Purpose <p>To compare axial length (AL) elongation in children with poor response to highly aspherical lenslet (HAL) wear, following different second-line myopia control interventions.</p> Methods <p>This retrospective study included 4097 myopic children who completed 1 year of HAL wear. Poor responders were defined as children with axial elongation ≥0.26 mm/year despite HAL therapy. These children were followed for an additional year and categorised into four groups based on the second-year interventions: continued HAL wear (HAL-HAL), HAL combined with 0.01% atropine (HAL-HALA), switching to diffusion optics technology spectacles (HAL-DOT) and switching to orthokeratology lenses (HAL-OK). Primary outcomes included changes in spherical equivalent refraction (SER) and AL. Logistic regression and multivariable linear regression analyses were performed.</p> Results <p>After propensity score matching, 168 subjects (42 per group) were included. Significant differences in second-year SER progression and AL elongation were observed among groups (both <i>p</i> &lt; 0.001). The HAL-DOT group exhibited the smallest AL elongation and less SER progression compared with the other groups. Logistic regression showed that, compared with the HAL–HAL group, the HAL-DOT (Odds Ratio (OR) = 0.11, <i>p</i> &lt; 0.001) and HAL-OK groups (OR = 0.34, <i>p</i> = 0.04) had significantly lower odds of a poor response (axial elongation ≥0.26 mm/year). No significant association was found for the HAL-HALA group (<i>p</i> = 0.12). Multivariable regression showed all intervention groups reduced AL elongation, with the greatest effect in the HAL-DOT group (<i>β</i> = −0.227 mm, <i>p</i> &lt; 0.001).</p> Conclusion <p>Among children with a poor response to initial HAL treatment, switching to alternative interventions, especially DOT, was associated with more favourable axial elongation outcomes and less SER progression. Early treatment modification may help improve outcomes in high-risk children.</p>