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Butterworth–Heinemann
An imprint of Elsevier Limited

© 2004, Elsevier Limited. All rights reserved.

No part of this publication may be reproduced, stored in a retrieval system, or transmitted in

any form or by any means, electronic, mechanical, photocopying, recording or otherwise,
without either the prior permission of the publishers or a licence permitting restricted copying
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‘Obtaining Permissions’.

First published 2004

ISBN 0 7506 5560 7

British Library Cataloguing in Publication Data

A catalogue record for this book is available from the British Library.

Library of Congress Cataloging in Publication Data

A catalog record for this book is available from the Library of Congress.

Note
Medical knowledge is constantly changing. As new information becomes available, changes in
treatment, procedures, equipment and the use of drugs become necessary. The
author/contributors and the publishers have taken great care to ensure that the information
given in this text is accurate and up to date. However, readers are strongly advised to confirm
that the information, especially with regard to drug usage, complies with the latest legislation
and standards of practice.

Printed in Spain by Grafos SA, Arte sobre papel.

 Preface

Recent years have seen an exponential gery is an elective procedure, as the patient (LASIK), although PRK is being replaced by
growth in the field of refractive surgery. In chooses to undergo surgical intervention on laser epithelial keratectomy (LASEK). Both
1996, the US Federal Drug Administration’s an otherwise healthy eye, and the surgeon of these use the same currently widespread
approval of certain excimer lasers to correct agrees to operate on an eye that is without excimer laser technology. Other techniques
myopia lead to a rapid increase in the uptake pathology. are available, but to a lesser degree.
of excimer laser procedures. Further In the UK refractive surgery is offered This book examines various aspects
approvals have been granted for other laser on a private basis only. There have been that may be relevant to those interested in
manufacturers, and for the correction of attempts to treat higher refractive errors learning more about the current status of
astigmatism and hyperopia. Popularity on the NHS, but these schemes tend to be refractive surgery, with particular atten-
increases as patients hear about the suc- regional and not the norm. Patients who tion paid to patient selection, available sur-
cessful outcomes for friends and relatives. decide to undergo refractive surgery gical techniques and the evaluation of
Famous people who undergo this surgery either book in to a refractive surgery clin- patients pre-operatively and post-opera-
are a further boost, and laser clinics are ic or go to see a consultant ophthalmol- tively (details of some specialist instru-
quick to state the names of famous patients ogist who offers treatment privately. mentation are also outlined). Clinicians
who have undergone treatment. Techniques Surgeons who offer refractive surgery do with a degree of knowledge in refractive
have improved, better lasers and other equip- not need to be consultant ophthalmolo- surgery may be interested in the chapters
ment are available and there seems to be an gists accredited with the Royal College of that discuss wound healing after refractive
unlimited supply of patients willing to Ophthalmologists, although many are. surgery and case reports from surgeons.
undertake surgical alternatives to wearing However, they must have suitable quali- Of general interest, the book also discuss-
spectacles or contact lenses. Practitioners, fications, such as Member or Fellow or es legal issues and future trends in this fast-
both optometrists and ophthalmologists, the Royal College of Ophthalmologists changing area.
seem to be split over refractive surgery. Some (MRCOphth or FRCOphth), Fellow of the
advocate its usefulness as a viable alterna- Royal College of Surgeons (FRCS) or be list- Notes for the CD-ROM
tive, whereas others feel it is nothing more ed on the European Specialist Register. Most The large size of the videos means that the
than cosmetic surgery for refractive error. It laser manufacturers ensure that doctors loading of video clips 4 and 5, in particu-
may be oversimplifying the issue to call who use their lasers have attended the rel- lar, may take 1–2 minutes on some com-
refractive surgery a cosmetic procedure, as evant training courses to use that particu- puters, and users of Mac OS9 may see a
patients often state that their disability lar apparatus. In the UK the most common white screen while the videos are loading.
requires the use of optical aids, almost like types of refractive surgery currently When the videos finish loading, the screen
using an aid to assist hearing. However, it employed are photorefractive keratectomy will change and the Play, Pause, and other
would be correct to say that refractive sur- (PRK) and laser in-situ keratomileusis buttons will appear

Shehzad A Naroo
 Contributors
Alejandro Cerviño
DOO (EC)

W Neil Charman
DSc, PhD

Paul MH Cherry
MBBS, LRCP, FRCS(Ed), FRCS, FRCSC, FRCOphth

Catharine Chisholm
PhD, MCOptom

Sandip Doshi
PhD, MCOptom

Stephen J Doyle
BSc(Hons), MRCOphth

Balasubraminiam Ilango
FRCS(Ed), MRCOphth

Mohammad Laiquzzaman
MBBS, PhD

Shehzad A Naroo
MSc, PhD, MCOptom, FIACLE

Sunil Shah
FRCS(Ed), FRCOphth

Baldev K Ubhi
BSc(Hons)
 1
Patient selection and
pre-operative assessment
Shehzad A Naroo

For many patients who want to find out tine practice to ensure they are best able to Most studies highlight that many
more about refractive surgery the first port serve their patient’s needs.1 Optometrists patients who present for refractive surgery
of call is often the local ophthalmic prac- are in a unique primary care position in are former contact lens users.4,5 Often the
tice, while others call dedicated clinic eye health from which they can offer an reasons why people want contact lenses
phone lines or browse the Internet. unbiased opinion. are similar to the motivation for patients
Prospective patient interest can be classed Various studies have shown the aver- to have refractive surgery, so it is not sur-
into two categories: those who make casu- age age of prospective patients to be the prising that there are some similarities in
al enquiries to see if they are suitable and mid-to-late thirties with an almost equal the types of patients who present for both
those who have decided that this is defi- ratio of male to female patients.2,3 The types of refractive correction. Both groups
nitely something they will opt for. The first author recently completed a study (not yet of patients often say that they want the
group may progress to become part of the published) that shows the average patient freedom from spectacles or they want to
second group when they feel they are more age to be creeping up to around 40 years, achieve a cosmetic look that spectacles do
informed. The latter group can sometimes and there seems to a shift towards more not allow, or perhaps the reasons are relat-
be difficult to dissuade from surgery if they female patients. Since refractive surgery ed to certain activities (work or sports,
are found to be unsuitable. Those patients usually involves an initial financial out- etc.). Patients who cease contact lens use
who make casual enquiries often seek gen- lay comparable to that for contact lens- in favour of refractive surgery often com-
eral advice only and can usually be es, which in the UK are often paid by plain of the inconvenience of contact lens-
referred to websites or professional bod- monthly bank debits, most studies seem es and/or complications with contact
ies that produce this type of information. to show a prevalence of patients from lenses, which is a primary motivation for
Whereas for patients who have decided to higher socio-economic groups. This may their decision. Often, many of the less seri-
opt for refractive surgery, it is usually advis- partly explain the age groups of refractive ous complications with contact lenses that
able to make a specific appointment to dis- surgery patients too. Figure 1.1 shows the patients complain of could be minimized
cuss the surgical options and perform the breakdown of the occupational groups of with improved contact lens management,
relevant tests (or else refer the patient to new patients who presenting for refrac- which requires the appropriate input from
a colleague who is able to do this). tive surgery. their contact lens practitioners.
Some patients may suspect that
optometrists have their own agenda and
advise against refractive surgery because
they want to protect their own livelihood. Unemployed
Furthermore, many optometrists may feel Student 5% Professional
Retired 3% 19%
that their knowledge about the current 6%
state of affairs is not adequate and thus
Unskilled Management
choose not to become involved at all and 12% 15%
advise patients not to proceed with this
option. A proactive approach towards
refractive surgery by optometrists is
advised by some refractive surgery clinics, Semi-skilled
and more recently the number of 9%
optometrists who have become involved in
Clerical
co-management schemes with refractive
31%
surgery providers has increased (discussed
in Chapter 7). However, a careful balance Figure 1.1
needs to be struck by optometrists in rou- Breakdown of the occupational groups of new patients who present for refractive surgery3
2 ■ Refractive surgery: a guide to assessment and management

