Comparison of the effects of spectacle lenses with highly aspherical lenslets combined with atropine for moderate to high myopia control in children

Abstract

Purpose

To compare the 1-year myopia control effects of spectacle lenses with highly aspherical lenslets (HAL), HAL combined with 0.01% atropine (HALA), and single-vision spectacle lenses (SVL) in children with moderate to high myopia.

Methods

This retrospective cohort study analyzed 175 myopic children treated at the Eye Hospital of Wenzhou Medical University between January 2020 and January 2024. Participants were divided into three groups based on treatment: HAL (n = 62), HALA (n = 55), and SVL (n = 58). Changes in axial length (AL) and spherical equivalent refraction (SER) under non-cycloplegic conditions were compared using one-way ANOVA. Post hoc pairwise comparisons were performed using the LSD method, and all pairwise p-values were subsequently adjusted for multiple comparisons using the false discovery rate (FDR) to control the risk of Type I error.

Results

After 12 months, mean AL elongation was 0.21 ± 0.15 mm in the HAL group, 0.21 ± 0.13 mm in the HALA group, and 0.28 ± 0.15 mm in the SVL group. AL changes between HAL and HALA were not significantly different (P = 0.837). However, both HAL (P = 0.004) and HALA (P = 0.009) significantly slowed axial elongation compared to SVL. In subgroup analysis, children aged 8–10 years showed no significant differences among groups. In the 11–12-year subgroup, both HAL and HALA significantly reduced AL elongation compared to SVL, with no difference between HAL and HALA.

Conclusion

HAL and HALA offer similar efficacy in controlling myopia progression in children with moderate-to-high myopia, both outperforming SVL. Their effects appear more pronounced in older children.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12886-025-04584-w.

Background

The prevalence of myopia has shown a continuous upward trend, evolving into a significant global public health concern. Current projections estimate that by 2050, approximately 50% of the global population will be affected by myopia, with an additional 10% anticipated to develop high myopia [1–4]. Research indicates that earlier onset of myopia is associated with more rapid progression. Moreover, early-onset myopia significantly increases the risk of developing high myopia in adulthood, which in turn elevates the likelihood of vision-threatening complications such as glaucoma, cataracts, myopic macular degeneration, and retinal detachment [5, 6]. Current strategies for the prevention and control of myopia primarily involve optical and pharmacological interventions. Optical approaches include functional frame spectacles [7–9], multifocal soft contact lenses [10], orthokeratology lenses [11, 12], and related modalities. Compared with corneal contact lenses, functional spectacle frames are often preferred as a first-line option for myopia prevention and control due to their advantages in safety and ease of use. Spectacle lenses with highly aspherical lenslets (HAL) consist of a central 9-mm vision correction zone and a peripheral defocus zone formed by 11 concentric rings containing 1,021 microlenses. These lenses reduce myopia progression by generating a myopic defocus signal anterior to the retina. The clinical study demonstrated that, compared with single-vision spectacle lenses (SVL), HAL lenses can effectively slow myopia progression by up to 67% [8].

Atropine, a pharmacological intervention, is a non-selective muscarinic receptor antagonist. Studies have shown that higher concentrations of atropine are associated with greater efficacy in controlling myopia, but also result in a higher incidence of adverse effects and increased rebound after discontinuation [13]. Multiple clinical trials, including ATOM and LAMP, have confirmed the efficacy and safety of low-concentration atropine [14, 15]. Among these, 0.01% atropine is widely considered the standard dose for slowing myopia progression in children, offering an optimal balance between effectiveness and minimal side effects. Although it has been shown to be effective in managing high myopia, its control effect may be less pronounced compared to that observed in low and moderate myopia [16, 17].

In clinical practice, for children whose myopia continues to progress rapidly despite monotherapy, combined pharmacological and optical interventions are frequently employed. This combined approach has been shown to provide superior efficacy compared to single-modality treatment. Several studies have reported that combining 0.01% atropine with Orthokeratology (OK) lenses or defocus incorporated multiple segments (DIMS) spectacle lenses yields more effective control of myopia progression than using OK or DIMS lenses alone [18–20].

