Combination Treatments for Myopia Progression in Children: A Narrative Review

Abstract

Despite a growing range of effective monotherapies for childhood myopia control, a subset of children continues to show suboptimal control, prompting interest in combination therapy. This narrative mini-review summarises recent evidence on combining pharmacological, optical, and device-based treatments to slow myopia progression, with emphasis on axial length (AL) as the benchmark of efficacy. The most studied combination is low-dose atropine plus orthokeratology (OK), with multiple studies and meta-analyses reporting greater slowing of AL elongation than OK alone, particularly in younger children and faster progressors. Emerging evidence supports combining low-dose atropine with other refractive interventions, such as defocus-incorporated multisegment (DIMS) and highly aspherical lenslets (HALs), and dual-focus soft contact lenses, although findings vary by study design, atropine dose, and cohort characteristics. Repeated low-level red light (RLRL) therapy combined with OK or DIMS spectacles has also shown improved AL outcomes in some studies, but retinal safety signals and rebound after cessation require careful monitoring. Combination therapy may be most appropriate for fast progressors, notably those with greater than 0.2 mm over 12 months or for inadequate responders to monotherapy, with stepwise escalation guided by AL response, safety, and adherence. Further long-term, randomised trials with standardised endpoints and responder definitions are needed.

1. Introduction

The incidence of myopia is rising and is occurring earlier [1]. The results show an increasing prevalence and incidence of myopia and high myopia (defined as <−6.0 Diopters (D) or 26.0 mm in AL) worldwide [2]. It is expected that an increasing number of sight-threatening eye conditions will develop in these patients as they transition into adulthood. The risk of retinal detachment increases by a factor of 3 at −3 Diopters (D) [3,4]. Similarly, the risk of glaucoma increases 3 to 4 times at −3 to −6 D and is 4 to 10 times greater at −6.0 D [5,6,7,8,9]. The risk of retinal detachment increases more than 20 times once the refractive error reaches <−7.0 D [10]. The risk of pathological myopia is linked to the greater AL of the growing myopic eye.

Treatment interventions have expanded significantly in recent years, including refractive, pharmacological and light therapies [11]. Monotherapy with these interventions has been evaluated in randomised controlled trials for 2 years or more, demonstrating statistically and clinically significant effects on AL change in children with myopia [12]. Additionally, there is a large body of evidence that our first line of intervention for myopia progression is lifestyle. It should be recognised that spending two hours a day with outdoor activity in at least 1000 lux [13,14] and reducing near work have beneficial effects on myopia progression.

There is a group of patients who do not seem to achieve control with monotherapy [15], defined as AL progression reduced to what is considered physiological growth for that patient’s age (and ethnicity), thus not achieving adequate control, with adherence confirmed. A pragmatic indicator of adequate control is reducing axial elongation to approximately ≤0.20 mm/year, acknowledging ongoing physiologic ocular growth in childhood [16].

The range observed across different ethnicities and ages, with children demonstrating axial elongation >0.30 mm over the preceding 12 months described as fast progressors and prioritised for active myopia control and closer monitoring [16]. This goal has prompted the need to determine whether combination treatment may achieve better outcomes for these patients [17]. It should also be noted that different trials reviewed in this article have a range of progression rate classifying fast progression, which may differ and are quoted where possible in the text and tables.

2. Method of Literature Search

A targeted, non-systematic search was conducted in PubMed/MEDLINE, Embase, and the Cochrane Library for records published between 2016 and June 2026. Foundational monotherapy trials and earlier key studies were additionally cited to provide historical context and to summarise mechanisms, safety, and rebound phenomena relevant to interpreting combination outcomes. Search terms included: “myopia control” AND atropine AND OK; atropine AND DIMS; atropine AND HAL; atropine AND dual-focus contact lenses; OK AND repeated low-level red light (RLRL); DIMS AND RLRL; and related combinations. Titles and abstracts were screened for paediatric populations and combination interventions, with full-text assessment where available. Exclusions were: non-English; non-human; studies not evaluating a combination therapy; studies primarily addressing premyopia prevention rather than progression; and interim publications where a final peer-reviewed report was available. Findings were synthesised and presented using a narrative approach.

