Indian Journal of Ophthalmology

: 1981  |  Volume : 29  |  Issue : 4  |  Page : 425--426

Penilisation therapy in a residual concomitant convergent squint-a case report

JN Singha 
 Command Hospital, Bangalore, India

Correspondence Address:
J N Singha
Department of Ophthalmic & Orpthoptic Centre, Command Hospital (Air Force) Bangalore-560007

How to cite this article:
Singha J N. Penilisation therapy in a residual concomitant convergent squint-a case report.Indian J Ophthalmol 1981;29:425-426

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Singha J N. Penilisation therapy in a residual concomitant convergent squint-a case report. Indian J Ophthalmol [serial online] 1981 [cited 2021 Jan 19 ];29:425-426
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Full Text

This case report pertains to a 2˝ years old child which has been successfully treated with this therapy as an alternative to prismothe­rapy, in a residual convergent squint.


This female child was first seen at the age of 1˝ years in May, 1977 at Air Force Hospi­tal. The parents had noticed inward deviation of Rt. eye especially towards evening or when the child was tired.

Past and family history was non contribu­tory. On examination, the child was found well nourished. Vision as tested on colline pictorial chart showed, Rt eye 6/36, Lt. 6/12. Cover test, both for distance and near revea­led R.C.S. Ocular movements did not show any significant over or under action. Angle of deviation by Hirschberg method varied bet­ween 25° to 35° with convergence excess. Ant. segments were normal. Refraction under 1 atropine ointment for three days revealed,


Fundii were within normal limits. Fixation in Rt eye was erratic to parafoveal, and in left eye central but un­steady. Child was too young to co-operate on major amblyoscope. Deviation was less by 5° after corrective glasses.

Diagnosis Partially accommodative con­comitant convergent squint with amblyopia Rt. eye.

Treatment. She was given full correction and conventional occlusion of 4 to 2.

Pre-operative check up.Vision Rt 6/12 (approx) Lt. 6/9 (approx). Cover test - ACS. Left eye is dominant both for distance and near.

PBCT-Distance 50∆BO Near 65 ∆BO (without glasses)

PBCT-Distance 35∆BO Near 45∆BO

(With corrective glasses)

There was no significant change on up and down measurements in horizontal or vertical deviation. Angle of deviation under sedation and with corrective glasses both for distance and near was about 30 to 35∆BO.

Operation notes. Bilateral medial rectus recession of 3.5 mm was done under general anaesthesia. Post operative recovery was uneventful. After 15-20 days, the child star­ted showing slight Rt esotropia and she was put on miotic drops (1 % Pilocarpine). It did not make much change. The child as well as the parents were reluctant to continue with occlusion again. Therefore penalization therapy was considered.


Under or over correction of some degree is a common occurrence after first operation in a squint surgery. To overcome this, various methods of bifoveal stimulation like prismo­therapy and machine orthoptics have been devised. Penalisation is one such therapy which promises many advantages over others.

In this case, this therapy provided the most acceptable alternative to prismotherapy or occlusion. This helped the child in overcoming the psychological embarrasment of occlusion and in full manifestation of the refractive errors which reduced the accommodative com­ponent of the objective angle. Eye hand co­ordination in daily life, as result of continuous stimulation of fovea for distance and near of the dominat and ambloypic eye respectively, helped in developing foveal spatial localisation of the amblyopic eye as was clear from BSV attainment after this therapy. She did not develop any atropine catarrh or eccentric fixation.


In conclusion it may be said that penalisa­tion therapy helps in changing from near to far fixation as results of therapeutic anisome­tropia combined with cycloplegia. Continuous bifoveal stimulation helps in the treatment of amblyopia. Increase in manifest hypermetro­pia and its subsequent correction with suita­ble corrective glasses, favourably influences accommodative component of the squint, as in this case[1].


1Moore Sally, 1975, Orthoptics Past, Present and Further-1975. Stratton Inter-continental Medical Book Corpora­tion, New York.