Research has demonstrated a strong association between earlier onset of myopia and the subsequent development of more severe forms of the condition, particularly high myopia in adulthood [21, 22]. However, a subset of children and adolescents already presents with moderate to high myopia at an early age, and this population remains under-investigated. Most existing studies on myopia prevention and management have focused on children with low to moderate myopia, or have included children with high myopia only as a small subset of the study population [23]. Some studies have reported the effectiveness and safety of combining orthokeratology with spectacle lenses [24], as well as red light therapy [25]. in children with moderate to high myopia. Nevertheless, there is a notable lack of literature examining the efficacy of combining functional spectacle lenses with atropine for the management of moderate to high myopia in pediatric patients.

Therefore, the objective of the present study was to evaluate and compare the one-year progression of myopia in children aged 8–12 years with spherical equivalent refraction (SER) between − 4.00D and − 7.75D treated with HAL lenses combined with 0.01% atropine, HAL lenses alone, or SVL. In addition, a subgroup analysis based on age was conducted to investigate the potential impact of age on treatment efficacy, with the aim of informing more ideas for the prevention and control of moderate to high myopia in children.

Methods

Participants

This retrospective cohort study collected clinical data from children with moderate to high myopia who were treated at the Eye Hospital of Wenzhou Medical University between January 2020 and January 2024. The collected data included date of birth, gender, subjective refraction, axial length, and best-corrected visual acuity. A total of 175 subjects were included in the final analysis based on the following inclusion criteria:

1. Age between 8 and 12 years;

2. Regular clinical follow-up for a minimum duration of one year;

3. In the HALA group, continuous administration of 0.01% atropine for at least one year, with prescribing records consistently documented in the hospital system;

4. SER ≤ − 4.00 D in at least one eye;

5. Astigmatism and anisometropia of 2.00 D or less;

6. Best-corrected visual acuity of ≤ 0.10 (logMAR);

7. Intraocular pressure between 10 and 21 mmHg, with an interocular difference of no more than 5 mmHg;

8. No presence of other ocular disorders, including cataracts, glaucoma, strabismus, or amblyopia.

The study was conducted in accordance with the principles of the Declaration of Helsinki and was approved by the Institutional Ethics Committee of the hospital (Approval No. 2024-127-K-111). All clinical data were obtained from routine outpatient visits. As determined by the ethics review, the requirement for signed informed consent was waived.

Grouping method

Participants were divided into three groups based on the type of spectacle lenses worn and the use of 0.01% atropine: wearing spectacle lenses with highly aspherical lenslets (Stellest lenses, Essilor International, Paris, France) (HAL, n = 62); wearing HAL lenses in combination with 0.01% atropine (The Eye Hospital of Wenzhou Medical University, Zhejiang, China) (HALA, n = 55); wearing single-vision spectacle lenses (SVL, n = 58). Participants were instructed to wear their assigned lenses throughout the day, except during periods when lens wear was unsuitable (e.g., sleep or vigorous physical activity). For those in the HALA group, 0.01% atropine was administered as one drop in each eye every night before bedtime.

Ocular examinations and outcome measures

All examinations for participants included in this study were conducted uniformly at the Eye Hospital of Wenzhou Medical University by experienced clinicians. The assessments included the following: axial length, measured using the IOL-Master 500 (IOLMaster-500; Carl Zeiss Meditec AG, Germany), with five consecutive measurements averaged for each reading. Only individual measurements with a signal-to-noise ratio (SNR) greater than 2.0 were accepted, and the combined signal was required to have an SNR greater than 32. The change in AL was defined as the primary outcome measure of this study, as it is a reliable and objective indicator of myopia progression. Objective and Subjective refraction (Topcon; Topcon Corporation, Tokyo, Japan), Conducted using an autorefractor and standard subjective refinement procedures. The change in spherical equivalent refraction (SER), obtained from non-cycloplegic autorefraction, was considered the secondary outcome measure. Although non-cycloplegic readings may be influenced by accommodation, this impact is expected to be minimal as all participants had moderate-to-high myopia.

