UPDATE/REVIEW

Anterior chamber depth measurement:

interchangeability between Pentacam and other devices
Alberto Domnguez-Vicent, MSc1; Daniel Monslvez-Romn, OD1; Vicent Sanchis, MSc1;
Santiago Garca-Lzaro, OD, PhD1; Robert Monts-Mic, OD, PhD1.

ABSTRACT: We reviewed a series of recently published studies in which the anterior

chamber depth (ACD) distance was measured by Pentacam or Pentacam HR and compared
with other measuring devices. Since some published studies reach contradictory conclusions
regarding device interchangeability and include different ocular conditions, for instance,
phakic eyes, pseudophakic eyes, cataractous eye, and so on, this review was carried out to
try to clarify which clinical devices can or cannot be considered as interchangeable with
Pentacam or Pentacam HR for the measurement of ACD distance in clinical practice.
J Emmetropia 2012; 3: 215-220

Nowadays, the measurement of anterior chamber The devices included in this review were Pentacam
depth (ACD) distance has become increasingly important (Oculus, Wetzlar, Germany), Pentacam HR (Oculus,
in ophthalmic practice, for instance, in the planning Wetzlar, Germany), A-Scan, Ultrasound Biomicroscopy
of cataract1-5 and refractive1-9 surgery, calculation of (UBM), Orbscan (Bausch&Lomb Surgical Inc., San
phakic or pseudophakic IOL power and diameter4,5,10-14, Dimas, California, USA), Orbscan II (Bausch&Lomb
screening for glaucoma risk factors2,3,14-16, and so on. Surgical Inc., San Dimas, California, USA), Galilei
Many papers focusing on device interchangeability for (Ziemer, Switzerland), Visante OCT (Carl Zeiss
the measurement of ACD distance have been published. Meditec Inc., Dublin, California, USA), IOLMaster
However, the studies published include different ocular (Carl Zeiss Meditec, Jena, Germany) and Lenstar LS
conditions. 900/Biograph (Haag-Streit AG, Koeniz, Switzerland/
For this reason, we decided to review all studies Alcon Laboratories Inc., Ft Worth, Texas, USA). In
published in Medline before August 2012. The inclusion this context, the purpose of this paper was to clarify
criterion was that the study had to evaluate device which devices are interchangeable with Pentacam or
interchangeability between Pentacam or Pentacam Pentacam HR in the measurement of ACD distances.
HR and other devices that measure ACD distance. We also included a brief description of the measurement
principle used by the devices included in this review.

MEASUREMENT PRINCIPLES
Pentacam
1
Optometry Research Group (GIO), Department of Optics. The Pentacam is a non-contact device using a
University of Valencia. Spain. rotating Scheimpflug camera. It uses a monochromatic
Financial disclosure: This research was supported in part by Research slit light source to measure anterior segment topography.
Grant #SAF2009-13342-E# awarded by the Ministry of Science and Up to 50 slit images with 500 measurement points on
Innovation (Ministerio de Ciencia e Innovacin) and by a BAF research the front and back of the corneal surface are acquired
scholarship (Generalitat Valenciana) awarded to Alberto Domnguez
Vicent. The authors have no proprietary interest in any of the products in 2 seconds over a 180-degree rotation. The internal
or devices mentioned in this article. software creates a three-dimensional reconstruction of
the anterior segment by using the elevation data of these
Corresponding Author: Alberto Domnguez Vicent.
Department of Optics - University of Valencia. C/ Dr. Moliner, 50 images, which gives information about the anterior
46100 - Burjassot. Spain. Phone: +34 963544764 - Fax: +34963544715 and posterior surface of the cornea, and ACD from
Email: aldovi@alumni.uv.es endothelium to crystalline lens.
2010 SECOIR ISSN: 2171-4703 215
Sociedad Espaola de Ciruga Ocular Implanto-Refractiva
216 COMPARISON OF ANTERIOR CHAMBER DEPTH MEASUREMENT DEVICES

Figure 1. Pentacam HR (left) and Galilei (right). Figure 2. Orbscan II (left) and Visante OCT (right).