Also, some patients choose refractive 10–21 days. Users who wear hard poly- eyes are operated on over an interval of
surgery as a primary alternative to spec- methylmethacrylate (PMMA) lenses may around 3 months, and the operated eye
tacles and present for surgery even though find that they have to leave their lenses out does not achieve its final prescription for a
they have not tried contact lenses. This for a few months, especially if they are long- few weeks and often is quite blurred dur-
may result, in part, from the way that laser term wearers, to ensure that any corneal ing the first week after surgery. So patients
refractive surgery is marketed. In many distortion is eliminated. who are amblyopic in the non-treated eye
cases it would be useful for the patient to Patients are often asked to produce may experience some degree of visual dis-
try contact lenses first. Laser refractive sur- past refraction details, for up to the previ- ability while the first treated eye reached
gery clinics advertise on the radio, news- ous 3 years, to show that they have some its final prescription.9,10
papers and television. There seems to be level of stability. A patient with a large Conical corneas, such as keratoconus or
an interesting shift in the way that adver- recent change in refraction would prob- keratoglobus, are considered as contraindi-
tisers have portrayed refractive surgery ably be advised to wait until two or three cations to refractive surgery. Both of these
over the years. In the early days the con- consecutive prescriptions were similar. If conditions have associated thinning at the
venience of refractive surgery was used to patients undergo refractive surgery and apex of the conical cornea, which may lead
herald it as being a ‘quick’, ‘painless’ and then find that a year later their prescrip- to ectasia after corneal refractive surgery.
‘safe’ treatment that only took a few sec- tions naturally became worse, they will However, a corneal topography pattern that
onds or minutes to complete and the often be dissatisfied with the outcome. It appears to indicate keratoconus without any
patient would return to work shortly after- has been suggested that refractive surgery other clinical sign of the disease may not
wards. The next wave of advertising may aid visual development in children necessarily be a contraindication.11,12 An
seemed to use people that patients could with squints that are purely accommoda- irregular corneal surface, possibly caused by
relate to, either celebrities who would tive. This type of service would not typi- other types of disease or dystrophy such as
advocate a certain clinic or ‘real’ people cally be offered by most commercial Fuchs’ endothelial dystrophy, is also consid-
that were respected in the community, refractive surgery clinics and currently it ered a reason not to proceed with refractive
such as firemen, nurses and even priests. is not widely available in hospital refrac- surgery. However, many corneal surgeons
The most recent advertising trend seems tive clinics either. Patients under the age use an excimer laser to perform a pho-
to focus on the technology that a particu- of 21 years who present for refractive sur- totherapeutic keratectomy (PTK) on patients
lar centre uses, although in the UK this gery are often advised to wait until they with conditions such as recurrent corneal
approach has come under the scrutiny of reach 21, or until their prescription has erosions or band keratopathy. In this an even
the Advertising Standards Association. stabilized.6 Although there is no upper layer of stromal tissue is removed to smooth
Patients who opted for refractive surgery age limit for refractive surgery, it may be off the irregularities at the anterior stroma,
gave the main factors shown in Figure 1.2 unwise to perform a corneal procedure on with a wide ablation diameter, without alter-
as those that influenced their decision to late presbyopic patients with lens sclero- ing the overall corneal curvature and refrac-
cease contact lens use; the values relate to sis, as they may be better suited to clear tion greatly.
the percentage of patients who offered the lens extraction with an accurately calcu- Patients with known, current viral
particular reason as an influential factor.3 lated intraocular lens implant. infections are not suitable for treatment
Patients who are former contact lens Patients with only one ‘seeing’ eye are while they have an active disease process.
wearers are advised to remove their contact considered a contraindication to refractive Patients undergoing drug therapy or treat-
lenses prior to their pre-operative refractive surgery, as infection in the good eye would ment that may affect their corneal healing
surgery consultation. The time period for seriously compromise the patient’s visual should consider refractive surgery only
lens removal depends on the type and function, although the risk of sight-threat- when they have completed their other
modality of lens worn. Typically, soft lens- ening infection is extremely rare after therapy. Glaucomatous patients may be
es are removed for 7–14 days prior to the refractive surgery.7,8 Also, in photorefrac- thought unsuitable for PRK, as they might
appointment and gas permeable lenses for tive keratectomy (PRK) surgery the two require the use of corticosteroid drops
post-operatively.13–15 Patients with a fam-
ily history of glaucoma should be made
aware that after corneal surgery the meas-
urement of intraocular pressure (IOP) can
Costs Red eye be affected.16–19 Similarly, pregnancy is
21% 14%
considered a contraindication to refractive
surgery as there may be subtle changes in
refraction during gestation, and also many
Dry eye patients may be wary if drug treatment is
Overwear 18% indicated after refractive surgery.
17%
Inappropriately motivated patients
should not be encouraged to have refractive
Professional advice surgery as they may have unrealistic expec-
5% tations that cannot be met. Motivation for
Intolerance to solutions Advice from friends
Intolerance to lenses treatment should be assessed carefully pre-
7% 1%
17% operatively, and patients should not feel
coerced into proceeding. This can be espe-
Figure 1.2 cially difficult, as most refractive surgery
Main factors that influenced the decision to cease contact lens use and opt for refractive surgery takes place in a very commercial environ-
(values relate to the percentage of patients who offered the particular reason as an influential ment in which competition, pricing and
factor)3 advertising is often fierce. Nonetheless, it
 Patient selection and pre-operative assessment ■ 3

