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The optical quality of the cornea

Antonio Calossi

he cornea is a relatively complex structure, consisting of a number of layers: the epithelium, the Bowman, the stroma, the Descemet membrane and the endothelium[1-3]. The stroma occupies 90% of the corneal thickness, which is about 530 m at the center and 700 m at the periphery. The stroma consists of layers of lamella consisting of bundles of collagen fibrils arranged in parallel and crossed-over in an approximately orthogonal arrangement between one lamella and the next. The arrangement of the fibrils is extremely important. Each fibril has a diameter of about 25-33 nm and their structure and their arrangement are the reason behind these refractive properties, while the regularity and uniformity of the dimension and the separation are crucial for the transparency of the cornea. The fibrils form a fairly regular substance, even though there is light dispersion due to the difference in the refractive index between the fibrils and the interstitial material. This lack of optical homogeneity creates the Tyndall effect, that is, dispersion of light inside the cornea, which permits the observation of this tissue in an optical section under the slit lamp. The light diffused by the stromal substance creates a destructive interference in all directions, except the direction of the incident light, which contributes to maintaining good corneal transparency[4-10]. For as long as the fibrils maintain this regular structure, the cornea will be transparent, otherwise, opacities will form that degrade the retinal image because of the light diffusion that reduces the contrast and the clarity of the image. On the basis of Rayleighs principle, an optical surface can be considered perfect when it produces a wave-front with aberrations that do not exceed one-quarter of the wave-length[11]. The visible spectrum ranges from 380 to 760 nm with a maximum of photopic sensitivity at around 555 nm (0.555 m); in this way the irregularities of the corneal surface have an insignificant optic effect only when they produce a

Antonio Calossi

wave aberration of less than 0.14 m, which approximately corresponds to a surface irregularity of 0.4 m (see appendix). The small irregularities in the external surface of the cornea due to microfolds and micro-villi of the corneal epithelium are smoothed by the tear film. One of the functions of the tear film is the maintenance of the smoothness of the optical surface. The mean central thickness of the tear film is about 10 m[12]. If the tear film is distributed over the corneal epithelium in a uniform manner, the dioptric effect is zero because it behaves as a afocal flat lamina. In reality, in the time span between one blinking action and the next, there are irregularities of thickness of the various components of the tear film, in the order of the light wave length, which can influence the quality of the retinal image[13-15]. The front surface of the cornea supplies the largest individual contribution to the overall dioptric power of the eye, because of the large jump in refractive index between air and the cornea. As a result, the shape is extremely important in the determination of the aberration of the retinal image. In Gullstrands schematic eye[16], which have an overall power of 60D, the anterior surface of the cornea has power of approximately +49 D (about 80% of the entire system) while the posterior face has a power of 6D. This means that the total dioptric power of the cornea is +43D. The paraxial power (P) of a dioptric surface depends on the radius of curvature (r), and the difference in the refractive index of the two media separated by this surface: n n P= 2 1 r the greater the difference in this index, the greater the dioptric power of that surface. The difference in refractive index between air and the cornea is nine and a half times greater that the difference between the cornea and aqueous; small variations in the shape of the anterior surface are sufficient to create a significant dioptric variation. Each change in radius curvature equal to 4/100 of a millimeter corresponds to a dioptric variation of 0.25D. In this way, it is obvious that the careful study of the corneal surface is particularly important in optical terms. The modern techniques of computerized video-keratography consent accurate quantitative measurements of thousands of points on the corneal surface. In order to analyze the optical quality of the cornea, we examined some video-keratographic indices that we have defined as kerato-refractive indices[17]. These indices have been devised to provide a simple method for quantity, with just a few yet significant numerical values how much the surface of the optical zone of the cornea in examination differs from the ideal cornea. Before we describe these indices, we should take a look at how an ideal cornea should appear. The area of the cornea that contributes to the formation of the foveal image is called the optical zone. This area of the cornea covers the entrance pupil. What we see when we observe an eye from the outside are not the real pupil and iris, but the virtual image of these structures created by the cornea. The virtual image of the pupil, back on the object

The optical quality of the cornea

Figure 1. The incident light rays are refracted by the cornea and pass through the real pupil. The only area of the cornea that is useful for the formation of the foveal image is the area of the cornea that covers the entrance pupil diameter because the light rays that are refracted from other parts of the cornea and directed towards the fovea are screened by the iris.

space, is called the entrance pupil. In Gullstrands schematic eye, the entrance pupil is about 14% larger than the real pupil[18]. The light rays directed towards the pupil are refracted by the cornea and pass through the real pupil (Figure 1). The only portion of the cornea useful for the creation of the foveal image is the area of the cornea that covers the entrance pupil because the light rays which are refracted by other portions of the cornea and directed towards the fovea are screened by the iris. More peripheral portions of the cornea contribute to the formation of images in the peripheral field, in a retinal zone outside the foveal area. The more one shifts away from the foveal area, the greater the width of the retinal receptive fields. This causes a rapid degradation of the resolution power of the peripheral retina[19,20]; in this way, the clarity of the images in the peripheral visual field has little effect on the general visual performance[21]. The diameter of the pupil determines the width of the useful optical zone, which varies as a function of the pupillary dynamics. For a constantly good retinal image, there should be no aberrations within the entrance pupil under conditions of maximum physiological mydriasis. Nevertheless, it should be remembered that under Stiles-Crawford Effect (SCE) of the first kind[22-24] the portion of the cornea that covers the more central area of the pupil supplies a brighter image that formed by the cornea which covers the peripheral area of the entrance pupil: if a light ray that passes through the center of the pupil is perceived with 100% brilliance, a light ray that passes through the pupil at a distance of 1 mm, will be perceived as 93% brilliance, at 2 mm 71%, and at 3 mm from the center of the pupil, only 41% of brilliance will be perceived due to this effect. The aberrations in the central optical zone have a greater effect than those closer to the edge. From an optical point of view, the ideal cornea must have an optical zone consisting of an elliptical surface, with an adequate shape factor (asphericity), it must be perfectly smooth and have the apex centered on the visual axis. There will be spherical aberration if the shape factor is not adequate; if the apex is not centered, there will be a prismatic effect, astigmatism from oblique incidence and coma; if the surface is irregular, there will be high order aberrations.

Antonio Calossi

 Corneal asphericity and spherical aberration

Conics
The expression aspheric surface simply means a surface that is not spherical. However, this expression is commonly used to indicate the surfaces that can be described by the equation of a conic. The conic curves have been given this name because they are generated by the section of a cone with a plane more or less tilted with respect to the base, and these are: the circle, the ellipse, the parabola and the hyperbole. Each of these curves, if rotated on its axis of symmetry creates respectively a sphere, and elipsoid, a paraboloid and a hyperboloid. These solid figures are called conicoids. The typical corneal section is a prolate ellipse, consisting of a more curved central part, the apex, with a progressive flattening towards the periphery. The asphericity of the cornea is usually defined by determining the asphericity of the conicoid which best fits the portion of cornea to be studied. If we accept this first approximation, the profile of a meridian can be defined with two values*: the apical radius (which is on the vertex of the conic), which can be expressed in terms of a circle with the same degree of curvature, and a shape factor, which represents the variation in curvature from the apex towards the periphery and which defines the degree of asphericity (Figure 2). This ultimate parameter can be defined in a number of different ways[25]. There are four different coefficients for expressing the shape factor of a conic, each one of which is used in a different way to quantify the same thing: the shape factors p and SF, the eccentricity e, and the coefficient of asphericity Q. If one of these indices is known, others can be calculated using the conversion formulas reported in Table 2. Any conic can be represented by the following equation[26]: y2 = 2r0 x px2 (1) where y is the semi-chord, or rather the distance of a point on the curve from the axis of symmetry; if the conic represents the section of an aspheric optical surface, the value y is the distance of a point on the surface from its optical axis, x is the sagitta of the section, r0 is the apical radius, while p indicates the rapidity of flattening or curving as we move away from the apex. In an ellipse, if a is the major semi-axis and b the minor semi-axis, the value p indicates the following proportion:
* One number is sufficient for the definition of a circle or a sphere: the radius of curvature; in order to define a conic or a conicoid two numbers suffice: the apical radius and the shape factor. In actual fact, in order to define a circle univocally, we also need to know the position of its center with respect to the reference system. In a similar manner, for the definition of a conic in an equivocal manner, in addition to the apical radius and the shape factor, we also need to know the position of the apex and the direction of axis of symmetry.

