Corneal Topography

Lecture outline
• Anatomy and topography of the normal
cornea/tear film
• History of measuring corneal topography
• Indications of automated corneal topography
• Principle of automated corneal topography
• Display and Interpretation of the data
• Limitations of automated corneal topography
 History
• 1619 - Scheiner compared size of corneal reflex to
reflex in glass balls of known radius (He held the
glass sphere close to the patient’s cornea and
compared the size of bars in a window reflected
from the glass spheres to that reflected from the
cornea).
• 1769- Ramsden constructed 1st keratometer
• 1821-1894) Helmholtz’s keratometer looked like
modern ones
• 19th century: Javal keratometer
• In 1980, the development of the
autokeratometr .
Klein hand-held keratoscope
+6 D lens in the centre
pure qualitative
Keratoscope-Placido images
 Normal corneal optics and structures
• The central 3 mm of the cornea considered spherical
• The more peripheral cornea is flatter and non-spherical
• Prolate shape:
Cornea gets flatter toward the periphery
Actually, the radius of curvature increases (gets bigger)
towards the periphery
• Oblate surface is flatter in the center and steeper in the
periphery. This is not usually found in normal corneas.
But can be seen after myopic laser photo refractive
keratectomy.
 Normal corneal optics and
structures
• The power of the cornea expressed as
refraction in diopters is an optical property
dependent on the shape of the surfaces and
the refractive index of the surface
F = (n’-n)/r (meters)
• The average central corneal thickness is
approximately 550 um (micrometer).
 Indications
The information given by corneal topography is useful
to:
• Contact lens fitting:
- To evaluate and correct different refractive errors and
astigmatism using contact lenses
- Essential in some forms of contact lens fitting e.g.
orthokeratology
•
• Planning for refractive surgery:
- to evaluate refractive errors and astigmatism
- to detect if there is any any corneal or corneal irregularities that
are contraindicated in refractive surgery e.g. Keratoconus,
corneal dystrophies.
• Follow up of refractive surgeries and collagen cross linking
• Adjusting post surgical corneal transplants
• Monitor and follow the progression of corneal surface diseases.
 keratoconus
• irregular shape of the corneal surface àvisual
disturbance.
• In order to effectively follow the progression of the
disease and to fit a keratoconic cornea with contact
lenses it is helpful to know the precise shape of the
cornea
• Keratoconus is contraindicated for refractive
surgeries
• Might benefit from collagen cross linking and
INTACTS (slowing the progression of the disease)
 Corneal topography
• Also known as videokeratoscopy/videokeratography
• It provides the most detailed information about the
curvature of the cornea ( keratometry central 3mm,
the reminder cornea is ignored).
• Using a very sophisticated computer and software,
thousands (>20.000) specific points across entire
cornea
• of measurements are taken and analyzed in just
seconds.
• The computer generates a color map
from the data.
 Corneal topography principle
• Based on Placido reflective image analysis.
• Multiple light concentric rings are projected
on the cornea.
• Uses the analysis of reflected images of
multiple concentric rings projected on the
cornea.
• The reflected image is captured on charge-
coupled device (CCD) camera.
• Computer software analyzes the data and
displays the results in a variety of formats
concentric rings in the corneal
topography
 Pentacam
Regular Camera Scheimpflug Principle
Picture / Focus Plane

Film Plane
Objective Plane
Picture / Focus Plane

Point of Intersection

Film Plane

Objective Plane
Advantage of the Scheimpflug Camera:
higher depth of focus,•
Problem of a normal Camera:
sharp picture•
limited depth of focus

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 cut each other in one line or one point of intersection.
 Camera- / Slit position and
Pentacam Anterior Chamber
Image Scan Overview Analyzer

Scheimpflug image:
Densitometry•
Quantification•
Measurement • Pachymetry
function Height
5.91
576 Topography
670
869

3D-Model of
the Anterior
Chamber
Oculus Pentacam
 Instrumentation and patient set up
• The patient is seated at the bowl with forehead
braced against a bar.
• The examiner has only to line the patient up
properly and snap an image.
• The procedure is painless and very fast.
• The computer then uses the snapped image to
produce a printout of the corneal shape using
colors to identify different steepnesses.
http://www.youtube.com/watch?v=Ck0iyKShTsA
 Interpretation of the data
• The cool shades of blue and green represent flatter
areas of the cornea, while the warmer shades of
orange and red and represent steeper areas.