Statistical analysis

Statistical analysis was performed using the SPSS statistical software package.

(version 25.0, IBM Corp., US), and since the biological measurements of the right and left eyes were strongly correlated (Spearman correlation coefficient = 0.952), data from the right eye were primarily used for analysis. If the refractive status of the right eye did not meet the inclusion criteria, data from the left eye were used instead. The Kolmogorov-Smirnov test showed that baseline age and SER were not normally distributed, whereas baseline AL followed a normal distribution. Categorical variables such as sex were compared using the chi-square test. Differences in baseline age and SER among groups were assessed using the Kruskal–Wallis (K-W) test, while differences in baseline AL were evaluated using one-way analysis of variance (ANOVA). Data are presented as mean ± standard deviation. Categorical variables are reported as counts and percentages, where applicable. One-way ANOVA was used to compare changes in SER and AL over one year among the three groups and among six age subgroups. Post hoc tests (LSD) was conducted to assess pairwise group differences. A p-value of < 0.05 was considered statistically significant.

Results

Baseline characteristics

In this retrospective study, a total of 1,796 subjects were evaluated. Of these, 236 passed the initial screening, and ultimately, 175 subjects (93 boys and 82 girls) met the inclusion criteria were enrolled. Participants were allocated into three treatment groups: the HAL group (n = 62), the HALA group (n = 55), and the SVL group (n = 58) (Additional file 1). The overall mean age of the enrolled subjects was 10.27 ± 1.27 years. At baseline, the average SER and AL were − 5.13 ± 0.91 D (range: −4.00 D to − 7.75 D) and 25.48 ± 0.79 mm (range: 22.82 mm to 28.28 mm), respectively. There were no significant differences among the three groups in terms of baseline gender distribution (χ² = 0.637, P = 0.727), age (Kruskal–Wallis test, P = 0.579), SER (Kruskal–Wallis test, P = 0.104), or AL (one-way ANOVA, P = 0.283) (all P > 0.05). Detailed baseline characteristics of the subjects are presented in Table 1.

Table 1.

Baseline demographics for the three treatment groups

Characteristics	Total			Subgroups			P
	Descriptive	Range		HAL	HALA	SVL
Numbers	175			62	55	58
Sex(M/F)	93/82			35/27	27/28	31/27	0.727
Age(y)	10.27 ± 1.27	8 ~ 12		10.37 ± 1.36	10.16 ± 1.24	10.28 ± 1.20	0.579
SER(D)	-5.13 ± 0.91	-7.75~-4.00		-5.20 ± 0.99	-5.22 ± 0.81	-4.96 ± 0.90	0.104
AL(mm)	25.48 ± 0.79	22.82 ~ 28.28		25.60 ± 0.74	25.42 ± 0.86	25.39 ± 0.78	0.283

AL, axial length; SER, spherical equivalent refraction; M, male; F, female; D, diopter; HAL, spectacle lenses with highly aspherical lenslets; HALA, spectacle lenses with highly aspherical lenslets combined with 0.01% atropine; SVL, single­vision spectacle lenses

Data are presented as mean ± SD unless otherwise indicated.P values were calculated using one-way ANOVA, Kruskal–Wallis, or chi-square tests as appropriate

Axial length change after 1 year of treatment

Figure 1A; Table 2 show the changes in axial length over time, and the overall AL changes after 1 year of treatment were 0.21 ± 0.15 mm, 0.21 ± 0.13 mm, and 0.28 ± 0.15 mm in the HAL, HALA, and SVL groups, respectively (F = 5.173, P = 0.007), with statistically significant differences in the AL changes between the HAL group and the SVL group (P = 0.004, FDR-P = 0.006), as well as between the HALA and SVL groups (P = 0.009, FDR-P = 0.006). However, no significant difference was found between the HAL and HALA groups (P = 0.837, FDR-P = 0.975) (Tables 2 and 3). To further quantify the treatment efficacy, the Cumulative Absolute Reduction in Axial Elongation (CARE) was calculated. The CARE values for the HAL and SVL groups and for the HALA and SVL groups were0.077 mm and 0.071, respectively.

