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 Step by Step®
Reading Pentacam
Topography
(Basics and Case Study Series)
basmala blog (always original)

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basmala blog (always original)

Notification
The information provided via this book is intended for
general information purposes.
The information provided via this book is published to assist
you, but it is not to be relied upon as authoritative.
The author accepts no liability whatsoever for any direct
or consequential loss arising from any use of the
information contained in this book.
 Step by Step®
Reading Pentacam
Topography
basmala blog (always original)

(Basics and Case Study Series)

MAZEN M SINJAB
MD, MS, CABOphth, PhD
Consultant Ophthalmologist
Ophthalmology Department
Medical School
Damascus University
Syria
 Published by
Jitendar P Vij
Jaypee Brothers Medical Publishers (P) Ltd
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basmala blog (always original)

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Step by Step® Reading Pentacam Topography (Basics and Case Study Series)
© 2010, Jaypee Brothers Medical Publishers

All rights reserved. No part of this publication and Photo CD ROM should be reproduced, stored in a retrieval system,
or transmitted in any form or by any means: electronic, mechanical, photocopying, recording, or otherwise, without
the prior written permission of the author and the publisher.

This book has been published in good faith that the material provided by author is original. Every effort is made
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First Edition: 2010

ISBN 978-81-8448-804-3

Typeset at JPBMP typesetting unit

Printed at
 Acknowledgments
basmala blog (always original)

The author would like to express his deep gratitude to Ruba

his wife whose unwavering support was critical for this
book.
The author would also like to thank all the researchers
concerned in the refractive field for their efforts.
His special thanks to Theo Seiler, Jack Holladay and
Michael W Belin for their pioneering work in the field.
 Preface
basmala blog (always original)

Taking the right decision in laser refractive surgery

depends to a great extent on good reading of corneal
topography and its clinical interpretation. This is very
important for having the aimed results and avoiding post-
operative complications.
Data in this book were obtained and gathered from the
user manual of the Pentacam, international conferences,
refractive journals, personal contacts with many refractive
professors and of course self experience.
The strategy in compiling this little book is making a quick
refreshment of what has been explained in the previous
book “Corneal Topography in Clinical Practice” published
by Jaypee, and then follows a systematic approach of
topographical pictures in chosen cases. This strategy allows
the readers to qualify and quantify any case in the future
in a way that no data may be lost.
There are sure to be some errors, as the ophthalmology
editor, I take full responsibility for these and look forward
to being further educated.
Mazen M Sinjab
 Contents
basmala blog (always original)

1. Instruments Measuring the Corneal Surface .... 1

Curvature Based Instruments 2
Elevation Based Topographers 3
2. Quick Review of Pentacam Main Maps ............ 9
Curvature Maps 10
The Sagittal (axial map) 10
The Tangential (local map) 12
Elevation Maps 16
Corneal Thickness Map 18
Main Page Analysis 21
3. Reading Pentacam Topography......................... 29
Introduction 30
Steps of Reading the Topography 30
Scoring the Case 50
4. Examining the Patient ......................................... 51
Ocular History 52
Family History 56
Medical History 56
Medications and Allergies 58
Prior Corrective Lenses 59

5. Case Study ............................................................. 61

Case 1: Myopic Astigmatism 62
Case 2: Mixed Astigmatism 74
 x Step by Step Reading Pentacam Topography

Case 3: Hyperopia 86
Case 4: Anisometropia 97
Case 5: Suspected Case 118
Case 6: Post-Lasik Ectasia 141
Case 7: Keratoconus 167
Case 8: Keratoconus Possible 179
Case 9: Abnormal Cornea 189
basmala blog (always original)

Bibliography ............................................................... 203

Index .......................................................................... 207
 Introduction
basmala blog (always original)

Here is my second book in this field. The Pentacam camera

is an attractive camera; by which you can get many data
and maps. It is essential in taking the right decision, hence
the need to explain all features, maps, tables and diagrams
this camera provides us with, this was the purpose of my
previous book “Corneal Topography in Clinical Practice”
published by Jaypee Brothers 2009. Since many
ophthalmologists need a quick and simple reference, I
edited this new book but with no repetition. This book
delivers—at the beginning—a quick short refreshment of
the main concepts of the Pentacam topography, then it
describes a step-by-step reading the Pentacam as a check-
list included in a table depicting all available data which I
find most useful to produce optimal results. To reach this
goal, I discussed many clinical cases in order to highlight
the subjects of concern. But still we have to refer to the
first book for more details about the principles of maps,
tables and diagrams, which is essential in understanding
my step-by-step approach.
 Instruments Measuring the Corneal Surface 1

chapter 1
basmala blog (always original)

Instruments
Measuring the
Corneal Surface
 2 Step by Step Reading Pentacam Topography

CURVATURE BASED INSTRUMENTS

The normal corneal outer surface is smooth; corneal
irregularities being neutralized by the tear film layer. The
anterior surface acts as an almost transparent convex
mirror; it reflects part of the incident light. Many
instruments have been developed to assess the anterior
basmala blog (always original)

surface by measuring the reflected light. These non-contact

instruments use light target (in different shapes) and a
microscope or other optical systems. The instruments are
either quantitative or qualitative, and either reflection-
based or projection-based. These instruments are as
follows:
1. The keratometer: it is a quantitative reflection-based
instrument.
2. The photokeratoscope: it is a qualitative reflection-based
instrument (Fig. 1.1).

