Efficacy and safety of orthokeratology sequentially combined with escalating atropine concentrations for myopia control in children

To evaluate the concentration-dependent efficacy and safety of sequential orthokeratology (Ortho-K) combined with atropine eye drops (0.01%, 0.025%, 0.05%) for controlling axial elongation in children with progressive myopia, and to characterize clinical outcomes of this stepwise regimen. In this retrospective cohort study, 101 children (199 eyes; age 8-13 years) with axial myopia initially treated with Ortho-K (2020-2024) were analyzed. Participants exhibiting suboptimal responses (axial elongation ≥ 0.15 mm/6 months or ≥ 0.30 mm/12 months) received sequential atropine therapy. Outcomes included axial length changes and adverse event rates across concentration groups. Sequential addition of 0.01%, 0.025%, and 0.05% atropine to Ortho-K reduced annual axial elongation by 28.4%, 31.4%, and 39.4%, respectively (p < 0.05 vs. Ortho-K monotherapy). While no severe adverse events occurred, photophobia incidence escalated with higher concentrations (0.05%: 26.3% vs. 0.01%: 8.9%, 0.025%: 11.8%, p < 0.001). Near-vision blur occurred exclusively in the 0.05% group (15%). Stepwise atropine escalation following Ortho-K demonstrates clinically meaningful, concentration-dependent myopia control with acceptable tolerability. This sequential strategy provides personalized management for children with rapid progression, balancing efficacy and ocular tolerability.