Pentacam HR different techniques: a Placido disk system, which screens

Pentacam HR (Figure 1 left) is one of the latest anterior corneal topography and creates an elevation
developments in three-dimensional topographers and is map; and a horizontally moving scanning camera,
based on the Scheimpflug principle. The rotating camera which acquires slit images. After image reconstruction,
rotates around the optical axes of the eye to calculate a a mathematical three-dimensional model of the cornea
three-dimensional model of the anterior segment. The and the anterior segment is calculated. To calculate the
system has two different three-dimensional modes. One ACD, the system software automatically detects the
is a regular three-dimensional scan that takes 50 images corneal endothelium surface and anterior surface of the
in 2 seconds. The other is a special three-dimensional crystalline lens on the acquired images.
high-resolution corneal mode, in which the camera
takes 50 images per second. The internal software creates Orbscan II
a three-dimensional reconstruction of the anterior The Orbscan II (Figure 2 left) is a non-invasive
segment by using the elevation data of these images, topography system that scans the anterior segment,
giving information about the anterior and posterior combining a three-dimensional scanning slit beam
surface of the cornea, and ACD from endothelium to system with an added Placido attachment for evaluating
crystalline lens. corneal surfaces. This device calculates ACD in the same
manner as Orbscan.
A-Scan
This ultrasound contact device, which works at Galilei
10-MHz, is used to measure eye biometric dimensions, The Galilei (Figure 1 right) is a non-invasive
i.e. axial length, anterior chamber depth, posterior diagnostic system designed for the analysis of the
chamber depth and corneal and lens thickness. It anterior eye segment. The system is based on a rotating
calculates ACD on the basis of the difference in the dual-Scheimpflug camera integrated with a Placido
time taken for ultrasound waves to reflect back to its topographer. This device captures slit images from
receiver from the posterior corneal surface and anterior opposite sides of the illuminated slit and averages the
lens surface. elevation data obtained from corresponding opposite
slit images. This dual Scheimpflug imaging technique
Ultrasound Biomicroscopy improves the detection of the posterior corneal surface
This ultrasound contact device, which works at 50 and provides outstanding accuracy in pachymetry across
MHz, is used to image ocular tissue depths up to 4 the entire cornea, even when the camera is decentered
to 5 mm with lateral and axial physical resolution of because of eye movements.
approximately 50 and 25 m. ACD is measured with a
ruler over the sonogram. Visante OCT
Visante OCT (Figure 2 right) is a time-domain
Orbscan non-invasive system that employs high-resolution
The Orbscan is a noncontact topography system images. The light source is a superluminescent
that is used for anterior segment evaluation. It uses two light-emitting diode with a short wavelength that has

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 COMPARISON OF ANTERIOR CHAMBER DEPTH MEASUREMENT DEVICES 217

Pentacam vs. A-Scan

Nmeth et al.7, Elbaz et al.17 and Su et al.18 studied
the interchangeability of Pentacam and A-Scan. These
authors included normal eyes in their sample but reached
different conclusions: while Nmeth et al.7 obtained
comparable ACD values, Elbaz et al.17 and Su et al.18
obtained significantly lower ACD values with A-Scan.
However, in these two latter studies the mean difference
lay within clinical tolerance limits. Nmeth et al.7 and Su
et al.18 also included pseudophakic eyes in their sample
and in these cases the ACD values provided by A-Scan
and Pentacam were not comparable. Therefore, it can
be concluded that A-Scan and Pentacam can be used
Figure 3. Lenstar (left) and IOLMaster (right).
interchangeably in clinical practice for phakic subjects,
but not for pseudophakic eyes.