Fig. 1.

Changes in AL and SER in the three groups (HAL, HALA, and SVL). A Line chart showing the change in AL for 1 year in the three treatment groups. B Line chart showing the change in SER for 1 year in the three treatment groups. Data are expressed using mean ± standard deviation. One-way ANOVA with post hoc test (LSD).AL axial length.SER spherical equivalent refraction; D, diopters; HAL, spectacle lenses with highly aspherical lenslets; HALA, spectacle lenses with highly aspherical lenslets combined with 0.01% atropine; SVL, single­vision spectacle lenses

Table 2.

Mean values of 1-year changes in AL and SER in the three groups

	HAL (n = 62)	HALA (n = 55)	SVL (n = 58)	P
AL(mm)
6 months	0.10 ± 0.10	0.10 ± 0.08	0.14 ± 0.10	0.018
12 months	0.21 ± 0.15	0.21 ± 0.13	0.28 ± 0.15	0.007
SER(D)
6 months	-0.22 ± 0.32	-0.14 ± 0.30	-0.25 ± 0.28	0.159
12 months	-0.43 ± 0.44	-0.33 ± 0.38	-0.52 ± 0.35	0.033

Data are expressed as mean ± standard deviation

Bold indicates a significant difference in spherical equivalent refraction or axial length change at 6 or 12 months between groups

AL, axial length; SER, spherical equivalent refraction; D, diopters; HAL, spectacle lenses with highly aspherical lenslets; HALA, spectacle lenses with highly aspherical lenslets combined with 0.01% atropine; SVL, single­vision spectacle lenses

P, represents the overall comparison among the three groups

Mean values of 1-year changes in AL and SER in the three groups (one-way ANOVA with LSD post hoc test)

Table 3.

Adjusted 12-month changes in AL and SER among the three groups

Outcom	Groups	Adjusted Mean ± SE	95%CI	HAL vs. HALA FDR-P	HAL vs. SVL FDR-P	HALA vs. SVL FDR-P
ΔAL (mm)	HAL	0.21 ± 0.02	0.18 to 0.25	0.975	0.006	0.006
	HALA	0.21 ± 0.02	0.17 to 0.25
	SVL	0.29 ± 0.02	0.25 to 0.32
ΔSER (D)	HAL	-0.44 ± 0.05	-0.54 to -0.34	0.149	0.276	0.024
	HALA	-0.32 ± 0.05	-0.42 to -0.22
	SVL	-0.52 ± 0.05	-0.62 to -0.42

AL, axial length; SER, spherical equivalent refraction; D, diopters; HAL, spectacle lenses with highly aspherical lenslets; HALA, spectacle lenses with highly aspherical lenslets combined with 0.01% atropine; SVL, single­vision spectacle lenses;ΔAL, axial length change; ΔSER, spherical equivalent refraction change

Adjusted 12-month changes in AL and SER among the three groups were obtained using ANCOVA, with baseline AL or SER, age, and sex as covariates. Post hoc pairwise comparisons were performed using the LSD method, and all pairwise p-values were subsequently adjusted using the false discovery rate (FDR)

To further control for baseline values and potential covariates, an analysis of covariance (ANCOVA) was performed. After adjusting for baseline AL, age, and sex, the adjusted 12-month ΔAL values were 0.21 mm (95% CI, 0.18–0.25) for HAL, 0.21 mm (95% CI, 0.17–0.25) for HALA, and 0.29 mm (95% CI, 0.25–0.32) for SVL, with a significant overall group difference (F = 5.882, P = 0.003). Post hoc pairwise comparisons with multiple testing correction (FDR-P) showed significant differences between HAL and SVL (P = 0.006) and between HALA and SVL (P = 0.006), but not between HAL and HALA (P = 0.975)(Table 3).