should be remembered that an unhappy Visual acuity Full refraction

patient is more likely to tell his or her
friends about the experience than a happy It is important to know the patient’s visu- It is vitally important that an accurate pre-
patient. It would almost be a false econo- al acuity (VA) before refractive surgery, as scription is measured for all prospective
my to treat patients who were unsure it can be used as a guide to post-operative patients. A patient whose prescription is
about going ahead. Many refractive sur- success, and also to detect amblyopia. Loss too minus will end up with a result that is
gery clinics allow a cooling off period for of best-corrected visual acuity (BCVA) can overcorrected and thus will become hyper-
potential patients between the time of their occur after excimer laser refractive sur- opic. A patient with an undetected latent
initial consultation and the actual surgery gery and can result from one or more of hyperopia will also end up with a result
so that they do not feel pressurized. This the complications of the procedure men- that is hyperopic. This is especially impor-
tends to be the norm for laser in situ ker- tioned here. Independent loss of BCVA tant in presbyopes and pre-presbyopes, as
atomileusis (LASIK) surgery, but opinions may be attributed to the alteration that a small hyperopic result will be more detri-
vary on this for surface-based laser treat- occurs in the magnification from the mental to them than a small myopic result.
ments like PRK and laser epithelial ker- patient’s spectacle lenses. In the case of Cycloplegic refraction is often useful to
atomileusis (LASEK; see Chapters 3 and a moderate hyperope, the patient does not eliminate any concerns of latent hyperopia
4 for details of the types of surgery). receive the extra magnification, after or an over-minus of the refraction. It is not
Patients who are unable to comprehend refractive surgery, in their VA that they unreasonable to assume that some of the
the rationale of treatment should not be previously had as a result of their hyper- hypocorrections and hypercorrections
treated, unless for therapeutic reasons. opic spectacles. Conversely, in refractive that occur after refractive surgery result
This includes anyone who is unable to give surgery for moderate myopia the patient from an incorrect pre-operative refraction.
informed consent, such as minors or men- does not have the reducing effect of their The author routinely performs cycloplegia
tally disadvantaged individuals. spectacle lenses after surgery. This means on all potential patients to avoid any
When assessed subjectively, it appears that the patient shows an improvement in refractive surprises.
as though the majority of patients are sat- the BCVA or, in the presence of other post-
isfied with the outcome of refractive sur- operative problems, the patient does not
gery.20, 21 The complications of refractive show a reduction in BCVA.27,28 Most cli- Pupil diameter
surgery are mentioned in patient literature nicians use Snellen acuity, although bet-
and detailed in ophthalmic literature. ter analyzes could be made if Bailey–Lovie Early excimer laser refractive surgery used
Patients with realistic expectations are charts were used. Often the figures quot- smaller diameter ablations of up to
more likely to be successful candidates.22 ed suggest that patients lose or gain lines 3–4mm, so that the depth of the ablation
Often it is asked why patients are will- of BCVA based on Snellen acuity. This may keratectomy was kept to a minimum. The
ing to undergo refractive surgery knowing hold true for a Snellen chart, but it is not downside of this was noted in some
the potential risks associated with it and as accurate as quoting Bailey–Lovie patients with larger pupils, who found, at
not knowing if there will be any long-term charts (Figure 1.3) in which the lines of night especially, that their pupil would
effects that are yet to be uncovered.23 letters have equal numbers of letters and dilate to beyond the treatment zone.31 The
Studies to carry out recognized psycho- an equal rate of change exists between result of this was a ghosting around bright
metric personality tests on a group of each line of letters.29,30 objects and lights.32,33 This is very similar
refractive surgery patients and compare to the ghosting that a patient may experi-
them to a control group, or maybe com- ence from a decentred corneal contact
pare them to patients who present for lens, where the optic zone diameter cross-
other types of elective or cosmetic surgery es over the pupil margin. Nowadays, this
are currently underway.24,25 Is there an is less of a problem as most excimer laser
underlying trait in some refractive surgery refractive surgery uses larger diameter
patients that leads them on a compulsive ablations,34 but it still may be an issue in
drive for perfection?26 cases for which a small diameter ablation
Practitioner’s who evaluate prospective is used (possibly because the patient has
patients for refractive surgery should first a relatively thin cornea; see Corneal
assess that the patient is suitably motivat- pachymetry below). Usually, a central stro-
ed towards undergoing surgery, as high- mal area is ablated with the full refractive
lighted above. It is usually advisable that correction and a blended zone is ablated
the patient be armed with some informa- around it, similar to the optic zone and car-
tion before attending for consultation. The rier portion of a contact lens. This allows
actual pre-operative assessment routine the depth of the ablation keratectomy to
may differ slightly from clinic to clinic, but be kept to a minimum.35,36 However,
the essence of the examination is the there remains the problem that this cre-
same. The individual tests that are usual- ates substantial spherical aberration in the
ly performed are mentioned below, outer zones of the dilated pupil, so that
although this list is not conclusive and some degradation of the retinal images
some tests can be omitted depending on occurs.37–39 Pupil diameters are meas-
the type of refractive surgery that the ured either with a ruler under normal
patient is to undergo. Most of these tests, lighting conditions or, preferably, using a
unless indicated, do not require equipment Figure 1.3 pupillometer such as the Colvard unit
additional to that currently available in the High-contrast (90 per cent) distance (Oasis Technologies, California, USA) or
routine ophthalmic practice. Bailey–Lovie chart Keeler pupillometer (Keeler Ltd, Windsor,
4 ■ Refractive surgery: a guide to assessment and management

Berkshire, UK) or similar. One clinic in the induced by contact lenses. For a patient in approximately one-quarter to one-third
UK exclusively uses a computerized pupil- whom warpage is observed, the topogra- into the depth of the cornea to create a
lometer device to measure pupil diameter phy measurements are repeated on sub- flap. Although there are no reported inci-
under different lighting levels. sequent visits until no further changes are dences of corneal ectasia after LASIK,
seen in the topography maps; only then is there is concern over what happens to the
the patient considered suitable for surgery. posterior corneal curvature after this pro-
Corneal topography Most corneal topography units use cedure, especially in high refractive cor-
Placido disc technology (Figure 1.4), which rections. It is not unreasonable to assume
Most routine optometric practices use a allows measurements of the anterior sur- that an alteration in posterior corneal cur-
keratometer to assess central corneal cur- face only. The change in the anterior cur- vature occurs in LASIK also.52,53
vature for contact-lens fitting. In the pre- vature is dependent upon the amount of
assessment of patients for refractive initial refractive error.43–47 Recent devel-
surgery a keratometer is inadequate since opments in corneal biometry include slit Slit-lamp examination
it takes measurements from the central scan topography machines, which use
3–4mm of the anterior cornea only.40 light slits across the cornea to take a three- Detailed slit-lamp biomicroscopy exami-
Excimer laser refractive surgery involves dimensional image.48 Until very recently, nation is important prior to refractive sur-
removal of corneal tissue by ablation over the Orbscan corneal topography system gery. Contraindications to refractive
a wide area. In myopic refractive surgery (Figure 1.5), developed by Orbtek, Salt Lake surgery should be identified, and include
this tissue is removed from the central City, Utah (Bausch and Lomb, Rochester, anterior corneal scars and opacities, clin-
corneal area (up to about 7mm), and in New York, USA), was the only commer- ical signs of conditions such as kerato-
hyperopic surgery the tissue is removed cially available machine able to assess the conus (e.g., Vogt’s striae and Fleischer’s
from the mid-peripheral cornea (up to posterior corneal shape, but a recent unit ring) and lenticular changes.54 A patient
about 9mm). The net result of the sur- by Oculus (Giessen, Germany) uses a rotat- with nuclear sclerosis may be deemed
gery means there is a change in the ante- ing Scheimplug camera to take similar unsuitable for excimer laser surgery, but
rior corneal profile. It is important to measurements. A map is produced by may benefit from clear lens extraction with
measure the full anterior corneal shape these newer devices that may be more rep- an appropriately calculated intraocular
before refractive surgery, to check for any resentative of the true corneal shape, with lens.55 Previous contact-lens complica-
contraindications, such as corneal con- attention given to the posterior surface tions, such as neovascularization, do not
ditions or dystrophies, and corneal irreg- topography and corneal thickness. This usually contraindicate refractive surgery.
ularities. All refractive surgery clinics use allows a better evaluation of anterior
a corneal topography unit to measure corneal and posterior surface astigmatism,
the whole corneal shape to obtain base- and of residual lenticular astigmatism. Corneal pachymetry
line data for the cornea, but also a very More information on corneal topography
flat cornea may prove to be more difficult is presented in Chapter 2. As mentioned above, PRK and LASIK
in flap creation with a microker- Recent literature shows that there can involve the removal of small areas of
atome.31,41,42 Contact lens users who be an associated change in the posterior corneal tissue by ablation with an
present for refractive surgery are advised corneal curvature, too, which is also relat- excimer laser, which results in an alter-
to remove their lenses for a period of time ed to the amount of treatment.49–51 In the ation of the overall corneal curvature. If
before surgery to eliminate warpage LASIK procedure the microkeratome cuts a patient has a very thin cornea, then

Figure 1.5
Original Orbscan corneal analysis unit, which uses scanning slit
Figure 1.4 technology. The Orbscan allows the posterior corneal surface curvature
Eyesys 2000 topography unit, which uses a large Placido disk and is able and corneal pachymetry to be viewed. Note the acquisition head does not
to give information about the radius of curvature on the anterior corneal use Placido technology, but contains two scanning slit lights. (Courtesy of
surface Bausch and Lomb)
 Patient selection and pre-operative assessment ■ 5

cutting a flap with a microkeratome may

not leave sufficient cornea under the flap Ablation depth depends on correction and diameter
to sustain corneal strength. Most sur- 200