Figure 2. Baker's equation: p indicates how rapidly the cornea flattens or curves as we move further from the apex, so it represents the degree to which the aspheric surfaces differ from the spherical form.

p=

b2 a2

(2)

The equation (2) shows that in the circle, which is the limit case of the ellipse, b = a and therefore p = 1 The parabola is another limit case, where a tends to infinity and therefore p = 0. The prolate ellipses are a family of curves where the major axis coincides with the x axis, b is less than a and therefore p varies between 0

The optical quality of the cornea

p Hyperbole <0 Parabola 0 Prolate ellipse 0 < p <1 Circle 1 Oblate ellipse >1 Average/normal cornea 0.8

Q < -1 -1 -1 < Q < 0 0 >0 -0.2

e >1 1 0 < e <1 0 <0 0.45

SF (= e2) >1 1 0 < SF <1 0 <0 0.2

Table 1. Different types of conical section with the corresponding values of the various coefficients of asphericity.

p= Q= e= SF =

p p1 1 p 1p

Q 1+Q Q Q

e 1 e2 e2 e2

SF 1 SF SF SF

Table 2. Formulas of conversion between the various shape factors of a cone.

and 1. The closer p is to 1, the less elongated the shape will be. In an oblate ellipse p is greater than 1. In this case, the minor axis will be found along the x axis and therefore the surface will be progressively more curved as we move away from the apex. In a hyperbole, p < 0. The shape factor p is a value that indicates how much a curve differs to a parabola instead of a circle. For this reason, a commonly used term for defining the asphericity is Q, which is related to p by the equation Q=p1 (3) If Q = 0 the curve is a circle; if Q lies between 1 and 0 the curve is a prolate ellipse; if Q = 1 it is a parabola; if Q < 1 a hyperbole; if Q > 0 the curve is an oblate ellipse. It is likely that the term Q is not highly intuitive because the normal prolate corneas, are expressed as negative numbers. An alternative way of expressing the degree of flattening of a conic is to use the term eccentricity (e). The relationship between e and p is the following: p = 1 e2 and therefore e=1p (5) If e = 0 the curve is a circle; if it lies between 0 and 1 the curve is an ellipse; if e=1, the curve is a parabola; if e > 1 the curve is a hyperbole. The main problem that emerges when eccentricity (e) is used to express the shape of a conic is that sometimes p can have a value greater than 1, so in these cases e2 is negative, and e no longer makes sense because it equals the square root of a negative number. Negative values of e are purely conventional and, for the oblate ellipse, they can be expressed in the following way: if p > 1 then e = p 1 With this convention, if e < 0 the curve is oblate. The second problem with the parameter e is that the relationship between the variations of eccentricity and the variations of peripheral flat(4)

Antonio Calossi

p 3.00 2.90 2.80 2.70 2.60 2.50 2.40 2.30 2.20 2.10 2.00 1.90 1.80 1.70 1.60 1.50 1.40 1.30 1.20 1.10 1.00 0.90 0.80 0.70 0.60 0.50 0.40 0.30 0.20 0.10 0.00 -0.10 -0.20 -0.30 -0.40 -0.50 -0.60 -0.70 -0.80 -0.90 -1.00 -1.10 -1.20 -1.30 -1.40 -1.50 -1.60 -1.70 -1.80 -1.90 -2.00 -2.10 -2.20 -2.30 -2.40 -2.50 -2.60 -2.70 -2.80 -2.90 -3.00
v

e -1.41 -1.38 -1.34 -1.30 -1.26 -1.22 -1.18 -1.14 -1.10 -1.05 -1.00 -0.95 -0.89 -0.84 -0.77 -0.71 -0.63 -0.55 -0.45 -0.32 0.00 0.32 0.45 0.55 0.63 0.71 0.77 0.84 0.89 0.95 1.00 1.05 1.10 1.14 1.18 1.22 1.26 1.30 1.34 1.38 1.41 1.45 1.48 1.52 1.55 1.58 1.61 1.64 1.67 1.70 1.73 1.76 1.79 1.82 1.84 1.87 1.90 1.92 1.95 1.97 2.00

Q 2.00 1.90 1.80 1.70 1.60 1.50 1.40 1.30 1.20 1.10 1.00 0.90 0.80 0.70 0.60 0.50 0.40 0.30 0.20 0.10 0.00 -0.10 -0.20 -0.30 -0.40 -0.50 -0.60 -0.70 -0.80 -0.90 -1.00 -1.10 -1.20 -1.30 -1.40 -1.50 -1.60 -1.70 -1.80 -1.90 -2.00 -2.10 -2.20 -2.30 -2.40 -2.50 -2.60 -2.70 -2.80 -2.90 -3.00 -3.10 -3.20 -3.30 -3.40 -3.50 -3.60 -3.70 -3.80 -3.90 -4.00

e2 -2.00 -1.90 -1.80 -1.70 -1.60 -1.50 -1.40 -1.30 -1.20 -1.10 -1.00 -0.90 -0.80 -0.70 -0.60 -0.50 -0.40 -0.30 -0.20 -0.10 0.00 0.10 0.20 0.30 0.40 0.50 0.60 0.70 0.80 0.90 1.00 1.10 1.20 1.30 1.40 1.50 1.60 1.70 1.80 1.90 2.00 2.10 2.20 2.30 2.40 2.50 2.60 2.70 2.80 2.90 3.00 3.10 3.20 3.30 3.40 3.50 3.60 3.70 3.80 3.90 4.00

LSA 3 mm +2.43 +2.33 +2.23 +2.12 +2.02 +1.92 +1.82 +1.72 +1.62 +1.52 +1.43 +1.33 +1.23 +1.14 +1.04 +0.95 +0.85 +0.76 +0.66 +0.57 +0.48 +0.39 +0.30 +0.21 +0.11 +0.03 -0.06 -0.15 -0.24 -0.33 -0.18 -0.50 -0.59 -0.68 -0.76 -0.85 -0.93 -1.01 -1.10 -1.18 -1.26 -1.35 -1.43 -1.51 -1.59 -1.67 -1.75 -1.83 -1.91 -1.99 -2.07 -2.15 -2.22 -2.30 -2.38 -2.45 -2.53 -2.61 -2.68 -2.76 -2.83

