Purpose: Optical and pharmacological penalization of sound eyes are infrequently used alternatives to occlusion for treating amblyopia. The authors evaluated the efficacy of penalization as their primary treatment of amblyopia. Methods: One hundred sixty-six patients underwent penalization treatment for strabismic or anisometropic amblyopia for a minimum of 3 months. Both atropine and optical penalization methods were used. Results: Visual acuity improved in 67 (77%) of 87 patients treated with optical penalization. There was a significant improvement of the geometric mean visual acuity of the amblyopic eyes from 20/38 to 20/28 (P < 0.001). Visual acuity of 60 (76%) of 79 patients treated with pharmacological penalization improved. There was a significant improvement of mean visual acuity of the amblyopic eyes from 20/61 to 20/40 (P < 0.001). Neither therapy produced an instance of occlusion amblyopia. Thirteen patients discontinued therapy because of blur or discomfort. Conclusions: This study demonstrates that penalization methods are effective methods for the treatment of amblyopia, with a low risk of occlusion amblyopia. Patient acceptance of these methods was excellent. Penalization should be considered more often for the primary treatment of amblyopia.
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