Theoretical ablation depth (␮m)

geons like to leave a bed of at least 175
250–300μm under the ablated stroma
left untouched. Pachymetry is also 150 4.0mm
important for cases in which repeated 125 4.5mm
PRK is warranted for similar reasons.
Conditions that lead to areas of corneal 100 5.0mm
thinning, such as keratoconus or pellu-
75 5.5mm
cid margin degeneration, may also be
detected by carefully positioned pachym- 50 6.0mm
etry measurements. Corneal thickness is
25 7.0mm
usually measured with an ultrasonic
pachymeter using an appropriate anaes-
thetic, since it is a contact device. The 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
amount of tissue removed during laser
Spherical refractive error (D)
refractive procedures depends on the
level of ametropia to be corrected and Figure 1.6
the diameter of the laser ablation. The Amount of ametropia on the horizontal axis and the estimated laser ablation depth on the
relationship between diameter and depth vertical axis for different ablation diameters. (Courtesy of Stefan Pieger)
of ablation was investigated by
Munnerlyn et al., 56 and many clinicians
still use their formula to estimate the
amount of treatment (Figure 1.6).
Intraocular pressure breakdown of binocularity. A patient who
measurement is a moderate-to-high myope has a base-in
Fundus examination prismatic effect when performing near
Active glaucoma is a contraindication to tasks with spectacles on. After refractive
To identify abnormal ocular conditions of refractive surgery, although most refrac- surgery the patient loses this additional
the fundus, patients should undergo full tive surgery clinics do not assess visual base-in prism and may develop a fixation
ophthalmoscopic examination. Some cli- fields on all potential patients, unless war- disparity. This is likely to be more prob-
nicians warrant dilated fundus exami- ranted. IOP is of interest to refractive sur- lematic in pre-presbyopic patients, who
nation with an indirect ophthalmoscope, geons as there have been suggestions in may find the need for a reading add if their
such as a Volk lens, in addition to direct the literature of instances of altered IOP base-in prism for near is removed from
ophthalmoscopy. Many patients who readings after PRK. It is thought that the their habitual state. Furthermore, in early
elect to undergo refractive surgery are thinner cornea still has the same mechan- and pre-presbyopes a change in accom-
high myopes. In the case of high myopia ical forces acting on it and that regular modative demand when moving from
the likelihood of spontaneous retinal tonometers do not make an allowance for spectacles to refractive surgery (or contact
detachment is about 1 per cent. 57,58 thinner corneas.65–71 Hence, a lower lenses) can occur and may be problemat-
After laser refractive surgery the retina is tonometer force may be required to ic for the myopic patient. As hyperopia
unchanged and the retina is as likely to applanate the cornea by the required increases, the demand on ocular accom-
detach spontaneously as before surgery. amount, and so the IOP reading is falsely modation increases. Hence, as the specta-
However, very often the patient’s lifestyle low. Attempts have been made by some cle refraction is moved towards the ocular
may change, especially if this was one of workers to quantify the change in IOP
the primary motivations for having readings with the amount of ablation
refractive surgery, and the patient may received by the cornea.16,17,19,72–79 The
partake in activities and sports that before altered IOP reading is of particular impor-
were hindered by the use of spectacles. tance if a patient who has undergone
Retinal detachment after laser refractive refractive surgery develops glaucoma in
surgery has been reported and patients future years. For this reason other con-
should be warned about the risks, in the tributing factors towards glaucoma should
same way as high myopes would be be noted, such as positive family history,
warned routinely. Authors have quoted refractive error, age, race and anterior
incidences of retinal problems after chamber depth.
LASIK of between 0.06 and 0.25 per cent
of eyes, and of about 0.08 per cent after
PRK.59–62 The low incidence of retinal Muscle balance
problems after refractive surgery may
reflect careful pre-operative assessment Although not essential, it can be useful to
of patients to assess potential risks. Some check the muscle-balance status of
clinics apply prophylactic treatment to patients. A post-surgical problem, which
patients deemed at risk of later retinal may only be theoretical, since it has not Figure 1.7
detachment problems.63,64 been described in the literature, is the Pelli–Robson CSF chart
6 ■ Refractive surgery: a guide to assessment and management

plane the hyperope benefits from the lower haze. The new stromal tissue deposited is not Supplementary tests
demand on accommodative effort, where- laid in a regular pattern, which leads to a
as the myopic patient places a higher reticular pattern of fibres. Studies have Altered tear secretion has been reported
demand on the accommodative effort.80 shown that severe haze is more likely with after LASIK,88,89 and it is useful to assess
patients who have high refractive correc- tear-film quality and measure tear break-
tions, since the ablation depth is deeper. up time. Appropriate instruments, such as
Contrast sensitivity function Lasers that use scanning micro-beam tech- the Keeler Tearscope (Keeler Ltd, Windsor,
nology appear to produce less haze than Berkshire, UK) could be useful in identify-
Reduced contrast sensitivity function (CSF) older broad-beam lasers,82–85 but this may ing patients with potentially low tear vol-
has been described after refractive surgery, be partly because these newer lasers make a umes or break-up times. This may be
and hence its measurement with a suitable central optic zone and a peripheral blended important for patients who undergo PRK,
test, such as a Pelli–Robson chart (Figure zone.35,36,86 Thus, the actual change in for whom an incidence of recurrent ero-
1.7), is useful.81 In PRK patients this may contour profile of the corneal shape is less sions of about 3 per cent is quoted.90–92
be the result of corneal haze. Haze is severe. Another factor may be the laser Many patients find ocular lubricants use-
thought to be an immune response of the beam itself. If the beam is able to produce a ful for a period of time after corneal laser
stroma and forms precisely at the level of the smoother ablation, the newly synthesized refractive surgery (corneal wound healing
site of laser ablation (i.e., the epithelial–stro- cells may be able to form a more regular pat- after these types of surgery is discussed in
mal interface). To combat haze, some sur- tern of fibres. Haze does not appear to form Chapter 3). There have been reports in the
geons use corticosteroids prophylactically on eyes that have undergone LASIK, which literature of changes in corneal sensation
with all patients, some use them only if haze suggests that when the flap is replaced some after PRK and LASIK, although most
is beginning to appear and others prefer to smoothing of the underlying tissue occurs, authors suggest the corneal sensation is
use them with patients who are deemed to although altered CSF has been described usually at its pre-operative level within a
be more likely to develop haze, such as after LASIK.29,87 Reduced CSF may occur year, or sooner.93–95 However, it is not
patients with higher refractive errors.14,15 in some older patients with early lens-age- common to take aesthesiometry meas-
It has been suggested that newly synthesized ing changes, in which case laser refractive urements before refractive surgery using
cells cause haze, and an aggregation of ker- surgery may be contraindicated and lens devices such as the Cochet–Bonnet aes-
atocytes may play a part in the aetiology of exchange may be warranted. thesiometer mounted on a slit lamp.

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31 Maloney RK (1990). Corneal topography excimer laser photorefractive 65 Dohadwala AA, Munger R and Damji KF
and optical zone location in keratectomy for myopia. Ophthalmology (1998). Positive correlation between Tono-
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Corneal Surg. 6, 363–371. 48 Dave T (1998). Current developments in corneal thickness. Ophthalmology 105,
32 Lohmann CP, Fitzke F, O’Brart D, Kerr- measurements of corneal topography. 1849–1854.
Muir M, Timberlake G and Marshall J Contact Lens Anterior Eye 21, S13–S30. 66 Doughty MJ and Zaman ML (2000).
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spectacles, contact lenses, or excimer laser Posterior corneal protrusion after PRK. measurement: A review and meta-
photorefractive keratectomy. Am J Cornea 16, 686–688. analysis approach. Surv Ophthalmol. 44,
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34 Martinez CE, Applegate RA, Klyce SD, after photorefractive keratectomy. J intraocular pressure in a Mongolian
McDonald MB, Medina JP and Howland Cataract Refract Surg. 26, 872–878. population. Ophthalmology 105,
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Ophthalmol. 116, 1053–1062. are related to residual corneal bed 76, 223–224.
35 Pop M and Aras M (1995). thickness. Ophthalmology 106, 70 Mills RP (2000). If intraocular pressure
Multizone/multipass photorefractive 406–409. measurement is only an estimate – then
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36 Pop M and Payette Y (1999). Multipass 106, 409–410. pressure measurement – the myth of
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power within the pupil after refractive 57 Ho P and Tolentino F (1984). 74 Damji KF and Munger R (1997).
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40 Bennett AG and Rabbetts RB (1989). Surgical success rate with various types of Editor. Ophthalmology 104, 1525–1526.
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8 ■ Refractive surgery: a guide to assessment and management