Spherical equivalent refraction change after 1 year of treatment

Figure 1B; Table 2 show the changes in spherical equivalent refraction over time, and the changes in SER after 1 year were − 0.43 ± 0.44 D, -0.33 ± 0.38 D, and − 0.52 ± 0.35 D in the HAL, HALA, and SVL groups, respectively (F = 3.480, P = 0.033). A statistically significant difference in SER change was observed only between the HALA and SVL groups (P = 0.009, FDR-P = 0.024), whereas no significant differences were found between the HAL and SVL groups (P = 0.215, FDR-P = 0.276) or between the HAL and HALA groups (P = 0.149, FDR-P = 0.149) (Tables 2 and 3).

After adjustment for baseline SER, age, and sex in the ANCOVA model, the adjusted 12-month ΔSER values were − 0.44 D (95% CI, − 0.54 to − 0.34) for HAL, − 0.32 D (95% CI, − 0.42 to − 0.22) for HALA, and − 0.52 D (95% CI, − 0.62 to − 0.42) for SVL, showing a significant overall group effect (F = 3.592, P = 0.030). Post hoc FDR-corrected comparisons revealed that HALA differed significantly from SVL (P = 0.024), whereas HAL vs. HALA (P = 0.149) and HAL vs. SVL (P = 0.276) showed no significant differences.(Table 3).

Factors associated with treatment efficacy

As shown in Table 4, correlation analysis revealed that in both the HAL group (P = 0.001) and the HALA group (P = 0.013), older age was significantly associated with slower axial elongation. However, no such correlation was observed in the SVL group. Baseline AL, SER, and gender were not significantly associated with axial elongation in any of the three groups.

Table 4.

Correlation analysis of factors associated with 1-year AL changes in the three groups

	HAL		HALA		SVL
	r	p	r	p	r	p
Sex(M/F)	0.155	0.230	0.214	0.116	0.025	0.853
Age(Y)	-0.420	0.001	-0.334	0.013	-0.213	0.108
AL(mm)	-0.042	0.745	0.006	0.968	-0.039	0.770
SER(D)	0.014	0.914	-0.253	0.062	-0.106	0.430

Bold text indicates significant differences (p < 0.05)

AL, axial length; SER, spherical equivalent refraction; D, diopters; HAL, spectacle lenses with highly aspherical lenslets; HALA, spectacle lenses with highly aspherical lenslets combined with 0.01% atropine; SVL, single­vision spectacle lenses

Axial length change at 1 year stratified by age

At baseline, there were no significant differences in sex or ocular parameters between the two age subgroups (8–10 years and 11–12 years) (Additional file 2 and 3). In the 8–10 years subgroup (Fig. 2A), the 1-year AL change values in the HAL, HALA, and SVL groups were 0.26 ± 0.15 mm, 0.24 ± 0.13 mm, and 0.32 ± 0.18 mm, respectively. There was no statistically significant difference in AL change among the three groups (F = 2.364, P = 0.100). In the 11–12 years subgroup (Fig. 2B), the 1-year AL changes in the HAL, HALA, and SVL groups were 0.16 ± 0.14 mm, 0.18 ± 0.11 mm, and 0.25 ± 0.12 mm, respectively (F = 4.365,P = 0.016). Significant differences were found between the HAL and SVL groups (P = 0.006) and between the HALA and SVL groups (P = 0.038), while no significant difference was observed between the HAL and HALA groups (P = 0.660). Detailed AL changes over time are presented in Additional file 4.

Fig. 2.

