger progressors.
The additive benefit of 0.01% atropine to either DIMS or OrthoK was also supported by a retrospective study performed in China, who concluded that either optical modality with atropine was superior to atropine alone at controlling myopic children progressing at 0.4mm in AL per year. There was no significant difference in result between DIMS and atropine or OrthoK and atropine at 12 months.
Atropine and HALT spectacle lenses
There is limited data on the combination effects of atropine and Highly Aspherical Lenslet Target (HALT) spectacle lenses. Most recently, a prospective cohort study was performed on children who were poorly controlled on atropine therapy.
The addition of HALT lenses showed a statistically significant overall reduction in progression, demonstrating a progression of -0.07D in SER and 0.13mm in axial length over 12 months.
This was in comparison with their progression prior to initiating combination therapy, which was -0.60D and 0.24mm. Interestingly, the authors did not find a difference in the rate of progression between children on different atropine doses while on combination therapy. This suggests that the benefits of the additive HALT lenses may not be tied to atropine strength but to prior progression.
Atropine and Dual Focus Contact Lenses
Yum et al. studied the combined effects of 0.05% atropine and dual focus contact lenses on children that were progressing beyond -0.75D/year or 0.25mm/year in axial elongation. Those that were progressing at a slower rate continued with nightly use of 0.05% atropine. As a result, progression in the combination group slowed down to a rate similar to the slow progressors by the end of the second year. They were also able to highlight a stronger additive effect for children with low to moderate myopia rather than those with high myopia.
Orthokeratology and RLRL
A RCT assessed a total of 47 children regarding the effects of RLRL and OrthoK in children who exhibited a fast rate of AL progression of more than 0.5mm over 1 year, despite ongoing orthokeratology alone. At 12 months, the mean AL change was -0.02mm in the combination group and 0.27mm in the sole orthokeratology group.
However, the limited cohort of participants, and its single-masked design may reduce the reliability of the findings.
Another study with a larger cohort of 100 children also noted AL shortening with the additive use of RLRL to OrthoK in children who had poor response to OrthoK monotherapy. They noted an AL shortening of 0.1mm for the combination group, whereas those who continued with orthokeratology alone showed an increase in AL of 0.19mm at the end of one year.
The authors ascertained that AL shortening at 12 months was more likely in those of older age, greater compliance and had shown AL shortening at one month. The application of RLRL was well tolerated with no structural changes noted on OCT or SLO (Scanning laser ophthalmoscopy). However, as it was retrospective and unmasked, results may also show bias.
DIMS and RLRL
A 12-month retrospective study compared the effectiveness of DIMS and RLRL alone to the combination of DIMS and RLRL. By the end of the study, a yearly axial length change of -0.13mm, -0.04mm, 0.16mm was noted for the combination, RLRL alone and DIMS alone groups, respectively. No adverse effects were reported. However, Yu and team did acknowledge that the retrospective nature of the study may affect the validity of the findings.
These studies show impressive results upon the addition of RLRL to orthokeratology and DIMS. However, RLRL is not widely prescribed, given its lack of long-term safety and efficacy data as monotherapy or in combination. As such, we remain cautious with its use.
Conclusion
Combination therapy offers a greater therapeutic effect than monotherapy, particularly for children with progressive myopia. While OrthoK with atropine has the most supporting data for its efficacy, other various combinations show great promise, offering patients a more tailored solution for treatment. However, further investigation and long-term information is required to confirm safety and efficacy.
As combination therapy becomes more commonplace, considerations such as increased financial burden, increased exposure to side effects and challenges with compliance will also need to be addressed.
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Dr. Dzung Tran is a clinical optometrist and educator at ACO Eye Health in Melbourne, Australia. She has a keen interest in pediatric optometry with a particular focus on myopia control. She is deeply committed to public health, providing essential eye care services to underserved communities. Dzung has also contributed internationally, working in Vietnam to deliver lectures and hands-on tutorials for optometry students, helping to support the next generation of eye care professionals. |
References
1 Muhammad Qasim et al., “The Efficacy of Combination Therapy Using Atropine and Orthokeratology in Limiting Myopia Progression in Comparison to Atropine and Orthokeratology Monotherapy—A Systematic Review,” Canadian Journal of Optometry 87, no. 1 (2025): 50–69, https://doi.org/10.15353/cjo.v87i1.6103.
2 Ziqi Guo et al., “Efficacy and Safety of Orthokeratology Sequentially Combined with Escalating Atropine Concentrations for Myopia Control in Children,” Scientific Reports 15, no. 1 (2025): 38911, https://doi.org/10.1038/s41598-025-22722-8.
3 Noemi Guemes-Villahoz et al., “Atropine and Spectacle Lens Combination Treatment (ASPECT): 12-Month Results of a Randomised Controlled Trial for Myopia Control Using a Combination of Defocus Incorporated Multiple Segments (DIMS) Lenses and 0.025% Atropine,” British Journal of Ophthalmology 109, no. 9 (2025): 1074–80, https://doi.org/10.1136/bjo-2024-326852.
4 Birte Graff et al., “Age-Matched Analysis of Axial Length Growth in Myopic Children Wearing Defocus Incorporated Multiple Segments Spectacle Lenses,” British Journal of Ophthalmology 108, no. 8 (2024): 1060–66, https://doi.org/10.1136/bjo-2023-324508.
5 Chia-Yi Lee et al., “The Effect of Defocus Incorporated Multiple Segment Spectacles’ Lenses Combined with Different Concentrations Atropine for Myopia Control,” Scientific Reports 15, no. 1 (2025): 12356, https://doi.org/10.1038/s41598-025-91089-7.
6 Xindan Cao et al., “Effect of 0.01% Atropine Eye Drops Combined with Different Optical Treatments to Control Low Myopia in Chinese Children,” Contact Lens and Anterior Eye 48, no. 1 (2025): 102317, https://doi.org/10.1016/j.clae.2024.102317.
7 Bryan Xiangrong Sim et al., “Additive Effect of Highly Aspherical Lenslet Target Spectacles to Children Inadequately Controlled by Atropine Monotherapy,” Ophthalmology Science 5, no. 4 (2025): 100753, https://doi.org/10.1016/j.xops.2025.100753.
8 Hae Ri Yum et al., “Synergistic Effect of Dual-Focus Soft Contact Lenses and 0.05% Atropine on Myopia Control in Children With Rapidly Progressing Myopia,” Eye & Contact Lens: Science & Clinical Practice 51, no. 2 (2025): 92–97, https://doi.org/10.1097/ICL.0000000000001154.
9 Ruilin Xiong et al., “Myopia Control Effect of Repeated Low-Level Red-Light Therapy Combined with Orthokeratology,” Ophthalmology 131, no. 11 (2024): 1304–13, https://doi.org/10.1016/j.ophtha.2024.05.015.
10 Mengting Yu et al., “Axial Length Shortening after Combined Repeated Low‐Level Red‐Light Therapy in Poor Responders of Orthokeratology in Myopic Children,” Journal of Ophthalmology 2024, no. 1 (2024): 4133686, https://doi.org/10.1155/2024/4133686.
11 Yan Yang et al., “Synergistic Effect of Defocus Incorporated Multiple Segment Glasses and Repeated Low Level Red Light Therapy against Myopia Progression,” Scientific Reports 15, no. 1 (2025): 3996, https://doi.org/10.1038/s41598-024-81363-5.