3. Combination Treatments

The direct comparison of these studies is difficult, as the methodologies, inclusion criteria (including age, treatment period, treatment doses and pre-treatment progression) differ. There is a variety of methods, including retrospective, randomised and systematic reviews. Future analysis of combination treatment may be more robust if more randomised controlled trials are published; however, given the difficulty of conducting these studies, we may need to continue to rely on real-world data as well.

As stated, the current evidence reviewed in this article is heterogeneous, as the area is only now expanding to include retrospective, randomised trials and systematic reviews; therefore, direct comparison is inappropriate. However, the growing body of evidence demonstrates that combination treatment may be more effective and can be considered a management tool.

In recent years, investigations into the possible additive effect of combination treatment have begun to be published. The most studied combination is with low-dose atropine and OK.

3.1. Atropine Drops and OK

Studies using monotherapy with low-dose atropine or OK have shown effective control of myopia progression in children [18,19,20,21]. More recent studies have demonstrated that the addition of low-dose atropine to OK results in a greater response in patients who did not achieve the required control with OK alone. (Summary Table 1).

Table 1. Characteristics and results of combination studies of orthokeratology (OK) and atropine drops.

Study	Study Design	Age (Years)	Ethicity	Intervention	Follow-Up	Effect as Reported
Kinoshita et al. 2020 [22]	Randomised clinical trial	8–12	Japanese	OK + 0.01% atropine vs. OK alone	2 years	AL change 0.29 vs. 0.40 mm/2 years with OK alone, especially in the first 6 months
Tsai et al. 2022 [23]	Systematic review + network meta-analysis	Review	Review	Atropine vs. OK vs. OK + 0.01% atropine	Review	Ranked efficacy: OK + 0.01% atropine highest among listed interventions
Tan et al. 2023 [24]	Randomised clinical trial	6–11	Chinese	OK + 0.01% atropine vs. OK alone	2 years	Combination ~50% more effective than OK alone
Du et al. 2023 [25]	Retrospective, age-matched comparative study	7–14	Chinese	OK vs. OK + 0.01% atropine	2-year	AL 0.16 mm lower in the combination group, especially in younger cohort
Wang et al. 2023 [26]	Meta-analysis	Review	Review	0.01% atropine alone vs. 0.01% atropine + OK	Review	Combination increased efficacy vs. either treatment alone.
Xu, S. et al. 2023 [27]	Stratified randomised clinical trial	8–12	Chinese	Atropine vs. OK vs. combined treatment	2 years	Combination treatment is effective for myopia control
Li, B. et al. 2024 [28]	Randomised, double-masked, placebo-controlled, cross-over trial	8–12	Chinese	OK + 0.01% atropine (vs OK only and swapped after 1 year)	2 years	Reduced axial elongation with combination (0.1 mm on average less per year)
Tu et al. 2025 [29]	meta-analysis of randomised controlled trials	Review	Review	OK + 0.01% atropine add-on	Review	Combination treatment is effective for myopia control
Yang, Xiao, et al. 2025 [30]	Retrospective analysis	8–14	Chinese	OK + 0.01% atropine added if fast progression	6 months in each group	Synergistic efficacy reported (reduced AL progression from 0.3 to 0.08 mm when atropine was added
Matsumura et al. 2025 [31]	Inclusion if treated with atropine or combination	5–13	Japanese	0.01% atropine vs. OK + atropine combination	1 year	Additive effect suggested using choroidal thickness/blood flow markers
Xu, H. et al. 2025 [32]	Randomised clinical trial	8–15	Chinese	OK vs. OK + 0.01% atropine vs. OK + 0.04% atropine	2 years	0.04% combo showed greater efficacy than 0.01% combo, with more side effects
Wen et al. 2025 [33]	Preliminary retrospective study	8–14	Chinese	OK + 0.05% atropine in fast progressors >0.3 mm/12 months	1 year	Add-on 0.05% atropine beneficial in fast progressors
Guo et al. 2025 [34]	Fast progressors ≥0.15 mm/6 months or ≥0.30 mm/12 months Stepwise regimen	8–13	Chinese	OK + escalating atropine (0.01–0.025% then 0.05%)	1 year	Increased efficiency but more side effects (blur, photophobia)
Yuan et al. 2026 [35]	Randomised clinical trial	8–12	Chinese	OK + 0.01% atropine vs. OK alone vs. 0.01% atropine alone	2 years	Significantly less AL change in combination group

