Myopia clinicians no longer face a shortage of treatment options. They face a selection problem. Atropine and optical interventions are established tools for myopia control. The more challenging question is what to do when a single treatment is unlikely to be enough. Combination therapy is therefore becoming increasingly attractive in clinical practice, particularly when a child continues to progress despite treatment (1-3).

However, combination therapy needs a clearer place in practice. It should not be framed as the routine next step for any child with ongoing progression,  but rather as a targeted escalation strategy for the child whose biological risk appears greater than the likely strength of monotherapy. The clinical task is not to combine treatments by default, but to identify the child in whom escalation is genuinely justified (1, 3, 4).

Which child should trigger escalation?

Not every child with progressing myopia needs two treatments. For many, monotherapy remains a reasonable and sufficient first step (2, 5).

The child who should make us think about combination therapy is not simply the child whose prescription has changed. In practice, the more relevant question is whether the overall growth pattern suggests a stronger drive toward progression. This means looking beyond refraction alone and asking whether axial elongation is continuing at a pace that seems excessive for age, treatment, and risk profile (1, 3, 5).

Some children clearly raise that concern more than others. Younger children, especially those with early-onset myopia, have more years of growth ahead and therefore greater cumulative risk. Rapid axial elongation is another warning sign, particularly when it continues despite treatment. Children who are already tracking high on axial length percentile curves may be more likely to develop future high myopia. A strong family history, long axial length for age, and a trajectory that remains steep despite treatment all strengthen the case that a single mild intervention may not be enough (5-8).

Combination therapy should therefore not be triggered by a single threshold or by simple progression alone. Rather, it is most relevant for children with a strong progression signal: those who are young, have fast eye growth, track high on axial growth curves, or continue to show concerning elongation despite treatment (5-8).

Audit before you add

Before moving to combination therapy, the first step should not be to label the child a non-responder. It should be to review whether the apparent progression truly reflects insufficient treatment control (5, 9).

Escalation decisions are only as good as the measurements and assumptions behind them. A child may appear to be progressing despite treatment, but that impression can be misleading if axial length has not been measured consistently, if adherence is poor, or if the current treatment has not been implemented as intended (5, 9).

A structured audit should therefore come first. Was the same biometer used? Were the measurements reliable? Has treatment been used consistently and as intended? If an optical intervention was prescribed, is it being worn correctly and consistently? Has the specific optical intervention been shown to have clinically relevant efficacy? These are not minor details. They are often the difference between true treatment failure and apparent failure.

The next question is whether the treatment was strong enough for the child’s baseline risk in the first place. A child with a powerful progression signal may not be poorly responsive to treatment; the initial treatment may simply have been too weak relative to the biological drive of the eye. This is particularly relevant when low-dose atropine is used in children who are young, progressing quickly, or already tracking high on axial length percentile curves. In such cases, ongoing elongation should prompt reconsideration of atropine dosage, rather than concern about compliance alone. Similarly, optical interventions differ substantially in efficacy, and treatment decisions should be interpreted in light of the evidence supporting the specific design used (3-5, 7, 9, 10).

Framed this way, combination therapy is not a reflex response to continued progression. It is a deliberate next step after confirming that the child remains at high risk and that the current management is both appropriate and insufficient.

What does the evidence actually show?

The evidence for combination therapy is promising, but it needs to be read carefully.

Most published combination studies are not broad head-to-head comparisons of multiple escalation strategies. The literature is largely built around one recurring model: 0.01% atropine combined with an optical intervention, most often orthokeratology, and less often peripheral defocus spectacle lenses or multifocal soft contact lenses. Across these studies, combination therapy generally performs better than 0.01% atropine alone (2, 11).

If combination therapy is mainly being compared with 0.01% atropine, then part of the apparent advantage may reflect the modest efficacy of the baseline atropine dose rather than a uniquely powerful effect of combination treatment itself (11, 12).