LSA 5 mm +7.90 +7.51 +7.13 +6.76 +6.39 +6.03 +5.68 +5.33 +4.99 +4.66 +4.34 +4.01 +3.70 +3.39 +3.09 +2.79 +2.50 +2.21 +1.93 +1.65 +1.37 +1.10 +0.84 +0.58 +0.32 +0.07 -0.18 -0.42 -0.66 -0.90 -0.48 -1.37 -1.59 -1.82 -2.04 -2.25 -2.47 -2.68 -2.89 -3.09 -3.30 -3.50 -3.69 -3.89 -4.08 -4.27 -4.46 -4.64 -4.83 -5.01 -5.18 -5.36 -5.53 -5.71 -5.88 -6.04 -6.21 -6.37 -6.53 -6.69 -6.85

LSA 7 mm +21.35 +19.89 +18.53 +17.24 +16.03 +14.88 +13.79 +12.76 +11.78 +10.85 +9.96 +9.11 +8.29 +7.51 +6.76 +6.04 +5.35 +4.69 +4.05 +3.43 +2.83 +2.26 +1.70 +1.16 +0.64 +0.14 -0.35 -0.82 -1.28 -1.73 -1.85 -2.59 -3.00 -3.40 -3.79 -4.17 -4.54 -4.90 -5.25 -5.59 -5.93 -6.25 -6.57 -6.89 -7.19 -7.49 -7.78 -8.07 -8.35 -8.62 -8.89 -9.15 -9.41 -9.66 -9.91 -10.16 -10.39 -10.63 -10.86 -11.08 -11.30

Table 3. Conversion table for the different notations of asphericity with the corresponding longitiudinal spherical aberration (LSA) (calculated for n = 1.376, r = 7.80 mm).

The optical quality of the cornea

tening coefficients is not linear. The variation in curvature which corresponds to 0.1 units of e is difference in the transition from 0.1 to 0.2 compared to the transition from 1.1 to 1.2 in the first instance the two curves are almost the same, in the second case, they differ considerably. For this reason, sometimes the shape factor of a cornea is indicated in terms of e2. Originally, this was chosen for the Wesley-Jessen[27,28] Photoelectronic Keratoscope (PEK), where the term e 2 was replaced by SF (shape factor). As a result SF = e2 and SF = 1 p (5) As for p, SF was introduced in an attempt to produce a definition for the oblate forms as well, that steepem from the apex towards the periphery. If e2= 0 the curve is a circle if e2 lies between 0 and 1, the curve is a prolate ellipse; if e2= 1 the curve is a parabola; if e2> 1 the curve is a hyperbole; if e2< 0 the curve is an oblate ellipse. We would like to point out that if we use SF (or e2) to describe the shape of the cornea, the terms negative and positive asphericity mean the opposite to Q, given that 0 < SF < 1 for a prolate ellipse and SF < 0 for an oblate ellipse. This may cause some confusion, given that the same surface can be described by a positive or negative number, depending on whether SF or Q have been used. Table 1 summarizes the various types of conic section with the corresponding values of the different shape factors; table 2 summarizes the equations of conversion between the various coefficients, while table 3 reports the various values of asphericity in different notations. In the more recent publications of optometric literature, the value p is reported frequently while the coefficient Q is used more frequently in the ophthalmology journals; in publications relative to contact lenses, the common term is eccentricity (e). Personally, we prefer the index e2, which we prefer to define as asphericity (e2), instead of SF, because for a sphere the value is zero. Contrary to Q, in the prolate surfaces, as in a physiological cornea, the value e2 is positive and increases with an increase in the degree of asphericity. In oblate corneas which have a reverse shape with respect to the physiological cornea, asphericity (e2) has a value of less than zero; the negative value is greater the more the geometry is reverse, or rather the more the cornea is oblate. The index e2 lacks the limits of eccentricity (e) in that it is linear and easily consents the representation of the oblate surfaces. If the index of asphericity (e2) is used, the equation of a conic (1) becomes: (6) y 2 = 2 r 0x (1 e 2) x 2 while in the three-dimensional version of the conic, that is a conicoid with the axis of revolution Z, can be expressed in the following form: x 2 + y 2 + (1 e 2) z 2 2 zr 0 = 0 (7) (4)

Antonio Calossi

The real cornea and the elliptical model

Approximating the corneal profile to a conic is useful from a mathematical point of view, because as we mentioned already, this permits the straightforward description of its shape, using just two parameters: the apical radius and an index that expresses how much the curve differs from the circumference described by the apical radius. In the field of eye optics, this approach is useful for examining the spherical aberration.[29] Generally-speaking, it is possible to closely approximate the profile of each meridian and semi-meridian of the cornea to an elliptical curve. The direct evolution of the elliptical model is the ellipso-toric model[30], that is, a surface where every meridian has a different apical radius; a meridian of maximum and minimum curvature can be identified and the difference between these two produces the corneal astigmatism, and along each meridian, from the center to the periphery, the curvature flattens with elliptical progression.[31] In actual fact the cornea differs from the mono-elliptical progression in the more peripheral areas, where the flattening is more accentuated and the asphericity is greater than at the center. However, in many cases, the ellipse is still a valid model for the optical zone of the cornea. Table 4 and figure 3 report the mean values of asphericity of the anterior surfaces of the cornea for a diameter of 8 mm, in addition to an optical zone of 4.5 mm in a sample of 1030 normal eyes of 515 patients (282 females and 233 males, aged between 14 and 82 years (mean 38.9, SD 14.6), measured using the Eye Top CSO topograph (Florence, Italy). The conic model includes some approximations and, in particular, assumes that the apex coincides with the vertex and with the geometrical center of the cornea, and that the corneal surface is symmetrical in relation to the line of sight. In actual fact, this model is excessively simplified, because each cornea has a specific profile, like a finger-print[32], and in some cases, particularly in the presence of pathologies, trauma, or resulting from surgery, the profile of the cornea is completely different to the one described above. In order to define corneal asphericity, the best-fit asphero-toric surface can be calculated, or rather, the profile that minimizes the difference in curvature between the surface and the portion of cornea that is represented. The degree with which this surface reflects the cornea may be defined by an index, RMS (root mean square) which means how far the surface measured differs on average from the best-fit. The RMS, or the standard deviation, of the instantaneous curvature can be used as an index of surface irregularity because it indicates how far the corneal surface dife2 8 mm 0.28 0.13 0.05 0.86 Q 8 mm 0.28 0.13 0.86 0.05 p 4.5 mm 0.86 0.12 0.47 1.21 e 4.5 mm 0.31 0.24 0.46 0.73 e2 4.5 mm 0.14 0.12 0.21 0.53 Q 4.5 mm 0.14 0.12 0.53 0.21

Distribution of the frequency of the corneal asphericity (e2) on a diameter of 8 mm in a sample of 1030 normal eyes (continuos line represent the normal distribution)

Distribution of the frequency of the corneal asphericity (e2) on a diameter of 4.5 mm in a sample of 1030 normal eyes (continuos line represent the normal distribution)
v

Figure 3

Mean Std. Dev. Minimum Maximum

v

p 8 mm 0.72 0.13 0.14 1.05

e 8 mm 0.51 0.14 0.22 0.93

Table 4. Mean values, standard deviation and range of asphericity, expressed in the various notations, relative to the anterior surface of the cornea on a diameter of 8 mm and an optical zone of 4.5 mm in a sample of 1030 normal eyes in 515 subjects, measured with the CSO topograph.

The optical quality of the cornea

fers from a perfectly smooth asphero-toric surface[17]. In the sample of 1030 normal eyes that we described above, for an area of pupil of 4.5 mm, the mean value of this irregularity index was 0.44 D (SD 0.11) (Tab. 5).