The initial combination studies focused on OK with low-dose atropine 0.01%. In 2020, a Japanese randomised controlled study demonstrated an additive effect of OK and the addition of atropine 0.01% [22]. In 2022, a meta-analysis demonstrated the efficacy of interventions in the literature, with a hierarchy of efficacy: OK combined with 0.01% atropine > high-dose atropine > moderate-dose atropine> OK> low-dose atropine [23]. In a randomised controlled trial also in 2022, atropine 0.01% combined with OK was 50% more effective than OK alone [24].

In a retrospective study, an age-matched group of patients undergoing OK, compared with a group receiving OK with the addition of 0.01% atropine, showed a statistically significant effect within the first 18 months, especially in the young cohort [25]. A 2023 meta-analysis also concluded that combining OK with atropine 0.01% together increased the efficacy of either treatment alone [26]. Similar results have been published, demonstrating the additive effect of combining OK with atropine 0.01%, with an emphasis on its effect in the younger cohort [27,28,29,30]. Monitoring choroidal thickness change as an early marker of treatment effect also demonstrated an additive effect of atropine 0.01% and OK [31].

In a recent study comparing the efficacy of atropine 0.04% combined with OK with that of atropine 0.01% combined with OK, the higher atropine dose showed greater efficacy; however, more atropine-related side effects were reported [32]. The use of atropine 0.05% combined with OK has also been found to be beneficial for fast progressors (those with greater than 0.3 mm elongation over 12 months prior to allocation to combined treatment in this study) [33]. The use of sequential atropine dosing in combination with OK has been advocated, with results showing that atropine 0.01% to 0.025%, then 0.05%, increased efficiency but also led to increased side effects, including blur and photophobia [34]. This approach highlights the need to maximise benefits while minimising the side effects patients are exposed to. Although it is difficult to compare across studies, it does demonstrate a trend that an increase in concentration of atropine may have a greater effect in combination, similar to the results with atropine as monotherapy. In 2026, confirming the combination of OK and atropine 0.01% had an additive effect in 96 randomised children aged 8–12 years, compared with lenses alone or atropine 0.01% alone. Over two years, the final AL change was significantly less in the dual treatment group [35].

3.2. Atropine Drops and Peripheral Designed Myopia Control Spectacles

There are now several peripheral-designed myopia-control spectacles that treat refractive error in the centre and reduce the relative hyperopic defocus caused by the length and shape of the myopic eye. The basis of this design stems from early animal studies that led to the development of the peripheral defocus theory, which holds that the peripheral retina receives myopic defocus as a signal to slow or stop eye growth [36]. However, although peripheral myopia-control spectacles have shown excellent effects in long-term studies [37,38], some patients continue to progress rapidly. The two main peripheral defocus lenses in the atropine combination studies are DIMS and HAL. (Summary Table 2).

Table 2. Characteristics and results of combination studies of peripheral defocus lenses/dual focus contact lenses and atropine drops.