measurements of intraocular pressure in photorefractive keratectomy and their 89 Patel S, Perez-Santoja JJ, Alio JL and Murphy
keratoconus and post-keratoplasty. effect on visual function. Ophthalmology PJ (2001). Corneal sensitivity and some
Ophthalmic Physiol Opt. 19, 236–241. 103, 1366–1380. properties of the tear film after laser in situ
78 Rosa N, Cennamo G, Breve A and La Rana 84 Lohmann CP, Gartry D, Kerr-Muir M, keratomileusis. J Refract Surg. 17, 17–24.
A (1998). Goldmann applanation Timberlake G, Fitzke F and Marshall J 90 Loewenstain A, Lipshitz I, Varssano D and
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79 Tuunanen TH, Hamalainen P, Mali M, 85 Lohmann CP, Gartry D, Kerr-Muir M, 91 Seiler T, Holschbach A, Derse M, Jean B and
Oksala O and Tervo T (1996). Effect of Timberlake G, Fitzke F and Marshall J Genth U (1994). Complications of myopic
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(1996). Visual performance after Ophthalmology 104, 1554–1565. Loss and recovery of corneal sensitivity
photorefractive keratectomy. Arch 87 Mutyala S, McDonald, Scheinblum KA, following photorefractive keratectomy for
Ophthalmol. 114, 1465–1472. Ostrik MD, Brint SF and Thompson H myopia. J Refract Surg. 15, 38–45.
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corneal haze over 18 months after after laser in situ keratomileusis. McDonnell PJ (2000). Corneal sensation
photorefractive keratectomy for myopia. Ophthalmology 107, 1864–1867. after laser in situ keratomileusis. J Cataract
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responsible for corneal haze after Surg. 16, 362–364. 158–161.
 2
Corneal topography and its role
in refractive surgery
Shehzad A Naroo and Alejandro Cervino

The cornea plays a fundamental role in but it served as a base for the development to the geometric centre.4 Other classifica-
both the structural integrity and the of the keratometers. In 1880 Antonio tions have also been developed, such as
refractive state of the eye. Thus, both the Placido introduced a flat disc with a series that of Rowsey and co-workers who con-
determination and representation of its of concentric black and white rings, with sidered the quantity and symmetry of
shape are important for refractive and sur- the corneal reflections of the rings exam- peripheral flattening,5 and classified the
gical purposes, as well as in the diagnosis ined through a central aperture. It is illu- corneas into essentially four types:
and evolution of several pathologies that minated from a light source above or • Type A: paracentral zone is symmetri-
express corneal shape alterations, such as beside the patient’s head. The Placido disc, cal (nasal–temporal difference less
keratoconus, marginal degeneration and as it became known, must be held normal than 0.2mm), peripheral zone is sym-
other ectasias. The adult cornea is char- to the line of sight or it will give a false metrical and the difference in flatten-
acterized by its specific distributions of cur- impression of the toricity of the cornea. ing between the paracentral and
vature and thickness along the different Gullstrand (1896) was the first to photo- peripheral zones is less than 0.2mm.
meridians, distributions that are essential graph the corneal image formed with the • Type B: paracentral zone is symmet-
for the correct function of the cornea as Placido disc.1,2 rical, as is the peripheral zone, but the
the most important and powerful refrac- difference in flattening between both
tive element of the human eye. zones is more than 0.2mm.
Classification of corneal • Type C: paracentral zone has a trace
topography asymmetry (about 0.2mm), the
History peripheral zone is symmetrical and the
Since the early investigations of Javal and difference in flattening between them
Early interest in corneal topography dates Helmholtz, a basic model of corneal topog- is less than 0.2mm.
back to Father Christopher Scheiner, who raphy has been established that uses the • Type D: paracentral zone has a
in 1619 compared corneal images to mar- ellipse as a first-order approximation to the nasal–temporal asymmetry and the
bles. Using daylight he viewed the image normal corneal profile. This classic model peripheral zone is symmetrical, but the
formed when daylight shone through the of the corneal contour corresponds to a difference in flattening between the
cross-shaped glazing frame bars of his surface with two zones, a central spheri- paracentral and peripheral zones is
windows onto corneas and compared the cal zone of 4–5mm diameter and a periph- greater than 0.2mm.
images formed to those formed on marbles eral zone that flattens towards the limbus. The classification of the cornea into
of a known size. Senff introduced the first The central zone is responsible for the anatomic zones is considered inappropri-
concepts about human corneal topogra- foveal image formation, and within this ate by several authors, because the cornea
phy in 1846, reporting that the anterior area of the cornea the changes in curva- is a smooth surface, the curvature of
corneal surface flattens towards the lim- ture are small, so often uniformity is which is submitted constantly to subtle
bus and compared the anterior surface of assumed. However, it has been demon- changes,3,6,7 which suggests that at any
the cornea with a revolution ellipsoid. strated by Bennett that this is not actually individual point the cornea is conical and
Henry Goode (1847) described the first correct,3 but rather each point on the represented by Equation (2.1)
keratoscope, which comprised a small cornea is conical (as mentioned below). y2 = 2ro – px2 (2.1)
luminous square held near to the eye. The anatomic centre of the apical zone where p is the shape factor of the cornea
Helmholtz (1853) invented the ophthal- rarely corresponds to the visual centre or (see below) and ro is the central radius of
mometer, and introduced the first dou- the geometric centre, although most curvature of the cornea.
bling image system to avoid the problems instruments assume this to be true. The However, in the central 3–4mm the
caused by the continuous micro-move- position of the apex is independent of the changes are small, as mentioned above,
ments of the eye that existed until then. geometric centre and is usually located and hence some level of uniformity is often
This ophthalmometer was difficult to use, 0.5mm on the temporal side with respect assumed. The anterior peripheral cornea
10 ■ Refractive surgery: a guide to assessment and management