Fig. 1.1: The ‘ring verification display’ in videokeratoscope. The

explorer is able to evaluate qualitatively the corneal surface. Corneal
irregularity appears as irregular rings with differing interspaces.
 Instruments Measuring the Corneal Surface 3

3. The computerized videokeratoscope: it is a projection-

based topographer consisting of a Placido disk (Fig. 1.2).
basmala blog (always original)

Fig. 1.2: The Placido cone. The larger the cone, the more the rings
and the wider the area to be estimated. The very central cornea and
the paralimbal area are excluded.

ELEVATION BASED TOPOGRAPHERS

Placido based (or curvature based systems) rely on the data
collected from the anterior surface of the cornea either with
reflection-based or projection-based systems. Additionally,
without the information about the posterior surface,
complete pachymetric evaluation of the cornea is not
possible. Of course, ultrasonic pachymetry can give us
central and few paracentral measurements, but now we
 4 Step by Step Reading Pentacam Topography

need full pachymetric map. Moreover, the posterior surface

of the cornea is being more appreciated as a sensitive
indicator of corneal ectasia and can often be abnormal in
spite of a normal anterior corneal surface. It is now
recognized that while the refractive power of the cornea is
mostly determined by the anterior surface, the
biomechanical behavior of the cornea is at least equally
basmala blog (always original)

determined by both surfaces.

On the other hand, in the curvature based systems the
elevation map of the anterior surface is derived from the
curvature map, while it is directly calculated in the
elevation based systems. For full discussion of the
curvature and elevation maps please refer to my book
“Corneal Topography in Clinical Practice” published by
Jaypee Brothers 2009.

Description of the Unit

The OCULUS Pentacam/Pentacam HR is a rotating
Scheimpflug camera (Figs 1.3 and 1.4). The rotational
measuring procedure generates Scheimpflug images in
three dimensions, with the dot matrix fine-meshed in the
center due to the rotation. It takes a maximum of 2 seconds
to generate a complete image of the anterior eye segment.
Any eye movement is detected by a second camera and
corrected for in the process to some extent. The Pentacam
calculates a 3-dimensional model of the anterior eye
segment from as many as 25.000 (HR: 138.000) true
elevation points.
The topography and pachymetry of the entire anterior
and posterior surfaces of the cornea from limbus-to-limbus
are calculated and depicted. The analysis of the anterior
 Instruments Measuring the Corneal Surface 5
basmala blog (always original)

Fig. 1.3: The Pentacam system. Central slit light with

lateral concentric rotating Scheimpflug camera.

Fig. 1.4: Captured section by the rotating

camera of the Pentacam.
 6 Step by Step Reading Pentacam Topography

eye segment includes a calculation of the chamber angle,

chamber volume and chamber height and a manual
measuring function at any location in the anterior chamber
of the eye. In a moveable virtual eye, images of the anterior
and posterior surface of the cornea, the iris and the anterior
and posterior surfaces of the lens are generated. The
densitometry of the lens is automatically quantified.
basmala blog (always original)

The Scheimpflug images taken during the examination

are digitalized in the main unit and all image data are
transferred to the PC.
When the examination is finished, the PC calculates a
3D virtual model of the anterior eye segment, from which
all additional information is derived.

Fig. 1.5: The image in the ordinary camera. The main disadvantage
is limited depth of focus because the picture plane, the objective
plane and the film plane are parallel.
 Instruments Measuring the Corneal Surface 7
basmala blog (always original)

Fig. 1.6: The Scheimpflug camera. Higher depth of focus, sharp image
but distorted. The picture plane, the objective plane and the film plane
cut each other in one line or one point of intersection.

To understand Scheimpflug principle, see Figs 1.5 and

1.6. Fig. 1.5 illustrates the image in the normal camera;
notice that the three planes (The picture plane, the
objective plane and the film plane) are parallel. Fig. 1.6
illustrates the Scheimpflug camera. The Scheimpflug law
says: To get a higher depth of focus, move the three planes,
provided that the picture plane, the objective plane and
the film plane have to cut each other in one line or one
point of intersection. The advantages of the Scheimpflug
Camera are: higher depth of focus and sharp picture, but
distorted.
basmala blog (always original)
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