Corneal aberrations following refractive surgery

v

The conventional procedures of photoablative or incisional refractive surgery, normally make a significant improvement to the low order refractive defects (defocus and regular astigmatism) but produce higher order corneal aberrations which were not observed prior to surgery.[33-35] There is usually only an increase of spherical aberration (Figure 4), while in cases which are complicated by decentering, surface irregularities, regression and ectasias, more invalidating aberrations, such as coma, may appear (Figure 5) in addition to other high order aberrations (Figure 6). The spherical aberration is symmetrical and the light rays that pass through the paraxial zone of the pupil focus at a different distance that the rays that pass through the marginal pupil. By convention, the spherical aberration is positive when the marginal rays focus ahead of the paraxial rays, whereas it is negative when the opposite is true. The difference in diopters between the marginal and paraxial focal points is called the Longitudinal Spherical Aberration (LSA). In general, a single dioptric surface that separates two homogeneous media can be made free from spherical aberration for a given pair of conjugate axial points (i.e. for an object point placed on the optical axis at a determinate distance) of its section os a perfect Cartesian oval[36,37]. This is a curve of the fourth degree, not an ellipse but a true oval. For certain special pairs of conjugates, the curve degenerates into various conic sections including a circle, hence the aplanatic point of a sphere. Unfortunately, a surface free from spherical aberration for a specified pair of conjugates will exhibit some aberration for all other pairs. If, as in the case of the cornea, the medium that gives origin to the light rays is air and the object is placed at infinity, the perfect oval has the shape of a prolate ellipsoid where the asphericity (e2) is given by the following equation: 1 e2 = 2 n where n is the refractive index of the medium that refracts the rays. For corneal tissue n is 1.376 and in this case e2 should be 0.5282 (e = 0.7268; p = 0.4718; Q = 0.5282). In a normal eye, it is unlikely that the cornea will have this value of asphericity. There is normally a certain quantity of positive spherical aberration that we can consider physiological[38-40]. As for all the monochromatic aberrations, the value of the spherical aberration increases with an increase in pupil diameter. If the value of asphericity remains constant, LSA will increase with the square of the pupil diameter (Figure 7). If the pupil diameter remains fixed, the spherical aberration

Figure 4. Spherical aberration.

Figure 5. Coma.

Figure 6. High order aberration.

Figure 7. Spherical aberration as a function of the diameter (p = 0.80, r = 7.80 mm).

Antonio Calossi

Figure 8. Spherical aberration as a function of r (p = 0.80; diam. 4.5 mm).

Figure 9. Spherical aberration as a function of p (r = 7.80; diam. 4.5 mm).

becomes a function of the value of asphericity, the refractive index and the radius of curvature. If we consider the refractive index, the pupil diameter and the asphericity as constant, the spherical aberration will be reduced if the corneal surface flattens, and increases as the cornea becomes more curved (Figure 8). With equal curvature, the longitudinal spherical aberration becomes negative if the surface is more prolate than Cartesian oval shape; it will become positive if it is less prolate, spherical or oblate (Figure 9). Table 3 reports different values of asphericity in the different notations with the corresponding longitudinal spherical aberration (LSA). Positive spherical aberration is greater the more the cornea is oblate. Following myopic photoablative treatment, the effect of reduction in the spherical aberration due to flattening is normally not sufficient to compensate for the increase in spherical aberration due to the substantial variation in shape obtained with the majority of the current ablation profiles. This effect is even greater in the incisional operations of radial keratotomy, where with equal dioptric correction, the cornea becomes even more oblate. The opposite occurs with hypermetropic treatments, the current ablation profiles produce a hyper-prolate cornea. This variation in shape produces a negative spherical aberration which is normally not compensated by the increase in positive from the increased curvature. The spherical aberration of the anterior corneal surface is added to that of the posterior surface and that of the lens. These will tend to compensate if they are of opposite signs.[38-40] If all the components of spherical aberrations do not mutually compensate, the image of a point-object will consist of a disk surrounded by a diffused halo. If the overall spherical aberration is not excessive, there will be a slight loss in contrast, with an improvement in the depth of the field.[41] The latter phenomenon is due to the multifocal effect of the spherical aberration. This is the reason why, in the event of residual ametropia, th eyes operated by corneal refractive surgery have a better unaided visual acuity that would be expected on the basis of the residual refractive error.[42,43] A slight residue of spherical aberration may also prove useful in the event of presbyopia. This is the principle of some type of multifocal contact lenses with simultaneous vision and the multi-focal intraocular lenses,

Figure 10. Asphericity as a function of the Surgically Induced Refractive Change (SIRC) to obtain physiological spherical aberration. Preop: Q = 0.2; r = 7.80 mm; LSA for 5 mm +0.84 D (Q =-e2).

10

The optical quality of the cornea

which have been created in such a way as to produce a certain degree of spherical aberration. With these lenses, if the spherical aberration is positive (as in a myopic treatment), the center of the pupil is used for distance vision and the peripheral zones for near; vice-versa, if the spherical aberration is negative (as in a hypermetropic photoablative treatment), the center is for near vision and the periphery for distance. If the spherical aberration becomes excessive, there can be a significant loss in contrast and blurring of the images that can be irritating and invalidating particularly under conditions of low light intensity, when the increase of the pupil diameter causes an increase in the value of spherical aberration. It is not easy to define a threshold for spherical aberration that can be tolerated or that might be useful, as the subjective responses to the loss of contrast sensitivity and tolerance to blurring are extremely variable. In the cases of refractive surgery treatments on virgin corneas, it is a good rule to leave the same value of spherical aberration. The graph in Figure 10 reports the values of asphericity necessary to maintain the physiological value of the corneas spherical aberration (the mean value of an un-operated eye) in function of the spherical equivalent corrected with photoablative surgery. However, when the surgeon intentionally aims for a certain degree of spherical aberration, it is possible to simulate different values of spherical aberration using contact lenses with appropriate eccentricity in order to choose the one that produces the most satisfactory visual results. Even when an optic system is correct in terms of spherical aberration and focuses all the rays perfectly on the optical axis, the quality of the images of the points which are just off the axis will not be perfect, unless the system is also corrected for coma. The coma aberration takes its name from the fact that the image of a luminous dot which is positioned just slightly off the axis of a lens appears like a comet, with a central nucleus, where the greatest quantity of light energy is concentrated, in addition to a tail that is laterally blurred. This phenomenon derives from the fact that the linear magnification of a lens is a function of the height with which the rays are incident on it. If the magnification of the rays that pass more externally through the lens is greater than that of the central rays, we say that the coma is positive; if the opposite is true, the coma is negative. In a real eye, the foveal image is affected by coma due to the loss in symmetry of the eye in relation to an appropriate axis. Coma is probably the worst type of aberration due to the asymmetrical blurring which produces very ugly image.

Keratorefractive indices
(Calossi, Vinciguerra) The peculiarities of the shape of a specific cornea which determine the optical propertys we mentioned before can be quantified using some numerical indices (Figure 11) and compared with those of an ideal cornea or with a range of normality. We will now describe our proposal[17] which

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was implemented in the eye top CSO topograph (Florence, Italy). We have already mentioned that the portion of the cornea useful for the creation of the foveal image is the area that covers the entrance pupil; each eye has its pupil diameter that changes with the various light conditions; however, in order to compare the different cases, for each eye we selected a fixed entrance pupil. The numerical values of our indices represent the following parameters.
v

Figure 11. Calossi-Vinciguerra keratorefractive indices.