A child who progresses on 0.01% atropine may indeed benefit from adding an optical intervention. But that does not automatically mean combination therapy is superior to every monotherapy option. It may simply mean that 0.01% was too weak a starting point for that child’s biological risk. Most combination studies come from East Asian cohorts, most use 0.01% atropine, and relatively few compare combination therapy with stronger atropine monotherapy. Evidence for higher-dose atropine in combination is still limited, even though that may be the next clinically relevant question (11-14).

Combination therapy can add benefit, especially when progression remains concerning under a relatively mild intervention. But the evidence does not justify presenting it as a universal next step, or as an inherently superior strategy across the board (2, 3).

A practical framework for clinic

A practical approach to combination therapy begins with a simple principle: treatment intensity should match biological risk (1, 3, 5).

The first question is therefore not whether combination therapy is available, but whether the child’s age, axial elongation rate, and position on age-based axial length curves indicate that a single mild intervention is unlikely to be enough.

Age-based axial length percentile curves can help make this decision more objective in everyday practice (Figure 1). They allow clinicians to identify children at higher risk and monitor whether treatment is moving axial growth onto a more acceptable trajectory over time.

A child who is very young, elongating quickly, or already tracking high on percentile curves may require a stronger initial strategy than a child with slower progression and a less concerning profile (7, 9).

Monitoring should rely on axial length wherever possible, rather than refraction alone. If follow-up shows that axial elongation remains faster than expected, the clinician should first audit adherence, measurement reliability, and whether the current treatment was sufficiently strong for the child’s baseline risk. Only after that should escalation be considered. When the progression signal remains concerning despite appropriate treatment and good adherence, combination therapy becomes a reasonable option (1, 3, 5, 9).

Trade-offs matter

Combination therapy may offer additional control, but it also comes with added demands. Two treatments usually mean more complexity for the child and family. That may involve daily drops plus a lens- or spectacle-based intervention, extra cost, more instructions, and a greater risk that one part of the plan is not followed consistently (5, 16).

Counselling should therefore be realistic from the start. The key question is not only which treatment is strongest on paper, but which treatment strategy is practical, acceptable, and sustainable for this child and their family. Higher-dose atropine may raise concerns about photophobia or near blur, while contact lens-based options require motivation, handling skills, hygiene, and an honest conversation about corneal safety. Even spectacle-based combination strategies add another layer to treatment and may affect daily wear behavior. Appropriate patient selection remains important, as underlying conditions such as ocular misalignment or other ocular pathology should be identified before initiating a specific myopia control treatment (13, 16).

Some families may prefer one stronger monotherapy option, whereas others may accept the burden of combination therapy because the child’s growth profile justifies a more intensive approach. The best treatment plan is the one that balances expected benefit with tolerability, safety, feasibility, and the likelihood that the family can actually sustain it.

Where evidence ends, judgment begins

Combination therapy sits in the space between evidence and judgement. Some parts of current practice are well supported. Atropine and optical interventions can slow myopia progression, and combination treatment, particularly 0.01% atropine combined with an optical intervention, generally performs better than 0.01% atropine alone (2, 3).

What remains less certain is exactly how clinicians should escalate treatment in individual children. The literature does not provide a universal threshold for when combination therapy should begin, nor does it fully resolve whether escalation should be based on baseline risk, inadequate response to monotherapy, or both.

Management therefore still depends partly on clinical judgement, including the interpretation of axial elongation, age, family history, and whether the current treatment is proportionate to the child’s biological risk. Recognizing this uncertainty helps prevent local protocols or experience-based strategies from being presented as settled evidence, while still allowing room for thoughtful, biologically informed care.

Conclusion

Combination therapy has an important place in contemporary myopia management, but that place should be defined carefully. The current evidence supports combination treatment as a useful escalation option, particularly when progression remains concerning under a relatively mild intervention.

Combination therapy should be considered for children with strong indicators of progression or a high-risk growth profile, especially when axial elongation remains too fast despite appropriate treatment and good adherence. Its value lies in providing a targeted escalation option for children whose biological risk or ongoing progression suggests that monotherapy may no longer be sufficient.