Study	Study Design	Age	Ethnicity	Intervention	Follow-Up	Effect as Reported
Huang et al. 2022 [39]	Retrospective comparative study	7–12	Chinese	DIMS + atropine 0.01% vs. DIMS alone vs. SVL alone	1 year	Combination showed a greater effect than DIMS or SVL alone
Nucci et al. 2023 [40]	Non-randomised, single-arm, masked cohort study	6–18	European	SVL vs. atropine 0.01% vs. DIMS vs. DIMS + atropine 0.01%	1 year	AL progression: 0.17 mm (control/SVL); 0.09 mm (atropine 0.01%); 0.066 mm (DIMS); 0.049 mm (DIMS + atropine 0.01%)
Jethani 2024 [41]	Small study (10 subjects) in atropine non-responders	Mean age 8.4 ± 2.1	Indian	Added DIMS lenses to children not responding to atropine 0.01%	1 year	Additive effect of adding DIMS to atropine 0.01% “non-responders”
Tang, T. et al. 2024 [42]	Retrospective comparative study with age stratification	6–14	Chinese	Orthokeratology vs. OK + atropine 0.01% vs. DIMS vs. DIMS + atropine 0.01%	1 year	OK and DIMS monotherapies had similar axial elongation; adding atropine slowed progression further; effect more pronounced in 10–14 yrs group
Lee, C. Y. et al. 2025 (Sci Rep) [43]	Retrospective	6–15	Taiwan	DIMS alone vs. DIMS + atropine 0.01% vs. DIMS + atropine 0.125%	1 year	Adding atropine significantly reduced elongation and refractive progression vs. DIMS alone; higher atropine concentration had little additional effect
Lee, C. Y. et al. 2025 (Cureus) [44]	Retrospective cohort study (fast progressors >1 D/12 month)	6–15	Taiwan	DIMS + atropine 0.01%	1 year	Reported benefit of DIMS plus atropine 0.01% in fast-progressing myopia
Lee, C. Y. et al. 2025 (In Vivo) [45]	Study in high myopia population (>−6.0 D)	6–15	Taiwan	DIMS spectacle lens + atropine 0.125%	1 year	Reported myopia control effect in high myopia (AL elongation less than half)
Cao et al. 2025 [46]	Retrospective study	6–11	Chinese	Atropine 0.01% + SVL vs. atropine 0.01% + orthokeratology vs. atropine 0.01% + DIMS	6 months	DIMS + atropine 0.01% outperformed atropine 0.01% + SVL
Guemes-Villahoz et al. 2025 [47]	Randomised study	4–16	European	Atropine 0.025% + SVL vs. atropine 0025% + DIMS	1 year	AL progression: 0.18 mm (atropine + SVL) vs. 0.07 mm (atropine 0.025% + DIMS)
Hassan et al. 2026 [48]	Systematic review	Review	Review	Defocus lenses vs. atropine vs. combined defocus lenses + atropine	Review	Concluded each intervention effective; combination produced greater effect than either alone
Zhao et al. 2024 [49]	Retrospective	6–15	Chinese	SVL vs. HAL alone vs. HAL + atropine 0.01%	1 year	HAL reduced axial elongation 0.34 mm → 0.19 mm vs. control; adding atropine reduced further to 0.09 mm
Hu et al. 2025 [50]	Retrospective study	8–15	Chinese	HAL + atropine 0.01% vs. atropine 0.01%	1 year	Combination yielded the best outcome
Sim et al. 2025 [51]	Prospective study progressing on atropine (0.01% daily, 0.01% twice daily, or 0.025% daily)	8–15	Singaporean	Added HAL lenses and continued their atropine dose	1 year	Benefit of combining HAL + atropine; no additional effect from higher atropine doses reported
Chen et al. 2025 [52]	Retrospective study	8–13	Chinese	Groups: OK, HAL, SVL; and each optical treatment combined with atropine 0.01%	1 year	All monotherapies better than SVL; HAL best monotherapy. Adding atropine 0.01% further reduced progression; HAL + atropine slower progression in older/low myopia)
Tang, Y. et al. 2025 [53]	Retrospective study: at least 4 D in 1 eye	8–12	Asian	HAL + atropine 0.01%	1 year	Minimal additive effect of atropine 0.01% when combined with HAL in moderate–high myopia
Erdinest et al. 2024 [54]	Prospective study	8–15	Mixed Caucasian	Atropine 0.01% + dual-focus contact lenses vs. atropine 0.01% + SVL vs. dual-focus contact lenses alone vs. SVL alone	3 years	No additional effect of adding atropine 0.01% to dual-focus contact lenses over 3 years (atropine 0.01% + SVL showed a statistically significant monotherapy effect)
Yum et al. 2025 [55]	Retrospective study	7–13	Korean	Dual-focus contact lenses + atropine 0.05% vs. dual-focus contact lenses alone	1 year	Combination significantly reduced progression vs. contact lenses alone