Astigmatism 3 mm: corneal toricity expressed in diopters in an area of cornea of diameter 3 mm, centered on the corneal vertex; 5 mm: corneal toricity expressed in diopters in an area of cornea of diameter 5 mm, centered on the corneal vertex. For the two diameters, these two values represent the degree and the axis of the regular astigmatic component of the cornea. A difference in the axis or power between the two diameters indicates the presence of irregular astigmatism, which cannot be efficaciously corrected with an spectacle lens. Mean pupillary power This is the mean axial curvature, expressed in diopters, for an entire portion of cornea of diameter 3 mm centered on the entrance pupil, taking the Stiles-Crawford effect into consideration; that is, giving greater importance to the central points. This parameter represents the spherical equivalent of the cornea within a pupillary zone of diameter 3 mm. This parameter is useful for the definition of the mean central curvature in irregular corneas, for example in keratoconus, perforating keratoplasty, trauma etc. or extremely aspherical corneas, for example after refractive surgery. Asphericity This is the mean asphericity of an area of cornea of diameter 4.5 mm, centered on the center of the pupil. It is a coefficient the degree to which the optical zone of the cornea is prolate or oblate. It can be expressed as any of the four parameters we described above. Spherical aberration Longitudinal spherical aberration (LSA) expressed in diopters of an area of cornea of diameter 4.5 mm, centered on the center of the pupil. It expresses the difference between the marginal and the paraxial power. It is calculated by applying a procedure called ray tracing to the best-fit conic on a pupillary zone of 4.5 mm.

Asphericity (p) Long. spher. aberration LSA (D) Irregularity of curvature RMS (D) Surface asymmetry SAI (D)

Mean +0.86 +0.82 +0.44 +0.27

Std. Dev. +0.12 +0.25 +0.11 +0.16

Mean 2SD +0.62 +0.32 +0.22 0.00

Mean + 2SD +1.10 +1.32 +0.66 +0.59

Mean 3SD +0.50 +0.07 +0.11 0.00

Mean + 3SD +1.22 +1.57 +0.77 +0.75

Minimum +0.47 0.00 +0.22 +0.04

Maximum +1.21 +1.69 +1.06 +1.18

Table 5. Kerato-refractive indices in a sample of 1030 normal eyes. These four indices have been calculated on an area of cornea of diameter 4.5 mm centered on the center of the pupil.

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The optical quality of the cornea

 Irregularity of curvature Standard deviation (or Root Mean Square RMS) of the instantaneous curvature with respect to a best fit aspherical surface, calculated for an area of cornea of diameter 4.5 mm centered on the pupil and expressed in diopters. A zero index of irregularity indicates a perfectly smooth surface that can be approximated to aspheric-toric. Surface asymmetry SAI (Surface Asymmetry Index) is the index of surface asymmetry of the area of cornea of diameter 4.5 mm, centered on the center of the pupil, calculated as the mean difference between the instantaneous curvature along two opposite semi-meridians on each meridian. A cornea with a perfectly symmetrical optical zone has a SAI value of zero. In the event of asymmetry, the mean instantaneous curvature of the flattest corneal hemisphere of the area of the cornea of diameter 4.5 mm, centered on the center of the pupil, is indicated in blue, while red indicates the mean curvature of the corneal hemisphere of greater curvature. In order to facilitate the clinical interpretation of these indices, the values of asphericity, spherical aberration, irregularity of curvature and asymmetry (SAI), are compared with the values measured in a sample of normal eyes. The values that lie between two standard deviations from the means of the normal population are considered to be the physiological values and are indicated in green; the values that lie between two and three standard deviations from the mean of the normal population are considered to be suspect and are indicated in yellow. The values that lie beyond three standard deviations from the mean for the normal population are considered to be abnormal and are indicated in red. Table 5 reports the mean values and the standard deviations of a sample of 1030 normal eyes, that we have described and that we can consider as physiological intervals of the shape defects of the corneas optical zone. Figure 12 reports the distribution of the frequencies. We will now present some examples where the keratorefractive indices contribute to quantifying the optical quality of the corneal surface. In order to make a direct comparison, all the maps of curvature have been reported on an absolute scale.

Normal cornea
Figure 13 reports the maps of axial curvature of a normal cornea with slight physiological with-the-rule astigmatism (Sim-K: 41.59/42.81 ax 10), Figure 14 reports the map of the instantaneous curvatures. The profiles of instantaneous curvature (Figure 15) highlight the regular

Figure 12. Distribution of the frequency of the Calossi-Vinciguerra keratorefractive indices for a sample of 1030 normal eyes. The asphericity, which in this case has been expressed in relation to p, has a normal distribution (shown by the continuous curve). The same applies to the spherical aberration (LSA). Corneal irregularity (RMS) and surface asymmetry (SAI) have an asymmetrical distribution (skewness RMS = 1.07; skewness SAI = 1.48) due to the fact that the minimum possible value of these two indices is ZERO; as a result the distribution tail of the frequencies can only develop in the direction of position values; the distribution of SAI is leptocartic (kurtosis = 3.23), that is, with a peak of the frequency superior to that expected of normal distribution, with a mode of 0.15 and a median of 0.23 D.

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Figure 13. Map of the axial curvature for a normal cornea with mild with-the-rule physiological astigmatism.

Figure 14. Map of the instantaneous curvature of a normal cornea with mild with-the rule physiological astigmatism.

Figure 15. Profiles of instantaneous curvature of the principal meridians of a normal cornea with mild physiological with-the-rule astigmatism. The red line indicates the meridian of greatest curvature, in this case 100, while the blue line indicates the meridian of flattest curvature, in this case 10, the green line (dK) indicates the difference between the two meridians, or the corneal toricity at different distances from the center, which in this case tends to be fairly constant.

Figure 16. Keratorefractive indices: the green numbers for asphericity, spherical aberration, irregular curvature and asymmetry indicate that the values in this case lie between the two standard deviations of the mean for a normal population.

form of the cornea with a slightly prolate central zone and mild toricity which is constant on the entire surfaces. The kerato-refractive indices in this case (Figure 16) are all within normal limits: corneal astigmatism is 1.30 D ax 8 at 3 mm and 1.14 D ax 11 at 5 mm. The slightly prolate asphericity (e2 = 0.21, e = 0.46) with a mean pupillary curvature of 42.27 D at 4.5 mm produce a slight physiological spherical aberration of +0.61 D; slight curvature irregularity (0.32 D) as with the slight surface asymmetry (0.33) are compatible with normal limits.

Herpetic keratitis
In this case, irregularity of the corneal surface can be observed due to scars from herpetic keratitis. The effects of this can be examined in the

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The optical quality of the cornea

axial map (Figure 17), in the map of the instantaneous curvature (Figure 18) and in the profiles of the extremely irregular curvature (Figure 19). The keratorefractive indices (Figure 20) indicate substantial irregularity in the keratometric astigmatism which is 2.72 D at 3 mm and becomes 1.02 D at 5 mm, the axis shifts from 26 for 3 mm to 69 at 5 mm; the irregularity of curvature has a value of 1.61 D which is significantly outside normal limits; asphericity that is greater than normal levels (e = 0.90, e2 = 0.81) produces slight negative spherical aberration of 0.58 D which is of minor significance; the same applies to the surface asymmetry of 0.84 D which is slightly greater than normal levels.

LASIK, small optical zone

This case of LASIK for myopia had a very poor qualitative outcome. The axial map (Figure 21) highlights large-scale asymmetric multi-focality; the map of the instantaneous curvature (Figure 22) indicates an excessively small zone of 4 mm and that the center of ablation is de-

Figure 17. Axial map of a cornea scarred

by herpetic keratitis.