flattens with respect to the central curva-

Table 2.1 Corneal descriptors and their mathematical relations
ture, a pattern mimicked by the posterior
corneal curvature. The rate of flattening Mathematical description Shape factor (p) Asphericity (Q) Corneal example
may be different along different meridians. Hyperbola shape p<0
The corneal asphericity is described in
mathematical terms as being a prolate Parabola shape p=0
shape or a flattening ellipse. This shape of
the cornea partially compensates the Prolate shape 0<p<1 Q<0 Normal corneal
spherical aberration of the eye and (flattening ellipse) shape
improves the quality of the retinal image.
The technical requirements for a cor- Circle p=1 Q=0
rect and reliable measurement of corneal
topography were established by Bibby:8 Oblate shape p>1 Q>0 Post-myopic laser
• The units used to describe the corneal (steepening ellipse) surgery or post-
topography must not depend on the radial keratotomy
method of obtaining the values.
• The instrument must measure the
total area of interest.
• All the information must be acquired
simultaneously. sively increases. Near the apex the are eccentricity (e), shape factor (p) and
• The technique employed must be pre- degree of change in the radius of cur- asphericity (Q). These indices are related
cise and reproducible. vature is very low, but it increases by simple mathematical equations:
Following these requirements, his work quickly towards the periphery. To p = 1 – e2 (2.2)
suggested mean values for the corneal establish the size of the central zone a Q = –e2 (2.3)
shape of 0.85 ± 0.18 in 2100 eyes and, 1D change criterion is usually accept- and
later, of 0.79 ± 0.15 in 32,000 eyes. ed or, in other words, the area of the Q=p–1 (2.4)
In the 20th century, the growth of the corneal surface at which the dioptric Table 2.1 shows corneal descriptors and
field of contact lenses, and later of refrac- powers differ by less than 1D. In most their mathematical relations.
tive surgery, led to an increased interest in cases this is a 4mm diameter central Some of the information collected by
corneal topography. This, along with the portion of the cornea. corneal topography is used to describe the
parallel development of the computer • From a mathematical point of view, a corneal shape in easy-to-understand
technologies, resulted in great advances in simple mathematical expression is terms, which can both aid interpretation
corneal topographical analysis. Various used to define the cornea as an ellipse of the data and decipher the colour maps.
workers have helped to develop better or polynomial expression. In most A few examples of these are given below,
designs of photokeratoscopic systems and normal corneas, the central zone is although many corneal topography units
better graphic presentation and analysis more curved than the peripheral zone, have their own individual indices.
of the data. Colour-coded topography which means it has the form of a sec-
maps were introduced by Klyce and later tion of a prolate ellipse (with a positive Corneal uniformity index or surface
developed further by Maguire.9,10 shape factor and an asphericity in the regularity index
range 0 to 1). There are studies that The corneal uniformity index (CUI) or sur-
draw the conclusion that the different face regularity index (SRI) represents the
Corneal shape refractive groups have similar corneal smoothness of the surface, a relation of the
eccentricity values, but different val- change in local corneal radius of curvature
Evaluation of the corneal shape is of great ues for the apical radius.12 or corneal power over a determined area.
importance in the monitoring and follow- • The third way to describe the corneal It is evaluated from the frequency distri-
up of corneal pathologies, contact lens fit- surface, as Mandell reports,11 is point bution of powers along the different merid-
ting and refractive surgery, and in the by point, which consists simply of a col- ians. This index is sometimes used to give a
evaluation of sequential temporal changes lection of values for the corneal radius value to the visual acuity (VA), based on
induced by contact lens wear, refractive of curvature or power found at differ- the assumption that the cornea is the only
surgery or orthokeratology. However, the ent positions on the cornea. If all the limiting factor in the patient’s VA; this is
description of the cornea may not be the adjacent numbers with the same value called the predicted corneal acuity (PCA).
same for a contact lens fit as for refractive are connected in a contour map, the
surgery purposes, for example. Mandell result obtained is transformed into an Simulated keratometry readings
described the cornea in three ways, easily comprehensible pattern that Simulated keratometry (SimK) readings
according to the viewpoint required:11 gives a global image of the particular are calculated using the steepest meridian
• From a qualitative point of view, sever- corneal shape. from the central area along every meridi-
al corneal zones are considered: the A series of descriptors of the corneal shape an (SimK1), and the power and axis of the
central, paracentral, peripheral and has been defined to unify the different cri- meridian orthogonal to the steepest
limbal. Also, a division into optic and teria of the range of normal corneal (SimK2). These readings are useful substi-
peripheral zones can be made for prac- shapes. Also, some investigators have tutes of traditional keratometric meas-
tical purposes, in which the central defined a number of corneal indexes to urements and have been reported as useful
optic zone, with an almost constant give a better understanding of corneal in the calculation of intraocular lens
curvature, is surrounded by a periph- topography and its variations. The com- power.13 They are often taken as the steep-
eral zone with a radius that progres- monly used descriptors of corneal shape est and flattest profiles, although if they
 Corneal topography and its role in refractive surgery ■ 11

are calculated perpendicular to each other • The working distance from the object Using the cornea as a reflector system
this may not be exactly correct. point to the image is constant. Nearly all optometry practices have a ker-
Elevation is a relative measurement of • The instrument axis is perpendicular atometer. The main function of the ker-
corneal topography, and is described as the to the corneal surface. atometer is to measure the radius of
elevation difference with respect to a plane • The light from the object is reflected in curvature of the central portion of the
or to a flatter or steeper surface. Elevation the same meridian onto the plane on front surface of the cornea.14 This result
may also be taken in relation to a reference which the image is created (i.e., it is is usually obtained indirectly by measur-
sphere, which may be a floating sphere (i.e., assumed that no circular inclination ing the angular size of the reflected image,
related only to that cornea) or a fixed sphere of the corneal surface occurs). formed by the cornea, of an object of
(used to calculate the elevation of all corneas • The position of the image on the plane known angular size; this is the first
with that machine). Usually a floating is unique for a determined surface. Purkinje image.6 In most instruments, this
sphere is used, and its radius of curvature is • The image point is on a non-curved is an object with a linear size that is fixed
the mean radii for that cornea; all other data plane. or measurable at a predetermined distance
points are related to this reference sphere, • The refractive index of the cornea is from the image plane. Since it would be dif-
which is termed the best-fit sphere (BFS). the same for all individuals and ficult to read off the reflected image height
Figure 2.1 shows a Holliday diagnostic remains constant in a particular from the cornea, because of involuntary
summary (HDS) from the EyeSys 2000 patient. eye movements, the principle of doubling
machine. Image capture in corneal topography can is used in keratometers. The image size is
be divided into two basic types: measured by lateral displacement of a dou-
• Reflection techniques: the cornea bled image (doubling may be achieved
Corneal topography works as a curved mirror and the using a series of lenses, mirrors or, more
measurement methods reflected image is viewed directly or commonly, prisms). In most keratometers,
captured and analyzed. Examples of doubling takes place in one meridian only,
Currently, numerous evaluation methods this technique are keratometry, ker- along the line that joins the mires. Such
for corneal topography exist, some more atoscopy and videokeratoscopy. an instrument must be rotated about its
precise than the others, but basically all are • Projection techniques: in this group of axis to align it with each of the principal
developments of the same fundamental techniques, the cornea acts as a pro- meridians of the cornea in turn, and is
theme. The idea is to make a three-dimen- jection screen. An example of this is therefore known as a two-position ker-
sional reconstruction of the corneal sur- rasterstereography, which is used suc- atometer, such as a Javal–Schiötz type.
face, but difficulties arise when trying to cessfully in other areas of medicine A one-position keratometer (such as
represent a three-dimensional shape using such as spinal curvature measure- the Bausch and Lomb type, see Figures 2.2
a two-dimensional image. To do this some ment. and 2.3) is an instrument in which vari-
assumptions and simplifications are made: Another technique is that of interferometry. able doubling of mutually perpendicular
pairs of mires is produced by two doubling
devices in the corresponding meridians.
The instrument is rotated about its axis to
align the mires with both principal merid-
ians of the cornea, and the images in each
can then be brought into contact without
further rotation.6
The primary use of the keratometer in
contact lens practice is to measure the cen-
tral radius of the cornea to determine the
back optic zone radius of a contact lens

Figure 2.1 Figure 2.2

Holliday diagnostic summary (HDS) from the EyeSys 2000 machine. The box underneath the Bausch and Lomb style keratometer
four maps shows some corneal parameters for this cornea measured over 3mm, except for the
asphericity value (Q), which is measured over an area of 4.5mm. Note that the steepest and
flattest refractive profiles (column 1) are not the same axes as the SimK axes (column 2)
12 ■ Refractive surgery: a guide to assessment and management

