penalization
Penalization is a treatment for amblyopia that reduces the vision of the fixating eye so that the patient uses the amblyopic eye. Atropine in the fixating eye blurs its near vision, and the patient then uses the amblyopic eye for near and the sound eye for distance.1 Optical overcorrection combined with atropine blurs the fixating eye at distance instead.1
Pharmacological penalization with atropine 1% forces the child to use the amblyopic eye for near tasks. In a randomized comparison in children aged 3 to 6 years with moderate amblyopia, 6 months of atropine and 6 months of patching each improved acuity by about 3 lines.2 Atropine penalization works best in mild to moderate amblyopia, 6/24 or better, and is conventionally used when compliance with occlusion is poor.3
Blurring the sound eye does not fully remove the inhibitory influence that stimulation of that eye produces. Except in moderate or high hyperopia, atropine may not reduce the sound eye's acuity enough to make the patient fixate with the amblyopic eye.1 A child given overcorrecting glasses may simply take them off, and amblyopia can develop in the atropinized eye.1
More detail
Penalization is a useful alternative to occlusion in milder amblyopia with central fixation and in children who will not or cannot tolerate a patch. After the amblyopia is cured, alternating penalization with two pairs of glasses, each carrying a -3.00 D sphere overcorrection for one eye, maintains the result.1
In a sizable strabismus, the power of the penalizing lens is set by whether fixation switches to the amblyopic eye. In microstrabismus, a prism is placed before the eye to be penalized, and the clinician prescribes the lowest lens power that abolishes a noticeable movement of the fellow eye toward the prism apex.1
Sources (9)
- von Noorden and Campos, Binocular Vision and Ocular Motility, ch. 24
- Yanoff and Duker, Ophthalmology (2023), ch. 11
- Kanski's Synopsis of Clinical Ophthalmology, ch. 18
- American Academy of Ophthalmology. 2019. Amblyopia Preferred Practice Pattern. San Francisco: American Academy of Ophthalmology.
- Dadeya, S., Dangda, S. and Shibal, F. 2016. Optical Penalization in Amblyopia Management. Journal of Pediatric Ophthalmology & Strabismus, 53(2), pp.86-89.
- Foley-Nolan, A., McCann, A. and O'Keefe, M. 1997. Atropine penalisation versus occlusion as the primary treatment for amblyopia. British Journal of Ophthalmology, 81(1), pp.54-57.
- Repka, M.X., Kraker, R.T., Beck, R.W., Birch, E., Cotter, S.A., Holmes, J.M., Hertle, R.W., Hoover, D.L., Klimek, D.L., Marsh-Tootle, W. and Scheiman, M.M. 2009. Treatment of severe amblyopia with weekend atropine: results from 2 randomized clinical trials. Journal of American Association for Pediatric Ophthalmology and Strabismus, 13(3), pp.258-263.
- Rutstein, R. and Daum, K. 1997. Anomalies of Binocular Vision: Diagnosis & Management. St. Louis: Mosby.
- Scheiman, M.M. and Wick, B. 2019. Clinical management of binocular vision: heterophoric, accommodative, and eye movement disorders. 5th ed. Philadelphia: Wolters Kluwer.
Reviewed October 2026