Figure 18. Map of instantaneous curvature relative to the previous case.

Figure 19. Profiles of instantaneous curvature relative to the previous case.

Figure 20. Keratorefractive indices relative to the previous case.

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Figure 21. LASIK for myopia, excessively small optical zone excessively prolate and decentered. The axial map highlights the asymmetrical multi-focal properties of the pupillary zone (the yellow ring represents the pupil diameter in this case under photopic conditions, the small yellow cross is the center of the pupil, the large white cross represents the main meridians of the sim-K. The meeting point corresponds to the corneal vertex).

Figure 22. Map of instantaneous curvature relative to the previous case.

Figure 23. Profiles of instantaneous curvature relative to the previous case.

Figure 24. Keratorefractive indices relative to the previous case.

centered by 0.5 mm in an infero-nasal direction. The profiles of instantaneous curvature (Figure 23) highlight that the optical zone is extremely oblate and has an irregular surface. From the kerato-refractive indices (Figure 24) we can observe a strong spherical aberration which with the pupil of 4.5 mm is +4.84 D, caused by excessive negative eccentricity (e = 1.6, e2 = 2.57); the index of surface irregularity is significantly outside normal levels (1.77 D); the same applies to values of asymmetry (1.36 D).

Asymmetric PRK
In this case, a decentered treatment was further complicated by epithelial hyperplasia in the upper zone which produced a strong asymmetry of the optical zone of this cornea. The instantaneous map (Figure 25)

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The optical quality of the cornea

Figure 25. Map of instantaneous curvature relative to the decentered PRK treatment, further complicated by epithelial hyperplasia in the superior zone.

Figure 26. Map of instantaneous curvature relative to the previous case.

Figure 27. Profiles of instantaneous curvature highlight the asymmetry of the vertical meridian represented by the red line.

Figure 28. Keratorefractive indices relative to the previous case.

highlights the morphological aspects of the treatment that, as can be seen from the axial map (Figure 26), has produced a very poor optical result. The profiles of instantaneous curvature (Figure 27) show strong vertical asymmetry. The keratorefractive indices (Figure 28) show a mild spherical aberration (LSA +1.61 D), which despite being outside normal limits, is of little importance. However, the asymmetrical component is important (SAI 2.00 D), as is the surface irregularity (2.06 D).

Excellent PRK
The map of axial curvature (Figure 29), and the map of instantaneous curvature (Figure 30), show the excellent outcome of a PRK treatment for a myopic defect of6.00. The profiles of curvature (Figure 31) highlight the extreme regularity due to the excellent smoothing of the surface treated. The indices (Figure 32) indicate a fairly flat pupillary area

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Figure 29. Map of axial curvature in a perfect case of PRK treatment for myopia of 6.00 D.

Figure 30. Map of instantaneous curvature relative to the previous case.

Figure 31. The profiles of istantaneous curvature underline that the optical zone is almost spherical and extremely regular.

Figure 32. The keratorefractive indices underline the good quality of the surface in the cornea.

(39.35 D), a minimally-oblate optical zone (e = 0.41, e2 = 0.17), and spherical aberration within normal limits (+1.14 D). Astigmatism lies with physiological levels at 3 mm (0.77 D ax 9) and at 5 mm (0.46 D ax 5). The indices of irregularity (0.40 D) and of asymmetry (0.11 D) are excellent.

Zernikes analysis of the corneal surface

An even more detailed examination of the optical quality of the corneal surface and the wave-front generated by the anterior surface of the cornea can be obtained using Zernikes analysis. This is a sophisticated analytical method ideal for representing surfaces of any shape. It is based on a set of orthonormal polynomials developed in the Thirties by

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The optical quality of the cornea

Frits Zernike,[44] a brilliant scientist who won the Nobel Prize for Physics in 1952 for his invention of the contrast-phase microscope. In the field of optics, Zernikes polynomials are widely used in the interferometric tests, to describe the quality of the surfaces in an optic instrument and in the aberrometric measurements, where wave-front sensors are used. Using Zernike's analysis, any surface can be described as the weighted sum of typical shapes represented by the polynomials. The series of polynomials is of increasing order and potentially infinite. Obviously, the greater the number of polynomials used, the more detailed the surface representation. The more the surface is complex, the greater the number of polynomials used. As we said before, this mathematical procedure is particularly suitable for providing the analytical description of both the optical surfaces and the wave-fronts. The essential advantage of Zernike's polynomials is that they allow the decomposition of any surface, even the most complex, into a series of basically independent components. The components chosen by Zernike are those specific for the wave aberrations. The ortho-normal characteristic of Zernike's polynomials permits the analysis of the individual components of the different aberrations independently of each other, to quantify the importance of any single component and to classify them by order or group. In this way, for example, in a complex aberration, we can quantify the prismatic component, the component of defocus, the degree of regular astigmatism, the spherical aberration, coma and so on. Or alternately we can group together all the spherical-like (of even-number order) or coma-like aberrations (of odd-number order); similarly we can differentiate the degree of aberration that can be corrected with spectacles, that is the entire second order (defocus and primary astigmatism), from the component that cannot be corrected with an ophthalmic lens, that is from the third order onwards; we can also distinguish the primary aberrations from the secondary and the tertiary etc. The various aberrations or groups or aberrations can therefore be quantified as a number or in graphical form. In optic terms, what is of interest is the description of the deformation of a surface, that is any modification of the form that makes it different to the desired shape. Normally the surface is not analyzed directly with Zernike's method, but the operator observes the different between the surface measured - irrespective of whether it is an optical surface or a wave-front - and what the desired surface should be. In this context, the evaluation of perfection of a surface does not refer to a specific absolute shape, but to the shape the surface was scheduled to have. A given optical surface, viewed singularly, can transform the perfect wave front (spherical or plane) into a strongly deformed wave-front. If this action corresponds to the expected action, the aberration is of no account because in the final analysis it will be compensated by those introduced by the others and the surface can be considered perfect for its final purpose. On the contrary, any modification of the surface shape that removes it from the desired shape, can be considered to be a deformation.

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The error of the wave-front associated with this deformation will propagate unchanged through the entire system and can be observed as the wave aberration that the system produced without any deformations. Moreover, the errors of the wave-front are directly additive, so the overall aberration is the algebraic sum of the contribution of aberration of all the components of the optical system. We have already mentioned that in order to describe any shape of surface exactly, it is necessary to have an infinite number of polynomials. In practice, with a finite number of components, we can normally describe even complex optic surfaces and wave-fronts in an extremely valid manner.[45] What remains after what has been described by a set of selected polynomials is the residue which can be quantified numerically or presented as a graph as the difference between the geometrical surfaces described by the set of polynomials and the real surface. The quantity that remains is a group of all the aberrations of higher order than those described by the selected set of polynomials. For example, with 36 polynomials, 7 orders can be represented, in this case the residue is the group of aberrations that are higher than the seventh order.

