The aim was to investigate the efficacy of binoculus orthokeratology with different optical zone designs in myopic children and adolescents, analyze influencing factors, and establish a dynamic follow-up model. This retrospective cohort study randomly selected 110 myopic patients (220 eyes), aged 8 to 13 years, who underwent orthokeratology correction at the Affiliated Hospital of Hangzhou Normal University from March 2022 to March 2024. Participants were divided into 2 groups: the 5.0 group (110 eyes) with a 5.0 mm optical zone and the 6.0 group (110 eyes) with a 6.0 mm optical zone. After 1 year, the differences in visual acuity, refractive error progression, and axial length control between the groups were assessed. Patients were classified into favorable (axial length change ≤ 0.20 mm) and unfavorable (axial length change > 0.20 mm) groups. Baseline characteristics were analyzed, and logistic regression was used to identify influencing factors. A nomogram-based risk prediction model was constructed and evaluated using receiver operating characteristic curves and area under the curve. A 1-year dynamic follow-up model was also established. The 5.0 group showed better visual acuity, less refractive error progression, and less axial length growth compared to the 6.0 group (all P < .05). Axial length growth > 0.20 mm was observed in 21.00% (42/200) of eyes (unfavorable group), while 89.00% (178/200) showed ≤ 0.20 mm growth (favorable group). Significant baseline differences were found in age, spherical power, cylindrical power, spherical equivalent, axial length, optical zone diameter, and mesopic pupil diameter (all P < .05). Logistic regression identified higher spherical power, cylindrical power, spherical equivalent, axial length, and optical zone diameter as risk factors for unfavorable outcomes, while older age and larger mesopic pupil diameter were protective factors. The nomogram model showed excellent predictive performance with an area under the curve of 0.958 (95% confidence interval: 0.922–0.993). Orthokeratology lenses with a 5.0 mm optical zone demonstrated superior efficacy compared to 6.0 mm lenses. Baseline factors such as age, spherical power, cylindrical power, spherical equivalent, axial length, optical zone diameter, and mesopic pupil diameter influenced treatment outcomes. Continuous dynamic follow-up is essential for optimizing efficacy.