Bar charts of changes in AL in the three treatment groups (HAL, HALA, SVL) in the two age subgroups at 1-year follow-up. A 8–10 years old. B 11–12 years old. *P < 0.05 indicates significant differences between the different groups. AL, axial length; HAL, spectacle lenses with highly aspherical lenslets; HALA, spectacle lenses with highly aspherical lenslets combined with 0.01% atropine; SVL, single­vision spectacle lenses

Rates of axial elongation

As shown in Fig. 3, after 1 year of follow-up, the percentages of axial elongation ≤ 0.3 mm in the HAL, HALA, and SVL groups were 79.1%, 76.4%, and 58.6%, respectively; axial elongation in the range of 0.3–0.5 mm was 17.7%, 23.6%, and 34.5%, respectively; and axial elongation >0.5 mm was 3.2%, 0%, and 6.9%, respectively. (Additional file 5)

Fig. 3.

Percentage distribution of axial elongation in the three groups at 1 year of follow-up. AL, axial length; HAL, spectacle lenses with highly aspherical lenslets; HALA, spectacle lenses with highly aspherical lenslets combined with 0.01% atropine; SVL, single-vision spectacle lenses

Discussion

In this retrospective cohort study, it was found that for children aged 8 to 12 years with moderate to high myopia, HAL lenses combined with 0.01% atropine had a similar effect in controlling myopia progression compared to HAL monotherapy. Both treatments were more effective than SVL, with the treatment effects being more pronounced in older children.

The 1-year changes in SER in the HAL, HALA, and SVL groups were − 0.43 ± 0.44 D, − 0.33 ± 0.38 D, and − 0.52 ± 0.35 D, respectively. Two points should be noted. First, non-cycloplegic refraction was used in this study; previous research has shown that non-cycloplegic measurements generally tend to be slightly more myopic. However, this difference is markedly reduced in eyes with higher myopia (>-2.50 D) [26]. Since this study population consisted of children with moderate to high myopia (≥-4.00 D), the effect of performing refraction without cycloplegia on the measured refractive outcomes is relatively limited. Second, as a retrospective study, subjective refraction was conducted by different optometrists, which may have increased measurement variability rather than introducing systematic bias. Therefore, this study emphasizes AL as the primary assessment indicator and SER as the secondary assessment indicator.The proportions of participants whose AL increased more than 0.3 mm within one year were 20.9%, 23.6%, and 41.4% in the HAL, HALA, and SVL groups, respectively, indicating that both HAL monotherapy and HAL combined with 0.01% atropine were effective in slowing rapid axial elongation in children with moderate to high myopia compared to SVL.

The present study observed that AL progression in the SVL group was lower than that reported in some previous prospective studies [27, 28], which may be attributed to some participants switching to other myopia control methods during the study period due to inadequate treatment response, thereby affecting the statistical results.

The study by Bao et al. reported a 1-year AL change of 0.13 ± 0.02 mm with HAL lenses [27], whereas the HAL group in the present study exhibited a slightly higher mean AL change of 0.21 ± 0.15 mm. This discrepancy may partly be explained by differences in baseline SER: This study included children with moderate to high myopia (mean baseline SER: −5.13 ± 0.91 D), whereas the mean baseline SER in Bao et al.’s study was − 2.70 ± 0.14 D. Another possible factor is the difference in spectacle wear time. Bao et al. strictly monitored daily wear time, with participants wearing the lenses for more than 10 h per day on average. In contrast, this retrospective study only recommended full-time daytime spectacle wear, without enforcing compliance or recording the actual wear time. Nevertheless, given the high degree of myopia (SER ≤ − 4.00 D) among participants, it is unlikely that children frequently removed their glasses in daily life. Furthermore, Tricard et al. reported that children with SER ≤ − 4.00 D experience significantly faster myopia progression compared to their peers with lower refractive error [22]. Thus, the difference in AL progression may be largely attributable to variations in baseline SER across studies.

