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    Assessing keratoconus using corneal topography

    Improving the outcome of LASIK surgery and any kerato-refractive procedures


    There are different types of corneal ectasia, including forme fruste keratoconus (both moderate and nonprogressive), with central and paracentral zones of irregular astigmatism. Three of these types are Pellucid Marginal Degeneration (rare and bilateral with peripheral corneal thinning), Iatrogenic Keractesia in post-LASIK patients and keratoconus. The latter may be either early-onset (at puberty, age 14—16), which is a severe form of keratoconus, or the other, less severe, being a late-onset form, which occurs between ages 20—30.

    Many instruments can detect advanced stages of keratoconus, for example, a slit lamp biomicroscopy. In order to make accurate observations, the pupils of the suspected corneal ectasia patient must be dilated. Then, using a cobalt filter, Fleisher's ring (a gray circle) can be observed. Through a cross-sectional view, it is possible to detect the presence of Vogt's striae. In addition, a retinoscope is used to observe an abnormal pupillary reflex, and a pachymeter employed to measure the thickness of the cornea. Finally, a keratometer can also be used to observe any distortion of the keratometric mires and to measure the central curvature of the cornea. Many indices have been proposed to detect keratoconus, and most of the calculations are based on keratometric readings. However, corneal topography and aberrometry remain the best and most comprehensive means of detecting the early stage of keractesia.

    Corneal Topographer: what it comprises

    In our study we used the Optivision computerized corneal topographer, EH-300- a fully automated topographer with auto-focus, auto-positioning and auto-capturing. The optical head of this instrument has 23 real rings, as compared with other existing topographers with 9 or 12 rings. The innermost central ring diameter is less than 1 mm and the outermost ring diameter is 10+ mm (depending on the asphericity of the cornea). The dioptric plot is displayed in sagittal as well as tangential modes.

    In corneal topography, the configuration of the rings and the optical working distance are determining factors in the accuracy of the measurements and how representative the data yielded from the topographer are regarding the shape of the cornea. The closer in distance the configuration of the rings, the less extrapolation in the calculations, so the more representative the data is of the corneal shape. The greater the optical distance between the corneal vertex plane and the keratoscopic rings, the smaller the amount of error at the periphery of the cornea.

    Four different displays

    We propose a technique for detecting corneal ectasia using corneal topography, as well as corneal aberrometry/wave-front technology, using four different displays: the Normal Average Cornea (NAC), Zernike polynomial, Fourier harmonics, and elevation plots. Due to the topographer's number of rings, their configuration, and their coverage of the quasi-totality of the cornea, the extrapolation is minimized, thus allowing a better assessment of corneal surface irregularity.

    For the keratoconus detection, the software has four special displays to check and balance each other. The first display shows the Normal Average Cornea (NAC), an average dioptric plot of several normal corneas, resulting in a Normal Average Corneal shape, with a central steepening and gradual peripheral flattening. The shape factor of the NAC is SF 0.442.

    The second display shows Zernike polynomials and their aberrations. The first order of Zernike polynomial is the piston. The second is the defocus and astigmatism. The third order is trefoil, the vertical and horizontal comas and the fourth order is tetrafoil, secondary astigmatism and the spherical aberration.

    The third display shows three Fourier harmonics. The first harmonic shows the degree of tilt, the second harmonic shows the degree of astigmatism and the third harmonic shows the higher order aberrations.

    The fourth display shows the corneal elevations and the differences between the cornea and the osculatory circle.


    Sami El Hage, OD, PhD, DSc
    Sami El Hage, OD, PhD, DSc is the founder of Eye Care Associates at 5320 Richmond Ave. Houston, Texas 77056. He may be reached by ...

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