a limited penetration depth into the eye. By moving Pentacam HR vs. A-Scan
the scanning spot laterally across the eye, this device Szalai et al.19 compared ACD measures provided by
acquires multiple A-Scans and aligns them to construct Pentacam HR and A-Scan. They observed that A-Scan
two-dimensional images analogous to an ultrasound yielded significantly higher ACD values than Pentacam
B-scan. The scanning speed is 4,000 axial scans/second HR, thus concluding that these two devices cannot
and each image frame has 500 axial scans/image. It can be assumed to be interchangeable in clinical practice.
be used to measure central corneal thickness and ACD. However, for IOL power calculation these devices can be
used interchangeably, since the mean difference between
IOLMaster these two devices is within clinical tolerance limits.
The IOLMaster (Figure 3 right) is designed to
measure the parameters used in intraocular lens (IOL) Pentacam vs. Orbscan
calculation, including axial length, corneal curvature, Lackner et al.12, Kiraly et al.20 and Yazici et al.21
ACD and WTW distance. The IOLMaster emits compared Orbscan with Pentacam, but the results
780-nm infrared light and uses partial coherence they achieved were rather contradictor. Lackner et al.11
interferometry to measure axial length. Keratometry obtained significantly higher ACD values with Orbscan,
and ACD are determined automatically using a lateral while in contrast, in the study of Yazici et al.21, it was
slit illumination of the corneal and crystalline lens and Orbscan that produced significantly lower ACD values.
a white-light-emitting diode of 590 nm as the light However, the mean difference observed by Lackner et
source. The lateral slit illumination is 0.7 mm wide al.11 and by Yazici et al.21 was within clinically acceptable
and employed at an angle of 30 degrees during ACD levels, which is why these two authors concluded that
measurements. these devices can be used interchangeably.
Lenstar Pentacam vs. Orbscan II
The Lenstar (Figure 3 left) optical biometer is based Five studies8,15,16,23,24 evaluated the interchangeability
on low coherence reflectometry, with an 820-mm between Orbscan II and Pentacam. Doors et al.8, Dinc
superluminescent diode. The Lenstar detects anterior et al.16, Hashemi et al.23 and Kim et al.24 obtained
and posterior corneal and anterior crystalline lens peaks statistically significant differences between the values
in the optical low coherence reflectometry waveform to produced by these two devices, thus concluding
measure the ACD and corneal thickness. In addition to that they should not be used as though they were
ACD and corneal thickness, the Lenstar also measures interchangeable. In contrast, Utine et al.15 did not
axial length. observe any statistically significant differences between
Orbscan II and Pentacam, thus assuming their
interchangeability. It is worth mentioning that the mean
difference between Orbscan II and Pentacam was within
ANTERIOR CHAMBER DEPTH clinically acceptable tolerance limits in four8,15,16,24 out
Each study included in this study compared of these five studies, which suggests that further studies
Pentacam or Pentacam HR with one of the following should be carried out to clarify whether or not these
devices: A-Scan, UBM, Orbscan, Orbscan II, Galilei, two devices are interchangeable for the measurement of
Visante OCT, IOLMaster, Lenstar and MRI. ACD in normal eyes.

