Abstract
BACKGROUND: Myopia in children has become increasingly prevalent worldwide, resulting in greater medical expenditures and a higher prevalence of retinal complications associated with high myopia, thereby significantly impairing quality of life. The use of orthokeratology and low-concentration atropine eye drops for myopia management has seen a notable rise in recent years. OBJECTIVE: This study aims to evaluate the efficacy and safety of orthokeratology combined with low-concentration atropine for the treatment of myopia in children through a meta-analysis. METHODS: A comprehensive search was conducted across eight electronic databases: PubMed, Web of Science, EMBASE, the Cochrane Library, China National Knowledge Infrastructure, Wanfang Database, SinoMed, and the VIP Database. The search encompassed all relevant studies published up to April 15, 2025, including randomized controlled trials that assessed the efficacy of orthokeratology lenses in combination with low-concentration atropine for the treatment of myopia in children. Statistical analyses were conducted using Stata 16.0 software, and study quality was evaluated using the Cochrane Risk of Bias Assessment Tool. RESULTS: Eleven randomized controlled trials (RCTs) were included. Compared with the orthokeratology (OK) group, the atropine-orthokeratology (AOK) group demonstrated a significant reduction in axial length [WMD = -0.16, 95% CI (-0.22, -0.10), p < 0.001], along with a significant increase in choroidal thickness [WMD = 17.29, 95% CI (0.95, 33.63), p < 0.05]. Additionally, baseline diopter influenced changes in axial length, while follow-up duration was associated with changes in both axial length and choroidal thickness. Moreover, the AOK group exhibited a slight increase in spherical equivalent refraction, diopter, and pupil diameter [WMD = 0.26, 95% CI (0.11,0.42), p < 0.005], [WMD = 0.61, 95% CI (0.01,1.20), p < 0.05], [WMD = 0.05, 95% CI (0.35,0.66), p < 0.001]. Corneal thickness showed a tendency to decrease [WMD =-9.79,95% CI (-15.52, -4.06), p < 0.005]. There were no significant differences between the OK and AOK groups for uncorrected visual acuity, intraocular pressure, keratometry, lipid layer thickness, and tear film break-up time. CONCLUSION: For children with myopia, orthokeratology combined with low-concentration atropine is more effective than orthokeratology alone in slowing axial elongation and enhancing choroidal thickness. Regarding safety, the findings were consistent across both studies, with no serious adverse events reported. PROSPERO (CRD420251103504). SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1186/s12886-026-04816-7.