Ophthalmic & Physiological Optics ISSN 0275-5408

Optical quality for keratoconic eyes with conventional RGP

lens and simulated, customised contact lens corrections:
a comparison
Amit Jinabhai1,2, W Neil Charman1, Clare ODonnell1,2,3 and Hema Radhakrishnan1
1
Faculty of Life Sciences, The University of Manchester, Manchester, UK, 2School of Life & Health Sciences, Aston University, Birmingham, UK,
and 3Optegra Eye Sciences, Optegra Manchester Eye Hospital, Manchester, UK

Citation information: Jinabhai A, Charman WN, ODonnell C & Radhakrishnan H. Optical quality for keratoconic eyes with conventional RGP lens and
simulated, customised contact lens corrections: a comparison. Ophthalmic Physiol Opt 2012, 32, 200212. doi: 10.1111/j.1475-1313.2012.00904.x

Keywords: customised lenses, higher-order Abstract

aberrations, keratoconus, RGP lenses,
rotation, translation
Correspondence: Hema Radhakrishnan
E-mail address: hema.radhakrishnan@manchester.
ac.uk
Received: 18 December 2011; Accepted: 2
March 2012
Purpose: To compare monochromatic aberrations of keratoconic eyes when
uncorrected, corrected with spherically-powered RGP (rigid gas-permeable)
contact lenses and corrected using simulations of customised soft contact lenses
for different magnitudes of rotation (up to 15) and translation (up to 1 mm)
from their ideal position.
Methods: The ocular aberrations of examples of mild, moderate and severe
keratoconic eyes were measured when uncorrected and when wearing their
habitual RGP lenses. Residual aberrations and point-spread functions of each
eye were simulated using an ideal, customised soft contact lens (designed to
neutralise higher-order aberrations, HOA) were calculated as a function of the
angle of rotation of the lens from its ideal orientation, and its horizontal and
vertical translation.
Results: In agreement with the results of other authors, the RGP lenses mark-
edly reduced both lower-order aberrations and HOA for all three patients.
When compared with the RGP lens corrections, the customised lens simula-
tions only provided optical improvements if their movements were constrained
within limits which appear to be difficult to achieve with current technologies.
Conclusions: At the present time, customised contact lens corrections appear
likely to offer, at best, only minor optical improvements over RGP lenses for
patients with keratoconus. If made in soft materials, however, these lenses may
be preferred by patients in term of comfort.

but also by partial correction of HOA, due to the

Introduction
It is widely accepted that the corneal distortions induced
by keratoconus increase the eyes optical aberrations and
that the resultant degradation in retinal image quality
reduces visual acuity and contrast sensitivity.14 Soft con-
tact lenses tend to drape over the irregular cornea, there-
fore preserving the distorted surface topography and the
majority of the higher-order aberrations (HOA); equally,
spectacle lenses also have little effect on the keratoconus-
induced HOA.5 In contrast, conventional rigid gas-perme-
able (RGP) contact lenses improve visual acuity not only
by correcting 2nd-order sphero-cylindrical aberrations,
smoothing effect of the tear lens trapped between the
contact lens and the cornea.57 The exact effects depend
upon the contact lens fit.8 Even so, visual acuity and con-
trast sensitivity are rarely improved to normal levels,9,10
due to residual HOAs, particularly from the posterior
cornea 11 and, perhaps, neural deficits.12,13
Many authors have proposed that customised contact
lenses designed to eliminate or partially correct both
lower-order aberrations and HOA of the individual eye, or
perhaps vertical coma alone, or some other limited combi-
nation of aberrations, would be particularly beneficial
for patients with keratoconus, the aberrations of the