• Other numerical data: base curve, power are also

available.
• This corneal map allows the examiner to formulate a
“3-D” perspective of the cornea’s shape.
 Interpretation of the data
• Steep areas represented by warm colours
• Flat areas represented by cool colours
• Maps classified into 5 main groups
round, oval, symmetrical bow tie, asymmetrical
bow tie, irregular

Astigmatism: Symmetrical bowtie Round

 Colour maps
• Axial (or sagittal) map
assumes single centre of curvature
• Tangential map
- distinct centre of curvature for each data point
referring to neighboring points
- useful for sharp power transitions
- e.g. in ortho-k and post-lasik
• Main differences
- found in the mid to far peripheral points
- eliminates ‘smoothing appearance’ of axial maps
 Two types of maps , absolute Vs normalized

Absolute maps
• have a preset color scale with the same dioptric
steps, dioptric minimum and maximum assigned to
the same colors for particular instrument.
• These maps allow direct comparison of 2 different
maps. Although, because the steps are in large
increments (generally 1.5 D), their disadvantage is
that they do not show subtle changes of curvature
and can miss subtle local changes (eg, early
keratoconus).
 Normalized maps
• have different color scales assigned to each map
based on the instrument software that identifies
the actual minimal and maximal keratometric
dioptric value of a particular cornea.
• The dioptric range assigned to each color
generally is smaller compared to the absolute
map, and, consequently, maps show more
detailed description of the surface. The
disadvantage is that the colors of 2 different maps
cannot be compared directly and have to be
interpreted based on the keratometric values
from their different color scales
 Colour maps

Absolute/standardised scale Normalized/relative scale

Absolute scale Normalized
scale

26
 Interpretation of topographic indices
• Simulated K (SimK):
- Simulated keratometry measurements
characterize corneal curvatures in the central
3-mm area
- These readings give an idea about the central
corneal curvature that is frequently visually
most significant
Interpretation of topographic indices
• The index of asphericity (Q)
- indicates how much the curvature changes upon
movement from the center to the periphery of
the cornea.
- A normal cornea is prolate (ie, becomes flatter
toward the periphery) and has the asphericity Q
of -0.26.
- A prolate surface has negative Q values and
positive oblate surface values.
- Most myopic laser vision corrections change the
anterior corneal surface from prolate to oblate.
 Interpretation of topographic indices

• I-S Value, inferior superior value

- used to assess patients with keratoconus,
- calculated by measuring the diopteric power of five
points at 30 degree interval along the inferior cornea
3 mm from the central cornea , summing these
values, and subtracting from this number the sum of
the diopteric power of five points at 30 degree
intervals along the superior cornea 3 mm from the
central cornea. The I-S value can be used as a
measure of the localized inferior steepening , typical
of keratoconus
• indexes that relate the variability of the
actual values of the anterior corneal
surface to the optical quality and potential
best VA that would be permitted by the
anterior corneal surface.

E.g, surface regularity index (SRI), corneal

uniformity index (CUI), predicted corneal
acuity (PCA), and point spread function
(PSF).
 Corneal topography in normal
corneas
• Flattens progressively from the center to the
periphery by 2-4 D, with the nasal area
flattening more than the temporal area.
• The topographic patterns of the 2 corneas of
an individual often show mirror-image
symmetry, and small variations in patterns are
unique for the individual.
• The approximate distribution of keratographic
patterns described in normal eyes includes the
following:
• - round (23%),
• - oval (21%),
• - symmetric bow tie typical for regular astigmatism
(18%),
• - asymmetric bow tie (32%),
• - irregular astigmatism(7%)
Normal cornea ( round pattern)
Normal cornea ( oval pattern)
Symmetrical bowtie of astigmatism( typical
for regular astigmatism)
Asymmetrical bowtie of astigmatism
Irregular pattern of astigmatism
 Keratoconus pattern
• The topographic diagnosis of keratoconus
often is suggested by:
- high central corneal power
- large difference between the power of the
corneal apex and of the periphery
- disparity between the 2 corneas of a given
patient.
- Other clinical sign seen in slit-lamp
Holladay Diagnostic Summary
keratoconus
Small nipple cone
Large inferior cone
Superior cone
Mild inferior steepening of the
cornea
Mild keratoconus Sever Keratoconus
Mild inferior steepening of the
cornea
A cornea after Photo Refractive Keratectomy
for Myopia
A cornea after orthokeratology or post-lasik
contact lens warpage at the bottom of the cornea in contact
lens wearer pt
Orbscan
Image capture
Keratoconus - 1
 Limitations of corneal topography
The error of corneal topography is under optimal
conditions in the range of ±0.25 D , but, in those
abnormal corneas seen in clinical practice, it often is
±0.50-1.00 D due to several limitations
• 1. The imaging requires an intact epithelial
surface and tear film .
• .2. Some of the errors of the Placido-based systems
are as follows: focusing errors, alignment and fixation
errors with induced astigmatism, difficulty to
calculate the position of the center from the small
central rings, increased inaccuracy toward the
periphery because the accuracy of each point
depends on the accuracy of all preceding points
• Different technologies use different algorithms à
difficult to compare
 Useful links
• http://www.oculist.net/downaton502/prof/eb
ook/duanes/pages/v1/v1c065.html
• http://cms.revoptom.com/handbook/oct02_s
ec3_6.htm