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Combination Treatments for Myopia Progression in Children: A Narrative Review

Submitted:

14 July 2026

Posted:

15 July 2026

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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 (HAL), 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.
Keywords: 
combination myopia treatment
;  
atropine
;  
orthokertology
;  
peripheral defocus lenses
;  
repeated low-level red light
Subject: 
Medicine and Pharmacology  -   Ophthalmology

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 greater than -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 or more [10]. The risk of pathological myopia is linked to the greater axial length 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 in natural light with 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 or inadequate response to treatment with failure to achieve clinically meaningful slowing after 6–12 months of treatment, with adherence confirmed. Children demonstrating axial elongation >0.30 mm in the preceding 12 months may be considered fast progressors and prioritised for active myopia control and closer monitoring [16]. A pragmatic indicator of adequate control is reducing axial elongation to approximately ≤0.20 mm/year, acknowledging ongoing physiologic ocular growth in childhood [16]. This goal has prompted the need to determine whether combination treatment may achieve better outcomes for these patients [17].

3. Combination Treatments

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).
The initial combination studies focused on OK with low-dose atropine 0.01%. In 2020, a Japanese randomised control 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 control trial also in 2022, atropine 0.01% combined with OK was 50% more effective than OK a0lone.[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. 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 axial length 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, 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)

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 control, 0.09 mm atropine 0.01% alone, 0.066 mm DIMS alone, and 0.049 mm 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 comparing 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]. 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 0.34mm 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 stratifying 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 RLR 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, the 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).
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 comparing 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]. 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. Patient's 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

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]
Finally, 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.
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 a 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.

Author Contributions

Conceptualization,. Loreto Rose; methodology, Loreto Rose; writing—original draft preparation, Loreto Rose; writing—review and editing, Loreto Rose; All authors have read and agreed to the published version of the manuscript.

Funding

This research received no external funding.

Institutional Review Board Statement

Not applicable.

Data Availability Statement

The original contributions presented in this study are included in the article/supplementary material. Further inquiries can be directed to the corresponding author(s).

Acknowledgments

None.

Conflicts of Interest

Medical consultant for Essilor; Speaking bursary from Eye rising International; Grammarly has been used in the text.

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Table 1. Characteristics and results of Combination studies of Orthokeratology (OK) and Atropine drops.
Table 1. Characteristics and results of Combination studies of Orthokeratology (OK) and Atropine drops.
Study Study design Age (Years) Ethicity
 Intervention Follow-up Effect
Kinoshita et al. 2020 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 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 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 Retrospective, age-matched comparative study 7*14 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 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 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 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 (0.1mm on average less per year)
Tu et al. 2025 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 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 Inclusion if treated with atropine or combination Mean age 8 0.01% atropine vs OK + atropine combination 1 year Additive effect suggested using choroidal thickness/blood flow markers
Xu, H. et al. 2025 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 Preliminary retrospective study Mean 10 years Chinese OK + 0.05% atropine in fast progressors 1 year Add-on 0.05% atropine beneficial in fast progressors
Guo et al. 2025 Fast progressors 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 Randomised clinical trial 8-12 Chinese OK + 0.01% atropine vs OK alone vs 0.01% atropine alone 2 years Significantly less axial length change in combination-group
Table 2. Characteristics and results of Combination studies of Peripheral defocus lenses/dual focus contact lenses and Atropine drops.
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
Huang et al. 2022 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 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 Small study in atropine non-responders Mean age 8.4 Indian Added DIMS lenses to children not responding to atropine 0.01% 1 year Additive effect of adding DIMS in atropine 0.01% “non-responders”
Tang, T. et al. 2024 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) 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 little additional effect
Lee, C. Y. et al. 2025 (Cureus) Retrospective cohort study (fast progressors) 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) Study in high myopia population (>-6.0D) 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 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 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 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 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 Retrospective study 8-15 Chinese HAL + atropine 0.01% vs atropine 0.01% 1 year Combination yielded the best outcome
Sim et al. 2025 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 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 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 Prospective study 8-15 Mixed causaian 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 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
Table 3. Characteristics and results of Combination studies of Red light therapy (RLRL) and refractive modalities.
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
Xiong et al. 2024 Multicentre randomised controlled trial 8-13 Chinese RLRL + OK vs OK alone (rapid progressors 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 Retrospective study
Fast progressors		 7-15 Chinese RLRL + OK in poor responders to OK 1 year Additive effect with no progression in combination group
Wu et al. 2024 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 Randomised controlled study 10-13 European RLRL + OK vs OK alone 1 year Combination showed axial length shortening; orthokeratology alone showed mild elongation
Elham and Meng 2026 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 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 Real-world observational study 5-16 Chinese DIMS alone vs RLRL alone vs DIMS + RLRL 1 year Axial length change: +0.16 mm (DIMS); −0.04 mm (RLRL); −0.13 mm (DIMS+RLRL)
Luo et al. 2025 Comparative study 6-14 Chinese SVL vs DIMS vs RLRL vs RLRL + DIMS 1 year Axial length 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
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