The CSO program

We applied Zernike's a analysis to altimetric data of the anterior surface of the cornea measured by the Eye Top CSO topograph. Moreover, from the instantaneous curvatures of the corneal surfaces measured using the same instrument, we can trace the normals of this surface. Then by applying Snell's law of refraction to every point measured, it is possible to calculate the wave-front that is generated by the corneal surface. The wave-front calculated is then analyzed by Zernike's method. In this way it is possible to decide whether to display the aberrations of the corneal surface or alternately, the aberrations of the wavefront generated by the anterior surface of the cornea.[46] The optical quality of the human eye is determined by the optical properties of both the cornea and the lens, their optical density and the distribution of their refractive index, their relative alignment, the position of the fovea and the position of the pupil. For this reason, the measurement of the overall optic aberrations consents the most complete description of the properties of formation of the image by the eye; while the combination of the information supplied by corneal topography, with the information on the ocular aberration, if expressed in the same language, provides information the individual optical properties of the single ocular components.[39,40,47,48] In the specific case of the analysis of the aberrations of the corneal surface, as we are not aware of the contribution of the other ocular structures, we presume that the internal aberrations have no influence and we analyze the aberrations by comparing the eye with an ideal cornea that produces a spherical wave-front. Zernike's analysis model can be found in the CSO topograph from ver-

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The optical quality of the cornea

sion 6.0 onwards. For the analysis of the various components of the total aberration, a set of 36 Zernike's polynomials. The results of the analysis are reported in a summary using numerical indices and graphical representations. In this summary (Figure 33), the aberrations are displayed together and split into their various components. In the top left part of the screen, there is the map of the 'Total Aberration' which corresponds to the sum of all the components of aberration with the exception of tilt and defocus, to the 36th polynomial which corresponds to Zernike's 7th order. Below the map, the RMS of the total aberration which consents the numerical quantification of how much the surface in examination differs from the perfect reference surface. When the surface aberration is analyzed, the reference surface is Cartesian oval, that is, the ideal surface that produces a perfectly spherical wave-front. When the aberration of the wave-front is analyzed, the reference surface is a spherical wave-front, that is completely free from aberrations. The wave aberration is represented in terms of OPD (optical path difference). The color scale to the side of the map is expressed in microns and is the same for the five maps presented in the summary. An absolute scale was chosen with a step that filters the physiological aberrations for a mean pupil diameter of 5 mm. The scale is 1.5 m for the corneal surface and 0.5 m for the wave-front. In the lower left part, there is a histogram of the expansion coefficients for Zernike's polynomials where each bar represents the weight of each polynomial. In the right of the screen, there are two panels where the different components of the aberrations are classified according to two different criteria. The panel Seidel shows the third order aberrations of Seidel,[49,50] which correspond to the primary aberrations: regular astigmatism (that is, primary), which reports the map, the degree expressed in diopters (D), the axis and the RMS; the spherical aberration with

Figure 33. Summary of the Zernike analysis, of the wave-front generated by the corneal surface of a keratoconus on an entrance pupil of 5 mm (for further details, refer to the description in the text).

Figure 34. The same case as the previous figure. In this image, the spherical-like and coma-like components group together the even and odd orders.

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map, quantity in diopters (D) for the longitudinal spherical aberration (LSA) and RMS; coma with RMS and direction; the high order aberrations which groups together all the components of aberrations of higher order that the primary; tilt, with the value expressed in prismatic diopters (Dp), direction and RMS; and finally, the power that represents the sum between the dioptric power of the reference surface and the defocus component, the power is expressed in diopters (D) and millimeters (mm) (the conversion is made using the refractive index of the stroma = 1.376). The panel radial orders (Figure 34) presents: regular astigmatism with the map, the degree, expressed in diopters (D), the axis and RMS; the group of the spherical-like aberrations (even aberrations) with the map and RMS; the group of the coma-like aberrations (odd aberrations) with the map and the RMS; the residue of aberration beyond Zernike's 7th order; tilt, with the value in prismatic diopters (Dp), direction and RMS; and finally the power which represents the sum of the dioptric power of the reference surfaces and the defocus component, the power is expressed in diopters (D) and millimeters (mm) (the conversion is made using the refractive index of the stroma = 1.376). Using these aberrometric data of the corneal wave-front, it is possible to calculate other parameters to quantify directly the optical quality of the retinal image that a specific cornea is in a position to produce. The first step is to perform a mathematical operation called autocorrelation on the aberrometric map of the corneal wave-front, which supplies the optic transfer function (OTF). The second step is to perform the mathematical operation called a Fourier transform on the OTF, to obtain the point-spread function (PSF), which represents the energetic distribution on the retina of the light originating from a point light source. The third step is to reproduce the PSF for each point of the object. This corresponds to the mathematical operation called convolution, that produces the simulation of a retinal image for any large object, in our case, we chose a table of high contrast EDTRS ottotypes and another at 10% contrast. All these findings, reported numerically and graphically are
v

Figure 35. Summary of the visual quality relative to the previous case.

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The optical quality of the cornea

displayed in a summary (Figure 35) that we have called summary of the visual quality. In the top left part of the window, there is a map of the total aberration of the corneal wave front in terms of OPD. Above this, the corresponding values of RMS. Below, for a more detailed analytical picture, the expansion of all Zernike's coefficients in a pyramidlike graph with gray scale shading. In this case a pyramidal display of radial order on the ordinate and angular frequency on the abscissa was used to display the value of the Zernike coefficient on a third axis. The way to display such a graph is as an image in which the gray-scale luminance is used to encode the Zernike coefficient value[51]. The second graph below reports the spot diagram, which indicates the aberration of the rays that pass through the pupil without any diffraction; each point represents the impact zone of each single ray on the retina; the spot domain (which in this example is 83 m) represents the size of a zone on the retina where all the rays are distributed. The second graph above shows the PSF with its domain and its maximum peak; different to the spot diagram, PSF also takes diffraction into account. The convolution of the high and low contrast ottotypes have been reported in order to provide an immediate qualitative evaluation. Figure 35 represents the corneal aberration of a keratoconus on a entrance pupil of 5 mm. The major coma component greatly degrades the visual quality of this eye with asymmetrical defocus of the images which is translated into almost total illegibility of the low contrast ottotypes.

Mean Sph Ab Coma High Horder Sph Like Coma Like Sph Ab Coma High Horder Sph Like Coma Like Sph Ab Coma High Horder Sph Like Coma Like
v

3 mm 3 mm 3 mm 3 mm 3 mm 5 mm 5 mm 5 mm 5 mm 5 mm 7 mm 7 mm 7 mm 7 mm 7 mm

0,04 0,05 0,10 0,07 0,09 0,15 0,14 0,16 0,18 0,20 0,52 0,42 0,35 0,57 0,52

RMS corneal wave-front (micron) Std. Mean Mean Min Dev. + 2SD + 3 SD 0,03 0,10 0,13 0,0000 0,03 0,11 0,14 0,0005 0,03 0,16 0,19 0,0400 0,02 0,11 0,13 0,0300 0,03 0,15 0,18 0,0300 0,05 0,25 0,30 0,0028 0,08 0,30 0,38 0,0100 0,06 0,28 0,34 0,0500 0,05 0,28 0,33 0,0600 0,08 0,36 0,44 0,0400 0,17 0,86 1,03 0,0200 0,23 0,88 1,11 0,0100 0,17 0,69 0,86 0,0900 0,16 0,89 1,05 0,1400 0,22 0,96 1,18 0,0900

Max 0,12 0,17 0,28 0,21 0,26 0,31 0,48 0,52 0,43 0,60 1,07 1,49 1,34 1,25 1,50

Mean 0,11 0,13 0,27 0,19 0,24 0,40 0,37 0,43 0,48 0,53 1,38 1,12 0,93 1,52 1,38

RMS corneal surface (micron) Std. Mean Mean Min Dev. + 2 SD + 3 SD 0,08 0,27 0,35 0,0001 0,08 0,29 0,37 0,0014 0,08 0,43 0,51 0,1064 0,05 0,29 0,35 0,0798 0,08 0,40 0,48 0,0798 0,13 0,66 0,80 0,0076 0,21 0,80 1,01 0,0266 0,16 0,74 0,90 0,1330 0,13 0,74 0,88 0,1596 0,21 0,96 1,17 0,1064 0,45 2,29 2,74 0,0532 0,61 2,34 2,95 0,0266 0,45 1,84 2,29 0,2394 0,43 2,37 2,79 0,3723 0,59 2,55 3,14 0,2394

Max 0,32 0,45 0,74 0,56 0,69 0,82 1,28 1,38 1,14 1,60 2,85 3,96 3,56 3,32 3,99

Table 6. Calossi - Vinciguerra statistics. Medium values, standard deviations and range of corneal surface aberrations, and phase front produced by the corneal anterior surface along three different pupillary diameters have been reckoned by the Eye Top CSO topographer over a sample of 500 subjects (1000 normal eyes). We may consider "physiological" the values included in two standard deviations from the normal medium, while we may consider 'abnormal' those that go beyond three standard deviations.