3.2.1. Atropine Drops and DIMS

The first retrospective study on the combined use of DIMS and topical atropine was published in 2022 [39]. This study compared 7- to 12-year-olds treated with combination DIMS and atropine 0.01% with DIMS or SVL alone and found a greater effect of the combination over 1 year. Another study trialled the combination of atropine 0.01% and DIMS in a non-randomised, single-arm, masked cohort study involving 146 children aged 6–18 years. Patients were placed in one of the following groups: SVL alone, atropine 0.01% alone, DIMS alone, or atropine 0.01% and DIMS combined. At 12 months, AL progression was 0.17 mm with control, 0.09 mm with atropine 0.01% alone, 0.066 mm with DIMS alone, and 0.049 mm with DIMS combined with atropine 0.01%, demonstrating the synergistic effect of combining atropine 0.01% and DIMS glasses [40]. Another small study added DIMS lenses to children who were not responding to atropine 0.01%. The results demonstrated the additive effect of DIMS in children considered non-responders to atropine 0.01% alone [41].

A retrospective study compared OK alone with the addition of atropine 0.01% or DIMS alone or DIMS with atropine 0.01%. The results demonstrated similar axial elongation between monotherapy with OK and DIMS, with an additional slowing when atropine was added to either modality. This effect was more pronounced in the stratified older patient group (10–14 years) [42]. Another 1-year study published in various journals found that, compared with DIMS alone, DIMS with 0.01% or 0.125% atropine significantly reduced elongation and refractive progression when atropine was added; however, increasing the atropine concentration had little additional effect [43,44,45]. These studies have slightly varying entry criteria but were from the same research group. A retrospective study combining atropine 0.01% with either SVL, OK, or DIMS glasses found that the combination of either optical correction was more effective than atropine with SVL. The best effects were observed with the combination of DIMS and atropine 0.01% [46]. In a recent publication, randomised atropine 0.025% to SVL or combined with DIMS glasses. The atropine with SVL progressed by 0.18 mm over 12 months, compared with 0.07 mm with atropine 0.025% combined with DIMS over 12 months [47]. Most recently, a review of the literature on DIMS combined with atropine found that each intervention was effective, but the combination produced a greater effect than either alone [48]. Across the different study designs, the addition of either modality increases efficacy in combination compared with monotherapy.

3.2.2. Atropine Drops and HAL

Similarly, there is evidence of the synergistic effect of HAL and atropine drops. A study comparing SVL to HAL alone and HAL with atropine 0.01% demonstrated that HAL, compared to the control, reduced axial elongation from 0.34 mm to 0.19 mm, with an additional reduction to 0.09 mm when combined with atropine 0.01%. This result was seen in all age-stratified groups [49]. In a retrospective 1-year Chinese study, the combination of HAL and atropine 0.01% was again found to yield the best outcome in a cohort of 8- to 15-year-olds [50]. In a recent publication, children aged 6–11 years who were progressing on atropine 0.01% daily, 0.01% twice daily, and 0.025% daily were given HAL lenses and maintained their atropine doses. This prospective Singaporean study again demonstrated the benefit of combining treatment and also found no additional effect with higher doses of atropine [51].

A retrospective 1-year study stratified children into OK, HAL, SVL, and combined with atropine 0.01%, and each refractive treatment. The results demonstrated that all monotherapies achieved statistically better results than SVL, with HAL achieving the best monotherapy results. In combination with atropine 0.01%, the progression was further reduced, with greater effects from OK and atropine in the older group with higher baseline refractive error, and slower progression in the HAL and atropine group in older children with low myopia [52]. Finally, another Asian retrospective study demonstrated a minimal additive effect of atropine 0.01% in moderate to high myopes when used with HAL [53]. Further investigations are required into the effect of combining higher-dose atropine and whether this results in a more pronounced benefit.