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218 COMPARISON OF ANTERIOR CHAMBER DEPTH MEASUREMENT DEVICES

Moreover, Doors et al.8 measured ACD in phakic eyes On the other hand, Reuland et al.11, Utine et al.15,
following IOL implantation and Hashemi et al.23 and Dinc et al.16, Elbaz et al.17 and Su et al.18 observed
Kim et al.24 following laser refractive surgery. While in all statistically significant differences between Pentacam
three cases the authors observed statistically significant and IOLMaster, but they concluded that Pentacam and
differences between Orbscan II and Pentacam, the mean IOLMaster can be considered as interchangeable for
difference was within clinically acceptance levels, except use in clinical practice to calculate IOL power since the
for the Doors et al.8 study. Thus, we can conclude that mean difference between these two devices lay within
these are interchangeable after refractive surgery but not clinical tolerance levels. However, contradictory results
after phakic IOL implantation. were found for the estimation of IOL vaulting: while
Reuland et al.11, Utine et al.15, Elbaz et al.17 and Su et
Pentacam HR vs. Orbscan II al.18 obtained mean differences within clinical tolerance
Salouti et al.22 compared Pentacam HR with Orbscan limits, Dinc et al.16 did not.
II, obtaining significantly higher ACD values with Moreover, Su et al.18 also compared Pentacam with
Orbscan II, thus concluding that these devices should IOLMaster in pseudophakic subjects. Since the authors
not be used interchangeably. did not obtain any statistically significant differences,
we may conclude that Pentacam and IOLMaster can be
Pentacam vs. Galilei used interchangeably for the measurement of ACD in
pseudophakic eyes.
Kiraly et al.20 compared the ACD values obtained
with Pentacam and Galilei. They did not find any Pentacam vs. Lenstar
statistically significant differences between the two
devices, thus concluding that Pentacam and Galilei can Only two studies so far (ODonnell et al.25 and
be employed interchangeably in clinical practice. Huang et al.26) have compared Pentacam with Lenstar
for the measurement of ACD. Although ODonnell et
Pentacam vs. Visante OCT al.25 found statistically significant differences between
these devices, as the mean difference was acceptable from
Doors et al.8, Dinc et al.16, Kiraly et al.20, Yazici et a clinical point of view, it was concluded that they were
al. and ODonnell et al.25 compared ACD measured
21
interchangeable. However, Huang et al.26 did not find
with Pentacam and with Visante OCT. No statistically statistically significant differences between Pentacam
significant differences were found either by Kiraly et and Lenstar. These studies, then, suggest that these two
al.20 or by Yazici et al.21, thus concluding that these devices can be used interchangeably in clinical practice.
two devices can be used interchangeably in clinical
practice. On the contrary, Door et al.8, Dinc et al.16 and Pentacam HR vs. Galilei
ODonnell et al.25 obtained significantly higher ACD
values with Visante OCT than with Pentacam, thus Salouti et al.22 also studied the interchangeability
concluding that these devices cannot be assumed to be between Pentacam HR and Galilei. They did not obtain
interchangeable. However, since the mean difference significantly differences and concluded that these
obtained in these studies was within clinically acceptable devices could be used interchangeably.
limits, we believe that Pentacam and Visante OCT can
be used interchangeably in normal eyes. Pentacam HR vs. IOLMaster
Doors et al.8 also included in their study a Nmeth et al.27 studied the interchangeability
comparison of patients that had undergone phakic IOL of Pentacam HR and IOLMaster in phakic eyes.
implantation. In this group they also found statistically These authors did not find any statistically significant
significant differences but the mean difference was again differences between these two devices. This study, then,
within clinical tolerance limits. Consequently, this study suggests that Pentacam HR and IOLMaster can be used
suggests that Pentacam and Visante OCT can be also interchangeably in the clinical practice.
used interchangeably to measure ACD in eyes that have
undergone phakic IOL implantation.
DISCUSSION
Pentacam vs. IOLMaster After these reviews, it can be concluded that
Eight studies6,10,11,15-18,20 have so far compared the following devices can be used interchangeably
Pentacam with IOLMaster for the measurement of with Pentacam or Pentacam HR in clinical practice:
ACD, all reaching similar conclusions. Savant et al.6, Pentacam-A-Scan7,17,18 for phakic patients, Pentacam
Woodmass et al.10, and Kiraly et al.20 did not obtain any HR-A-Scan19 to calculate IOL power, Pentacam-
statistically significant differences between Pentacam Orbscan12,20,21 for phakic patients, Pentacam-Orbscan
and IOLMaster, and they concluded that these two II24 after laser refractive surgery, Pentacam-Galilei20 for
devices may be used interchangeably in clinical practice. phakic patients, Pentacam-Visante OCT8,16,20,21,25 for