a b
giving rise to 360 data points, a total of
5760 data points. The latest EyeSys topog-
raphy unit, EyeSys-2000, uses 18 rings, but
maintains a longer working distance. It still
collects data from 360 points along each
ring, to give a total of 6480 data points. The
TMS-2, like its predecessor, uses a Placido
cone, but increases the number of rings to
34, while maintaining 256 data points per
ring over a maximum corneal diameter of
11.5mm. The latest offering from Tomey, the
TMS-3, boasts an impressive automated
Figure 2.3 image-capture system. It has 31 rings with
Reflection of the mires from a Bausch and Lomb style keratometer. (a) The mires incorrectly 256 data points per ring, to give a total of
aligned. (b) The mires correctly aligned when the keratometry readings are taken 7936 data points. The automated image
capture of the TMS-3 leads to a small sacri-
fice in corneal coverage, and offers up to a
that will produce the best fit. It is also used Videophotokeratoscopy maximum diameter of 9.5mm.17,18
to check the radii of a corneal lens and to Modern corneal topography devices are an As corneal topography has become less
assess the fit of soft contact lenses. accumulation of techniques learned from of a research tool and more clinically wide-
Changes in central corneal shape can also the historical methods of keratoscopy and spread, the number of models available has
be detected with the keratometer, both photokeratoscopy, described above. High- increased. All use either the Placido cone
quantitatively and qualitatively (by assess- resolution video cameras record the reflec- system, as in the TMS units, or the Placido
ing the regularity of the mires), and in this tion of the Placido disc mires from the disc system, as in the EyeSys units. Most use
capacity it is often used by clinicians to patient’s cornea. Once the patient is aligned a working distance that is between the two
assist in the diagnosis of keratoconus.14 in front of the videophotokeratoscope, with extremes of these two units. Haag-Streit and
Keratometry has a number of inherent the chin on the rest, the images are cap- Oculus both offer the same unit, but pack-
problems. The one-position keratometer tured. The system is aligned when the aged slightly differently. This machine has
described above assumes that the two prin- tracking lights of the two superimposed 22 rings on a Placido disc and offers 10,000
cipal meridians of the cornea are perpendi- laser beams reflected by the cornea are data points, which is currently the most of
cular. All keratometers measure corneal placed in the centre of the cross-hair tar- any topography unit; this device also has a
radius with pencils of light reflected by small get located in a box displayed on the mon- very accurate collimating measurement for
areas, each situated not less than 1mm and itor screen. The reflected image of the mires more accurate SimK readings. While a
up to about 1.7mm from the centre. The ker- is recorded on a close-circuit video camera greater number of sampling points, in prin-
atometer does not allow for decentration of and analyzed by computer software to yield ciple, allows the topography to be assessed
the corneal apex or for corneal asphericity. a representation of the corneal contour. in more detail, the validity of the device’s
The main source of error is focusing. If the data depends on the algorithms used and, as
mire images formed by the object are not Examples of different machines yet, few comparative studies have been made
focused accurately in the intended primary The machines mentioned here are just a few on the performance of different units.
image plane, the radius measurement will of the many types of topography units cur- Topcon offer a novel system, the KR-
be incorrect, since the object–image sepa- rently available. This is not intended to be 7000P, which is a combined autorefrac-
ration is then incorrect, and the unfocused an exhaustive list, but merely a representa- tor–autokeratometer–topographer. As well
mire images have a different separation from tion of the variety of designs around. The as providing automated refraction and
the sharply focused ones.15 These blurred two most widely used computer-assisted central corneal curvature readings along
images may not appear to be so if compen- videophotokeratography systems are the the two principal meridians, it gives the
sated for by the observer’s accommodation EyeSys Corneal Analysis System (by EyeSys topography over a corneal diameter of
and his or her own uncorrected ametropia Technologies) and the Topographic 7mm, but it only offers 2600 data points
(especially astigmatism). Also, local distor- Modelling System (TMS, by Tomey instru- in total. This unit can be used as a stand-
tion of the cornea in the region of the reflec- ments), and these represent the two alone machine with a built-in printer or
tion area causes a corresponding distortion extremes of design. The EyeSys machines can be linked to a desktop computer.
of the mire and renders focusing of the have a Placido disc and a longer working Once a patient is aligned on the topog-
instrument uncertain.6,16 distance than their Tomey rivals, which raphy machine and the cornea is in focus
Adaptations of keratometers have been have a Placido cone. A larger working dis- the actual image capture (automated or
used to assess the peripheral corneal tance makes the instrument less sensitive manual) is very quick, typically 33 mil-
shape. New keratometers have been to small displacements of the eye, but has liseconds, as with the TMS-3 unit. Each
designed and modifications made to older the disadvantage that the instrument is less data collection point measures the curva-
designs. A modified Bausch and Lomb ker- compact. The cone systems use a shortened ture at that reflected point on the cornea
atometer with the mire separation reduced working distance, and the size of the cone and all the data points are represented on
from 64mm to 26mm and a series of off- means they are able to move closer to the a colour map display.
axis fixation points was able to take meas- eye, which allows a larger corneal coverage.
urements of the corneal periphery.11 The TMS-1 uses a 25-ring Placido cone, Presenting topography data
Bennett describes a keratometer based on with a total of 6400 data points, and utilizes Two scales are commonly used to display
the Drysdale effect and used to measure a short working distance of approximately topographic features; the absolute (also
the central and peripheral cornea.3 70mm. The EyeSys-1 uses 16 rings, each called standard scale) and the normalized
 Corneal topography and its role in refractive surgery ■ 13

(also called the relative scale or autoscale).

The absolute scale generates a colour-coded
map with 1.0D increments on a pre-set
scale, usually between 37D and 51D, and
thus allows comparison of different
corneas and different machines. The nor-
malized scale uses smaller increments to
span the range of dioptric powers of an
individual cornea, and thus the same
colour may not represent the same numer-
ical value on different corneal pictures. The
normalized scale is created by assigning the
red range of colours to the steepest curva-
ture of the cornea being examined, and the
blue range of colours to the flattest curva- Figure 2.4 Figure 2.5
ture. The remaining colours are divided Absolute (or standardized) scale of a Normalized (or relative) scale of the same
into equal step sizes and assigned their par- corneal topography map. The scale is preset cornea as in Figure 2.4. In the map the
ticular ranges (Figures 2.4 and 2.5). by the machine manufacturer. (Note the dioptric scale has a much smaller range,
The normalized scale is intended to ren- large range of the dioptric scale) which enables differences in the radius of
der similar contours similar in appearance, curvature to be detected more easily
irrespective of their absolute radius of cur-
vature. Hence, the normalized scale, being a Figure 2.6
more specific to an individual, is more sen- Corneal topography maps
sitive in detecting subtle topographic of a patients’ eyes taken
changes in the anterior corneal surface. with the Orbscan
With both scales, steep areas are depicted topography unit. The map
by so-called ‘hot colours’ (i.e., reds and on the left in both (a) and
browns) and flatter areas are represented (b) represents sagittal
by ‘cold colours’ (i.e., blues and greens). data and that on the right
The keratometric data display gives represents tangential
details of the steepest and flattest corneal data. Both (a) and (b)
curvature in the central 3mm, 5mm and b show clearly how sagittal
7mm (the central data may be represented and tangential data can
on the colour map). The profile map shows look very different for the
the corneal curvature in dioptric powers same eye, but the main
over the corneal surface by calculating the emphasis remains the
profile along the steepest and flattest merid- same
ians from the central 3mm zone.19 Most
software algorithms assume that the
corneal contour changes smoothly and
hence ‘average’ the curvature over an area
of a few square millimetres. Unfortunately,
little information is available on this effect, they may look different (Figure 2.6), Similar technology is adopted in the
which may be of importance in relation to although the main features of the map Orbscan topography unit (Orbtek Inc., Salt
ablation geometry in laser refractive sur- remain the same. Lake City, Utah). The Orbscan takes 40 slit
gery. Each local area of the cornea is gen- sections of the cornea during two scans,
erally a toric surface, rather than a Using the cornea as projector each scan lasting 0.7 seconds. Each slit
sphericalone, and hence possesses both system section is similar to an optical section
spherical and cylindrical power. The cornea was first used as a projector viewed through a slit lamp. Similar to
system to determine the corneal topogra- Placido-based topography, the patient rests
Sagittal and tangential data phy by Bonnett and Cochet (1962).20 It on a chin rest and the instrument is
In corneal topography, the light from the consists of the projection of a diffraction aligned using an XYZ manipulator base
topographer mires is directed onto the grid onto the corneal surface and the pat- (see Figures 1.5 and 10.1). The image cap-
cornea. Off-axis light, when reflected from tern produced by the grid is a function of ture takes a total of 1.4 seconds and any
a curved surface, gives rise to two focal the corneal topography. However, the eye movements render the image void.
points. One represents the radius of cur- cornea must first be made opaque to allow The corneal curvature results are usu-
vature normal to the reflected mires, the grid pattern to be detected. Initially, tal- ally presented in the form of a contour
known as the sagittal (or axial) reflection. cum powder (in conjunction with topical map that shows height deviations from the
The other focal point represents the radius anaesthesia) was used for this purpose, but best-fitting spheres, but a variety of other
of curvature that contains the reflected more recently sodium fluorescein has been numerical descriptions can also be
mires, the tangential image. used. Accuracy of the measurements obtained. It has been shown that the
Sagittal and tangential data can be taken depends on the magnification used measurement of anterior surface curva-
represented as different types of topog- on the slit lamp and the way that the ture, as assessed using calibrated stan-
raphy maps, and for the same cornea image is viewed or captured.7 dards, has a high accuracy and that the
14 ■ Refractive surgery: a guide to assessment and management