3.3. Atropine Drops and Dual Focus Contact Lenses

The combination of atropine 0.01% with dual focus contact lenses was studied in a prospective study of children aged 8 to 15, compared with atropine 0.01% with SVL, atropine 0.01% with dual defocus contact lenses, or SVL alone. In this study, there was a statistically significant effect of atropine 0.01% added to SVL as monotherapy; however, there was no additional effect with dual-focus contact lenses over 3 years [54]. A recent Korean retrospective study combining dual-focus contact lenses with atropine 0.05% significantly reduced progression compared with contact lenses alone [55]. Further studies with varying atropine concentrations will help determine whether higher concentrations are more effective when combined with dual-focus contact lenses.

3.4. OK and RLRL

A trial combined patients with rapid progression (>0.5 mm over 12 months) who were previously on OK alone, and then RLRL was added. In the additional treatment group, there was no progression over 1 year, compared with 0.27 mm in the OK-alone group [56]. A similar result has been reported in another study group with a retrospective design [57], demonstrating the additive effect of RLRL with OK. Another retrospective study of children and adolescents (5 to 15 years) utilised RLRL combined with either SVL or OK and found a statistically significant benefit of RLRL, as well as an additive effect of OK [58]. Recently, a Caucasian study of Spanish children aged 10 to 13 years that combined RLRL with OK was published. In 1 year, RLRL combined with OK demonstrated AL shortening, whereas OK alone showed a mild elongation [59]. Similarly, a study of fast progressors (greater than 0.4 mm/year) found a significantly greater effect with the combination of OK and RLRL than with OK alone [60]. A recent meta-analysis of adjunctive treatments to OK with RLRL found a significant additive effect [61]. (Summary Table 3).

Table 3. Characteristics and results of combination studies of red light therapy (RLRL) and refractive modalities.

Study	Study Design	Age	Ethnicity	Intervention	Follow-Up	Effect as Reported
Xiong et al. 2024 [56]	Multicentre randomised controlled trial	8–13	Chinese	RLRL + OK vs. OK alone (>0.5 mm over 12 months previously on OK)	1 year	No progression with add-on RLRL (0.00 mm) vs. 0.27 mm axial elongation with OK alone
Yu et al. 2024 [57]	Retrospective study in fast progressors (>0.3 mm/12 months)	7–15	Chinese	RLRL + OK in poor responders to OK	1 year	Additive effect with no progression in combination group
Wu et al. 2024 [58]	Retrospective study	5–15	Chinese	RLRL combined with SVL or OK	2 years	Statistically significant benefit of RLRL; additive effect of OK
Fernandez Fidalgo et al. 2025 [59]	Randomised controlled study	10–13	European	RLRL + OK vs. OK alone	1 year	Combination showed AL shortening; orthokeratology alone showed mild elongation
Elham and Meng 2026 [60]	Retrospective study in fast progressors (>0.4 mm/year)	8–14	Chinese	RLRL + OK vs. OK alone	1 year	Combination had significantly greater effect than OK alone
Zhang et al. 2026 [61]	Meta-analysis	Review	Review	Adjunctive RLRL with optical myopia control (including as adjunct to OK)	Review	Significant additive effect of adjunctive RLRL
Yang, Liu, et al. 2025 [62]	Real-world observational study	5–16	Chinese	DIMS alone vs. RLRL alone vs. DIMS + RLRL	1 year	AL change: +0.16 mm (DIMS); −0.04 mm (RLRL); −0.13 mm (DIMS + RLRL)
Luo et al. 2025 [63]	Comparative study	6–14	Chinese	SVL vs. DIMS vs. RLRL vs. RLRL + DIMS	1 year	AL change: 0.26 mm (SVL); 0.16 mm (DIMS); −0.21 mm (RLRL); −0.14 mm (RLRL + DIMS); adding DIMS to RLRL not statistically significant

However, given the large effect observed with RLRL, it would be important to determine whether OK enhances RLRL as an adjuvant and to study its longer-term effects, including rebound.

3.5. Peripheral Designed Myopia Control Spectacles and RLRL

The combination of DIMS design lenses and RLRL was published as a real-world observational study comparing DIMS alone, RLRL alone, and the combined DIMS and RLRL. DIMS alone achieved +0.16 mm progression, RLRL −0.04 mm (shortening) and the combined effect of DIMS and RLRL −0.13 mm over the year [62]. In 2025, a publication compared RLRL with SVL or DIMS design. Children aged 6–14 years showed elongation over 12 months of 0.26 mm with SVL, 0.16 mm with DIMS alone, −0.21 mm with RLRL alone, and −0.14 mm with RLRL and DIMS. However, the effect of adding DIMS was not statistically significant [63]. The effect of RLRL is so pronounced that the additional benefit of adding DIMS was not statistically significant. Currently, no studies combine HAL design with RLRL.