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 COMPARISON OF ANTERIOR CHAMBER DEPTH MEASUREMENT DEVICES 219

phakic patients and after phakic IOL implantation, chamber depth in relation to refractive status measured with
Pentacam-IOLMaster6,10,11,15-18,20 to calculate IOL the Orbscan II Topography System. J Cataract Refract Surg.
power and after pseudophakic IOL implantation, 2003; 29: 2115-2121.
Pentacam-Lenstar25,26 for phakic patients, Pentacam 3. Hashemi H, Yazdani K, Mehravaran S, Fotouhi A.
Anterior chamber depth measurement with a-scan
HR-Galilei22 for phakic patients and Pentacam
ultrasonography, Orbscan II, and IOLMaster. Optom Vis Sci.
HR-IOLMaster26 for phakic patients. 2005; 82: 900-904.
The device pair whose interchangeability is still 4. Salouti R, Nowroozzadeh MH, Zamani H, Ghoreyshi
unclear is Pentacam-Orbscan II8,15,16,20,23,24 for phakic M, Salouti R. Comparison of horizontal corneal diameter
patients. Moreover, the device pairs that cannot be used measurements using Galilei, EyeSys and Orbscan II systems.
interchangeably in clinical practice are Pentacam-A- Clin Exp Optom. 2009; 92(5): 429-433.
Scan7,18 for pseudophakic patients, Pentacam-Orbscan 5. Baumeister M, Terzi E, Ekici Y, Kohnen T. Comparison of
II8 after phakic IOL implantation and Pentacam manual and automated methods to determine horizontal
HR-Orbscan II22 for healthy subjects. corneal diameter. J Cataract Refract Surg. 2004; 30: 374-380.
6. Savant V, Chavan R, Pushpoth S, Ilango B. Comparability
The present review clarifies the interchangeability of
and intra-/interobserver reliability of anterior chamber depth
ACD measurements between Pentacam or Pentacam measurements with the Pentacam and IOLMaster. J Refract
HR and other devices. However, discrepancies between Surg. 2008; 24: 615-618.
studies may be due to the differences in the measurement 7. Nmeth G, Vajas A, Kolozsvari B, Berta A, Modis L. Anterior
method upon which each device is based. For instance, chamber depth measurements in phakic and pseudophakic
A-Scan and UBM rely on ultrasound; Orbscan and eyes: Pentacam versus ultrasound device. J Cataract Refract
Orbscan II rely on scanning-slit topography; Pentacam, Surg. 2006; 32: 1331-1335.
Pentacam HR and Galilei use Scheimpflug photography; 8. Doors M, Cruysberg LPJ, Berendschot TTJM, Bradander
Visante OCT uses low coherence interferometry; J, Verbakel F, Webers CAB, Nujitis RMMA. Comparison
of central corneal thickness and anterior chamber depth
IOLMaster uses a lateral slit illumination and is based
measurements using three imaging technologies in normal eyes
on partial coherence interferometry; whereas Lenstar and after phakic intraocular lens implantation. Graefes Arch
measures ACD with optical biometry. Other sources Clin Exp Ophthalmol. 2009; 247: 1139-1146.
of discrepancies may be the age group included in each 9. Kohnen T, Thomala MC, Cichocki M, Strenger A. Internal
study and the ability of the researcher to control the anterior chamber diameter using optical coherence tomography
accommodation state during measurement in those compared with white-to-white distances using automated
studies that included young subjects. measurements. J Cataract Refract Surg. 2006; 32: 1809-1813.
Finally, further studies should be undertaken, aimed 10. Woodmass J, Rocha G. A comparison of Scheimpflug imaging
as studying the interchangeability of ACD measurements simulated and Holladay equivalent keratometry values with
partial coherence interferometry keratometry measurements in
across different age groups, ocular conditions and phakic eyes. Can J Ophthalmol. 2009; 44: 700-704.
interchangeability with other devices. It would also be 11. Reuland MS, Reuland AJ, Nishi Y, Auffarth GU. Corneal
interesting to define a relationship between the gold radii and anterior chamber depth measurements using
standard for ACD and the rest of the devices that are the IOLMaster versus the Pentacam. J Refract Surg.
able to measure these distances. This would be useful 2007; 23: 368-373.
for surgeons who could then know the ACD that a gold 12. Lackner B, Schmidingrer G, Skorpik C. Validity and
standard would yield without the need for having the repeatability of anterior chamber depth measurements with
device in the ophthalmology clinic. As a result, some Pentacam and Orbscan. Optom Vis Sci. 2005; 82: 858-861.
13. Reddy AR, Pande MV, Finn P, El-Gogary H. Comparative
postsurgical problems, such as those related to IOL
estimation of anterior chamber depth by ultrasonography,
power, could be avoided. Orbscan II, and IOLMaster. J Cataract Refract Surg.
To conclude, Pentacam (for phakic eyes) and 2004; 30: 1268-1271.
Pentacam HR (for cataractous eyes) can be used 14. Rosa N, Lanza M, Capasso L, Lucci M, Polito B, Romano
interchangeably with the two gold standards used to A. Anterior chamber depth measurement before and
measure ACD (IOLMaster and A-Scan). This review after photorefractive keratectomy. Ophthalmology.
also reveals that the interchangeability of the device 2006; 113: 962-969.
depends on the patients ocular condition and this must 15. Utine C.A, Altin F, Cakir H, Perente I. Comparison of anterior
be taken into consideration in clinical practice. chamber depth measurements taken with the Pentacam,
Orbscan IIz and IOLMaster in myopic and emmetropic eyes.
Acta Ophthalmol. 2009; 87: 386-391.
16. Dinc UA, Gorgun E, Oncel B, Yenerel MN, Levent A.
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