Figure 2.7 Another option that the Orbscan allows

The quad map consists of is called ‘surgical options’. This view pro-
maps of the anterior duces a three-dimensional schematic image
corneal height, the of the examined eye. It can be adjusted to
posterior corneal height, produce a view of the anterior or posterior
the keratometric data and cornea, or both simultaneously. The ante-
the pachymetry, but rior lens can also be imaged using this
these maps can be altered option, although lens curvature data are not
to suit the user’s available directly. This type of three-dimen-
preferences (see text) sional schematic view is available on other
types of topography systems too, but is usu-
ally calculated from radius of curvature
data, whereas the Orbscan uses elevation
data. Figure 2.8 shows a ‘birds-eye’ view of
a normal cornea (note the central steepen-
ing of the cornea). Figure 2.9 shows a cornea
that has undergone myopic photorefractive
thickness measurement on human posterior corneal height, the keratometric keratectomy (PRK), with the associated cen-
corneas has a high reproducibility.21,22 data and the pachymetry, but these maps can tral corneal flattening. Figure 2.10 shows an
The default topography map that the be altered to suit the user’s preferences. eye after refractive keratectomy.
Orbscan produces, the quad map, consists Height maps indicate the relative height A new device recently available from
of four pictures (Figure 2.7). The quad map above or below a mean of the radii of cur- the Birmingham Optical Group is the
has maps of the anterior corneal height, the vature of the surface (anterior or posterior). Oculus Pentacam system (Oculus,
The mean radius of curvature of the corneal Giessen, Germany). This is discussed
surface, the BFS, is subtracted from all other again in Chapter 10, as currently no pub-
radii of curvature points of the surface. Thus, lished studies have used it. Essentially, it
the height maps do not indicate the curva- is a rotating Scheimplug camera and is
ture of the cornea at a particular point, but able to image up to the fourth Purkinje
rather the relative height with regard to the image in a patient with a dilated pupil; oth-
BFS (similar to an Ordnance survey map, in erwise, it is able to at least obtain data from
which heights are shown with respect to sea three surfaces, like the Orbscan. The image
level). The height maps use ‘hot’ colours to creation and caption system is different to
indicate areas that are higher than the BFS, that of the Orbscan, so it remains to be seen
and ‘cold’ colours to indicate areas that are how the two systems compare. The
Figure 2.8 lower than the BFS. The keratometric map Pentacam is a table-mounted device and,
Surgical options, ‘birds-eye’ view of a shows the radius of curvature data of the similar to standard topography units, it uses
normal cornea (note the central steepening cornea at any point. In the quad map, it is an XYZ manipulator base with the patient
of the cornea) viewed as an overall value for the anterior lined up in front of the instrument with his
and posterior corneal surfaces, but these sur- or her chin upon a chin rest (Figure 2.11).
faces can be viewed individually. The final The data are collected in around 2 seconds
map in the quad selection is a pachymetry and approximately 25,000 data points are
map that shows the thickness of the entire taken. The data can be represented as ele-
area of cornea assessed. vation data or radius of curvature data.

Figure 2.11
Figure 2.9
The Oculus Pentacam
Surgical options, view of cornea that has
system is a table-
undergone myopic PRK, with the associated
mounted device that
central corneal flattening
uses an XYZ
manipulator base with
the patient lined up in
front of the instrument
and his or her chin
upon a chin rest

Figure 2.10
Surgical options, view of an eye after radial
keratotomy. (Courtesy of Orbtek)
 Corneal topography and its role in refractive surgery ■ 15

Corneal topography in lar pattern. For a patient in whom warpage healing changes that occur to an eye over
refractive surgery is observed, the topography is repeated on a period of time post-surgery (Figure 2.14).
subsequent visits until no further changes During aftercare appointments topogra-
Irregular and regular astigmatism can be are seen in the topography maps and only phy is often conducted to pick up abnor-
observed using topography after cataract then is the patient considered suitable for malities such as central islands, which can
surgery and post-penetrating keratoplas- surgery. Figure 2.13 shows a patient with be identified clearly. Decentred zone abla-
ty, which allows the surgeon to assess sta- corneal warpage in the right eye, but a rela- tions can also be identified with corneal
bility. For cases in which there is a lot of tively normal left eye. topography. Areas of surface scarring,
post-surgical astigmatism, corneal topog- Post-operative assessment is essential such as complications of corneal flaps, ero-
raphy maps can be used to indicate poten- to check astigmatic results, stability and sions and sutures, are also detectable.
tial areas of suture removal (Figure 2.12). irregular healing. Different techniques of
Corneal topography is a vital tool in refractive surgery show characteristic post-
refractive surgery. Pre-operative assessment operative changes. For example, myopic Limitations of corneal
checks for any contraindicated corneal con- excimer laser surgery shows central flat- topography
ditions and dystrophies. Contact lens users tening, whereas after hyperopic surgery a
who present for refractive surgery are mid-peripheral flattening is seen. Post-ker- The quality of the anterior reflective sur-
advised to remove their lenses for a period of atotomy, steepening of the areas of surgical face of the cornea and inaccuracies in
time before surgery to eliminate warpage incision and an accompanying flattening of numerical assumptions can limit the use-
induced by the contact lens. Warpage other areas of the cornea are seen. fulness of topography. Images are restrict-
appears as an irregular topography picture Topography pictures taken at different ed nasally and superiorly because the
with distortion that does not have a regu- visits allow the clinician to observe the recording mechanisms are eclipsed by the

Figure 2.12
A patient’s right eye after penetrating keratoplasty. The map labelled A
was taken 1 week after surgery. Her corrected VA was 6/18, as there
was some irregular astigmatism present. The surgeon removed one
suture to try and make the astigmatism more regular. Picture B was
taken a few minutes later, and gives corrected VA of 6/9 (Refraction:
+6.00/–3.00 × 100). The main map shows the difference map obtained
by subtracting map B from map A

Figure 2.13
Patient with corneal warpage in the right eye, but a relatively normal left
eye

Figure 2.14
A cornea before and after photorefractive keratectomy. The initial
refraction was –3.25/–0.25 × 175 and the 12 weeks post-surgical
refraction was +1.00/–0.50 × 10. Picture A is the post-surgical map
and picture B is the pre-surgical map. The larger picture is the difference
between the two. The pre-surgical map has been subtracted from the post-
surgical picture to demonstrate the area of cornea removed by ablation. It
can be seen that a central area of approximately 5mm has been flattened
(the actual laser setting for the ablation diameter was a 5.5mm optic
zone and a total ablation zone of 6.5mm)
16 ■ Refractive surgery: a guide to assessment and management

nose, brow and upper eyelid. Superficial rometers are able to separate aberrations of technique to measure ocular high-order
corneal scars and similar abnormalities the cornea from those of the whole eye, aberrations. The combination of both tech-
confuse the topographies, especially if they whereas other devices only give the whole- niques means that corneal aberrations can
are central. The patient’s ability to main- eye aberrations. The custom ablation tech- be separated from whole-eye aberrations.
tain fixation is vital. niques allow a method of correcting the
whole eye’s aberrations on the corneal sur-
face. In a similar way, traditional refractive
Corneal topography and surgery would correct a patient’s full ocu-
aberrometry lar refraction on the cornea, even though
some components of the prescription may
Currently, practically aberrometry is be elsewhere, such as the crystalline lens.
becoming a very popular technique in Most corneal topography devices now
refractive surgery. It is used to create better have software that enable radius of curva-
ablation profiles and also to assess post- ture data to be interpreted to express the
operative patients, especially those with corneal high-order aberrations, often in
complications. In fact, pre-operative wave- terms of Zernike polynomials or Fourier
front aberrometry examination should help analysis. Some newer topography devices
the surgeon decide whether a traditional now take aberrometry measurements in
refractive surgery procedure would solve the addition to corneal curvature data. The
visual problems of the patient, or if a cus- Nidek OPD device (Figure 2.15) has a Placido Figure 2.15
tomized ablation is indicated. Some aber- disc and, in addition to that, uses a skiascopy The Nidek OPD

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