In this study, no significant difference was observed in 1-year AL elongation between the HAL and HALA groups (0.21 ± 0.15 mm vs. 0.21 ± 0.13 mm), which is consistent with the findings of Kinoshita et al. [29]. The study reported that, in children with low myopia, orthokeratology combined with 0.01% atropine were more effective than orthokeratology alone, whereas in those with moderate to high myopia, the two treatment modalities showed comparable efficacy. Similarly, Li et al. [30]. found that, compared to children with low myopia, monotherapy with orthokeratology exerted a more pronounced effect in controlling axial elongation among children with moderate to high myopia. These findings suggest that, for children with lower initial myopia, especially those who respond poorly to HAL lens monotherapy, early initiation of combination therapy with low-concentration atropine may be more effective.

Further age-stratified analysis revealed that in the 8–10 years subgroup, there were no significant differences in AL changes among the three groups. Across all treatments, younger children exhibited faster myopia progression and axial elongation, consistent with findings from previous myopia control trials [31]. In contrast, in the 11–12 years subgroup, both the HAL and HALA groups demonstrated significantly less axial elongation compared to the SVL group, but no significant difference was observed between HAL and HALA. This suggests that, in younger children with moderate to high myopia, the addition of 0.01% atropine may not provide substantial added benefit. According to the 2-year results of the LAMP study, similar myopia control efficacy was achieved when 6-year-olds children used 0.05% atropine, 8-year-olds used 0.025% atropine, and 10-year-olds used 0.01% atropine, indicating that younger children may require higher concentrations (e.g., 0.05%) to achieve equivalent myopia control as older children using lower concentrations (0.01%) [32]. Therefore, in younger children with moderate to high myopia who do not respond well to the combination of HAL lenses and 0.01% atropine, increasing the atropine concentration may be worth considering. For older children, the combination of HAL lenses and 0.01% atropine appears to offer similar efficacy to HAL monotherapy. In such cases, where treatment response is favorable, HAL monotherapy may be the preferred option. Given the concentration-dependent nature of low-dose atropine in slowing myopia progression [33, 34], combining HAL lenses with higher concentrations of atropine in cases of moderate to high myopia may result in greater efficacy than monotherapy.

This retrospective study compared the 1-year axial length changes among children with moderate to high myopia treated with HAL lenses, HAL lenses combined with 0.01% atropine, and SVL lenses. The findings provide valuable insights for clinicians in guiding myopia control strategies in this population.

However, this study has certain limitations. As this study is a non-randomized retrospective investigation, potential selection bias cannot be completely excluded. However, the comparable baseline characteristics among groups suggest that the impact of such bias may be limited. Additionally, data on spectacle wear duration and atropine adherence were based on regular outpatient follow-up records. Due to the lack of objective monitoring, differences in adherence may have influenced treatment outcomes. Future prospective studies may be needed to better control for this factor. Future research should focus on stratifying treatment strategies by age and baseline refractive error, as our findings suggest that the addition of 0.01% atropine to HAL lenses may not offer substantial added benefit in older children with moderate-to-high myopia.

Conclusion

HAL lenses and HAL lenses combined with 0.01% atropine provide similar myopic control in children with moderate to high myopia, and both significantly slowed axial elongation compared to SVL monotherapy. HAL and HALA appear to offer better myopia control in older children.

Supplementary Information

Below is the link to the electronic supplementary material.

Abbreviations

HAL

Spectacle lenses with highly aspherical lenslets

HALA

Spectacle lenses with highly aspherical lenslets combined with 0.01% atropine

SVL

Single-vision spectacle lenses

AL

Axial length

SER

Spherical equivalent refraction

D

Diopters

Author contributions

YT and XM conceived and designed the study. JS and YH collected the data. YT and JS performed the data analysis. YT drafted the manuscript, and XM revised it critically for important intellectual content. All authors read and approved the final manuscript.

Funding

This research received no external funding.

Data availability

The datasets used during the current study are available from the corresponding author upon reasonable request.

Declarations

Ethics approval and consent to participate

The study was conducted in accordance with the principles of the Declaration of Helsinki and was approved by the Institutional Ethics Committee of the hospital (Approval No. 2024-127-K-111). All clinical data were obtained from routine outpatient visits. As determined by the ethics review, the requirement for signed informed consent was waived.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.