200 Ophthalmic & Physiological Optics 32 (2012) 200212 2012 The College of Optometrists
A Jinabhai et al.
correction being equal in magnitude but opposite in sign
to those of the eye.1422 Such customised lenses are manu-
factured using lathe cutting18 or excimer laser ablation.23
The elevated level of HOA in keratoconic eyes means that
the potential visual benefit of correcting the aberrations
is greater in such eyes than in normal eyes.24 However,
any translation or rotation of a customised correction
reduces its effectiveness at eliminating the HOA of the
eye, although some movement is required to allow tear
exchange underneath the lens to supply the cornea with
essential lubrication and nutrients.25 If the magnitude of
translation or rotation, or their combination, is too large,
the resultant residual HOA may rise to a level higher than
in the original uncorrected eye. Using the criterion that
optical performance should always exceed that of the
naked eye with only a 2nd-order correction, theoretical
calculations suggest that maximal tolerable rotations and
translations for customised corrections are of the order of
10 and 0.5 mm respectively; the exact effects depending
on the magnitude of the movement, the initial aberrations,
the pupil diameter and the criterion used to set the toler-
ance limit.14,15,17,2629 Furthermore, it has been suggested
that a larger degree of movement may be tolerated in eyes
with higher magnitudes of HOA, since the resultant aber-
ration is still lower than the uncorrected level, further
strengthening the argument for customisation being par-
ticularly useful for patients with keratoconus.22,30
To illustrate the order of magnitude of typical lens
movements found in practice, Tomlinson et al.31 reported
that, for normal subjects with astigmatism, prism-bal-
lasted toric soft contact lenses typically translated by
about 0.5 mm and rotated by about 4. Chateau et al.32
measured similar translations of about 0.5 mm and
Young et al.33 reported that soft toric lenses rotated by
around 12, depending upon the type of stabilisation
method used. Chen et al.23 found that conventional soft
lenses fitted to keratoconic patients showed typical trans-
lations and rotations of about 0.1 mm and 12 respec-
tively, which could be reduced considerably using
customised back-surface lens designs, to <0.05 mm and
3; the findings of Sabesan et al.22 and Lopez-Gil et al.34
were also of a similar magnitude. Consequently, it is
expected that customised soft contact lenses with this
degree of movement should be capable of providing use-
ful improvements in visual performance over that
achieved by keratoconic eyes with conventional soft lenses
or spectacle lens corrections.
From a clinical point of view, it would be helpful to
have better insight into the optical improvements that
might be achieved when keratoconic patients at different
stages of the condition wear customised corrections with
typical amounts of on-eye movement. However, we argue
here that, when assessing the benefits of customised
Ophthalmic & Physiological Optics 32 (2012) 200212 2012 The College of Optometrists
Simulating customised corrections for keratoconus patients
corrections, it is more realistic to compare the results
with those obtained with a conventional RGP contact lens
correction. This is in contrast to most previous studies,
where improvements were typically assessed in relation to
an eye where the HOAs were completely uncorrected.
Conventional RGP lenses are comparatively inexpensive
and more straightforward to fit than bespoke customised
lenses. Thus the extra expense, in terms of equipment,
lenses and chair-time, of fitting customised lenses can
only be justified if, with typical amounts of movement,
they usefully decrease aberrations below the level of those
measured with conventional RGP lenses, with consequent
worthwhile improvements in visual performance.
The present study therefore explores, theoretically, the
impact of translation and rotation of ideal customised
corrections in typical clinical cases of mild, moderate and
severe keratoconus. The optical quality of the eye is
assessed in terms of its wavefront aberration and point-
spread function. The results are compared with aberrations
measured when each eye is uncorrected and whilst wearing
an appropriate spherical RGP contact lens correction.
Methods
The three patients with different severities of keratoconus
who participated in this investigation (average age
30 6 years) were recruited from the contact lens clinics
at the University of Manchester. All three patients had
previously been diagnosed with bilateral keratoconus and
habitually wore spherical RGP contact lenses. Only data
for the right eyes were considered in this analysis. The
study followed the tenets of the Declaration of Helsinki
and patients gave their informed consent after being told
the purpose of the investigation. The study protocol was
approved by the National Health Service Research Ethics
Committee.
Baseline logMAR (logarithm of the minimum angle of
resolution) visual acuity measurements were taken for
each patient with their habitual RGP lenses. Patients were
then instructed to remove their lenses and a slit-lamp
examination of the external eye was conducted, recording
the presence or absence of prominent corneal nerves, Flei-
schers ring and Vogts striae. None of the patients evalu-