3.6. Peripheral Designed Myopia Control Spectacles and Dual Focus Contact Lenses

Although these peripheral myopia control spectacles have shown excellent results, there are clinical situations in which considering the peripheral design of the spectacle lens can be useful when combined with dual-focus contact lenses. Patients’ needs, including sporting requirements, may require an alternative to their spectacles. Although this may not directly increase efficiency, it might be important to maintain the efficiency provided by peripheral-designed myopia-control spectacles. Currently, no publications are addressing the effect of combining these two modalities, either DIMS or HAL design.

4. Evidence Gaps and Future Combinations

Current evidence reviewed in this article is heterogeneous in nature, given that the area is only now expanding to include retrospective, randomised trials and systematic reviews. Although direct comparisons cannot be made, the general body of evidence suggests that combination myopia treatments may assist in better control of progression. The extent of the effect of combining therapies remains unclear, as the available studies are short on follow-up, have diverse inclusion criteria, are small in sample size, and some are not randomised.

Although adding treatment modalities has more evidence of additive effects, many questions remain about their mode of action and the biological basis for synergism. There is also little evidence on when to add treatment or which treatment addition will best aid the patient. The effect of ethnicity is also unclear, as most combination studies have been conducted in Asia. Additional considerations include the cost and compliance of combination treatment, which may limit the uptake of multimodal treatment regimes. A recent review of combination treatments has proposed criteria for initiating combination therapy based on the patient’s progression and response to monotherapy, which seems a logical, stepwise approach [64]. This review has focused on the effect on axial growth to best assess combination treatment; however, the effect of combined treatment should also be assessed in the context of financial cost, additional difficulties with compliance and the potential short- and long-term risk. Limitations in the current data do not allow analysis of risk factors such as parental myopia, ethnicity, specific age groups and baseline refraction or AL and their contribution to combination efficacy. It would be helpful in personalised myopia management to understand how different combination treatments may have possible differential effects across patient groups. This remains an area for more research. Additionally, with new tools to access efficiacy of myopia treatments such as choroidal thickness measurement, we may begin to understand the more immediate effect of adding treatment modalities with future research.

There is little to no research designed to test the effect of rebound with combination treatment and how the possible combination may add to or reduce rebound. For example, when the patient has good control and is only on atropine drops, it may be helpful to add peripheral-designed myopia control spectacles to protect against possible rebound when reducing atropine drops. However, there are no studies on whether this is a helpful approach or whether certain combination treatments may add additional rebound. This may also imply longer treatment periods, especially in high-risk patients, usually the patient group you might consider for combination treatment.

Finally, triple therapy (for example, environmental/behavioural measures plus an optical modality plus pharmacologic therapy) is conceptually attractive for high-risk children, but controlled evidence comparing dual versus triple combinations is limited. Future trials should test whether adding a third modality provides clinically meaningful incremental AL benefit without compromising safety or adherence.

5. Conclusions

Myopia management can now have a more cohesive framework that considers a combination of modalities where necessary. Evidence is available for the combination of atropine with optical correction and optical correction with RLRL, showing greater efficiency in retarding myopic elongation than these modalities alone. Studies are required to obtain further evidence to determine whether combining treatments within modalities, such as contact lenses and peripherally designed myopia-control spectacles, yields synergistic effects or is at least as effective as monotherapy myopia control. The use of increasing atropine concentration in combination with other modalities remains unclear, with conflicting reports across different modalities.

Further studies with longer treatment intervals and larger cohorts are needed to continue evaluating the use of combination treatments, especially at different atropine concentrations. The concerns include the cost, potential increased side effects and the need for compliance when combining treatment modalities. Close monitoring of treatment response may enable stepwise myopia management with a combination of modalities to achieve optimal control and practice for our young patients.