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Figure 36. Zernike analysis of the wave-front generated by the surface of a normal cornea with mild with-the-rule physiological astigmatism on a pupil entrance of 5 mm.

Figure 37. Summary of the visual quality relative to the previous case.

Table 6 shows the RMS values range of the corneal surface aberrations and the phase front produced by the corneal anterior surface that we may consider as physiological intervals. The statistical analysis has been carried out over a sample of 1000 normal eyes: 500 subjects, 277 females and 223 males, aged 14 - 80 (proportional mean 38,8 SD 14,3), reckoned by the Eye Top CSO topographer. As follows, we will now present Zernike's analysis of the previous examples. In order to have a direct comparison, we will present all the cases with the same pupil diameter of 5 mm, the summary of the vision quality is reported without the effect of the lower orders, and is therefore considered to be the best potential vision that may be corrected with spectacles.

Figure 38. Zernike's analysis of the wave-front generated by the corneal surface in a case of herpetic keratitis.

Figure 39. Summary of the visual quality relative to the previous case.

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The optical quality of the cornea

Figure 40. Aberrometric analysis of the wave-front generated by the corneal surface in a Lasik case to treat myopia with an optical zone that is excessively small, excessively oblated and slightly decentered.

Figure 41. Summary of the visual quality relative to the previous case.

Normal cornea
Figure 36 reports the aberrometric analysis of the wave-front generated by the surface of a normal cornea with slight with-the-rule physiological astigmatism as we described above. With an entrance pupil of 5 mm, the regular astigmatic component (Zernike 2nd order) is 0.47 m with axis at 13, corresponding to 0.95 D. The other components: spherical aberration 0.13 m, coma 0.16 m and the sum of the other high orders 0.09 m, are of minor significance and consent good vision, as confirmed by the summary of vision quality (Figure 37).

Herpetic keratitis
In this case (Figure 38) the spherical aberration and the low orders, with the exception of tilt (RMS 1.31 m), are irrelevant. However, the irregularity of the corneal surface caused by the scars of keratitis produce a certain degree of coma (RMS 0.52 m) and other high order aberrations (RMS 0.72 m). As shown in the summary of the visual quality (Figure 39), this justified the poor quality of the best vision correctable with spectacles.

LASIK, small optical zone

The aberrometric analysis of the wave-front generated by the corneal surface in the case of LASIK for myopia (Figure 40) underlines the poor qualitative outcome due to the excessively small optical zone of 4 mm, that is excessively oblate, with the ablation center decentered 0.5 mm in an infero-nasal direction with respect to the center of the pupil. The total aberration of the corneal wave-front for a 5 mm pupil entrance in this case has an RMS of 1.96 m, the regular astigmatic component (Zernike second order ) is 1.33 m with the axis at 174, corresponding to 2.67 D. The excessively small and excessively oblate optical zone in this case has produced considerable multi-focal component with a wave 25

Antonio Calossi

Figure 42. Zernike's analysis of a PRK with a decentered and asymmetric optical zone.

Figure 43. Summary of the visual quality relative to the previous case.

spherical aberration of 0.96 m, corresponding to a longitudinal spherical aberration (LSA) of +7.10 D. Decentering of treatment, even to a minimum degree, associated with considerable negative eccentricity and tilt (RMS 3.02 m), produced a significant coma component (RMS 0.92 m in the direction of 284). The higher orders, due to irregularities of the curvature, in this case contribute 0.40 m. The poor qualitative result is confirmed by the summary of the visual quality (Figure 41).

Asymmetric PRK
In this case (Figure 42) the decentering and the vertical asymmetry within the optical zone have produced an important coma component (RMS 1.35 m), which produces considerable asymmetrical defocus of the images, as can be seen in the summary of the visual quality (Figure 43).

Figure 44. Aberrometric analysis of the wave-front generated by the corneal surface treated by PRK with an excellent optical outcome.

Figure 45. Summary of the visual quality relative to the previous case.

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Excellent PRK
The aberrometric analysis of the wave-front generated by the corneal surface in this case (Figure 44) shows an excellent result for a PRK treatment of myopia of6.00. The smoothness of the treated surface, the good symmetry and the good shape factor of this cornea have combined to cerate an excellent aberrometric quality: all the components are compatible with those of a normal cornea. The summary of the visual quality (Figure 45) underlines the excellent optic result of this treatment. In conclusion, we can state that the keratorefractive indices permit the immediate and straightforward interpretation of the optical qualities of the cornea, while Zernikes analysis of the video-keratographic data permit the detailed examination of all the components of aberration in the corneal surface.

Acknowledgements
We would like to thank Silvano Pieri, optical analyst of Officine Galileo, and Alessandro Foggi, engineer, for the invaluable suggestions and enthusiastic collaboration that permitted the development of Zernike's analysis we described in this chapter.

Appendix
(Silvano Pieri) Let us consider a front F which crosses a surface of separation between two media of refractive indexes n and n', and propagate up to the front F'. If we create a perturbation in a given zone of the wave front that will modify the optical path along the specific trajectory, it will cause a variation in the shape of the wave-front. This modification will propagate with the wave and its maximum value, in terms of longitudinal variation (OPD) will remain unchanged for the entire propagation. In figure A1, let us consider a wave that propagates through an optical surface. Even if in this case both the surface and the wave are plan, the line of reasoning is completely general and can be applied to any other shape. The picture shows a front F which meets a surface of separation between two media of refractive index n and n' will propagate as far as the front F'. If we consider the perfect surface, the optical pathway OP0 along a ray between a point P on F and the corresponding point Q on F' passing through the point of impact S on the surfaces, can be expressed as: OP = PS n + SQ n (1)

Figure A1. OPD propagation.

If the surface contains a deformation of depth d at point S, the impact of the radius will occur at the point S; with a few approxima-

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tion, we can state SS = d: OP0 = (PS + d) n + (SQ d) n (2)

The difference in the optical pathway OPD introduced by the deformation will be: OPD = OP OP0 = d (n n) (3) The presence of deformation means that point Q is no longer found on the wave-front F, which will pass through the displaced point Q. That is, the deformation of the surfaces produces deformation on the emerging wave F, which has an approximated value given by (3). As a result, in an approximate manner, for a given surface deformation, the corresponding of the wave-front error is obtained by multiplying by the difference of the refractive indices. For n = 1, the refractive index of the air, and n = 1.376, the refractive index of the corneal tissue, we have n n = 0.376, so if the maximum OPD allowed is 0.14 mm, the maximum deformation d of the corneal surface that can be considered. According to Rayleigh's principle, perfect is 0.14/0.376 = 0.37 mm.

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