ated showed corneal scarring detectable upon slit-lamp
examination.
The Oculus Pentacam (http://www.pentacam.com/sites/
basic.php) was used to measure each patients keratomet-
ric readings and corneal thickness at the thinnest point.
Topographic data from the Pentacam were also acquired.
Four repeated measurements were made for each patient
under monocular conditions with the room illumination
switched off. The mean of the four measurements was
used for analysis. The severity of the patients keratoconus
201
Simulating customised corrections for keratoconus patients
was graded using the Collaborative Longitudinal Evalua-
tion of Keratoconus (CLEK) study groups criteria, where
steep keratometric readings <45 D were graded as mild
keratoconus, steep keratometric readings between 45 and
52 D were graded as moderate keratoconus and finally
steep keratometric readings >52 D were graded as severe
keratoconus.35 The three patients studied here included
single examples of mild, moderate and severe keratoconus;
their anterior and posterior corneal surface topographies
are illustrated in Figure 1.
Following this, ocular wavefront aberrations were mea-
sured using a Hartmann-Shack aberrometer (IRX-3;
http://www.imagine-eyes.com/content/view/38/94/), again
under monocular conditions with the room illumination
switched off. The instrument records pupil diameter at
the same time as the wavefront aberrations and uses a
dynamic fogging method to relax accommodation to the
far point of the eye. Four repeated monocular measure-
ments were made for each patient. The Zernike coeffi-
cients for each of the four measurements were then
separately averaged. All aberrations were calculated up to
the 5th Zernike order for a 6-mm pupil diameter (the
largest pupil size common to all three patients), using the
IRX-3 devices software (Version 1.2; http://www.imagine-
eyes.com/content/view/25/50/). For comparison purposes,
the aberrations were re-measured with the patients wear-
ing their habitual RGP lens corrections. The captured
aberrometry data were then exported and analysed using
Microsoft Excel 2003 (http://office.microsoft.com/en-gb/
excel/) and MatLAB (Version 7.6.0.324; http://www.
mathworks.co.uk/).
Anterior corneal surface topography
Mild keratoconus
Posterior corneal surface topography
Mild keratoconus
Figure 1. The anterior (upper half) and posterior (lower half) corneal surface topographies from the right eyes of the three keratoconic patients studied.
202
A Jinabhai et al.
The theoretical effect of either translating or rotating
an ideal aberration correction, on the HOA for each
patient, was evaluated over a 4-mm pupil diameter. The
ideal customised correction was assumed to have Zer-
nike coefficients which were equal in magnitude and
opposite in sign to those for the original uncorrected
wavefront error (6-mm diameter) at the pupil centre.
Either a rotation or translation of the required magni-
tude15,36 was applied to the wavefront aberration of the
correction with respect to the ocular aberrations over the
central 4 mm pupil diameter, and the combined aberra-
tions for the correction and eye were determined using
the MatLAB Code provided by Lundstrom and Unsbo.36
As translations of up to 1 mm were evaluated both hori-
zontally (in a nasal direction) and vertically (in a superior
direction), evaluation of a central 4-mm circular zone
meant that the translated movements did not fall outside
of the original pupil diameter of 6 mm for which wave-
front measurements were available. This model assumes
that the ideal correction is conjugate to the patients pupil
plane. In reality this aberration correction lies in the cor-
neal plane in the form of a contact lens. No correction
was made for this small effect.15,29 An infinite number of
combinations of rotation and translation are possible;
however, the calculations presented here were restricted
to pure clockwise rotations up to 15 and to horizontal
(nasal) and vertical (superior) translations up to 1 mm. It
was felt that this would be sufficient to give a useful
insight into the effects that might be expected, given the
typical range of lens displacements observed in clinical
practice.23,3133 Additional data on the effects of temporal
Moderate keratoconus Severe keratoconus
Moderate keratoconus Severe keratoconus
Ophthalmic & Physiological Optics 32 (2012) 200212 2012 The College of Optometrists
A Jinabhai et al. Simulating customised corrections for keratoconus patients

and inferior displacements and anti-clockwise rotations
are presented in the Data S1: their effects are broadly
similar to those discussed in this paper.
Note that only the HOA were considered in the first
stages of the analysis, the eyes initially being treated as
though they were emmetropic with regard to 2nd-order
aberrations. However, lens displacements will also affect
2nd-order aberrations, both as a result of interactions of
the HOA of the eye and its ideal correction, and as a
result of the interactions between the 2nd-order aberra-
tions of the eye and their correction. For example, rota-
tion of a 2nd-order astigmatic correction will generate
superfluous cylindrical errors. The effects of displacing an
ideal HOA correction, on the lower-order aberrations,
are considered in the second part of the analysis.
Results
Corneal profile and aberrometry data
Table 1 summarises the corneal parameters, spectacle
refractions, visual acuities and major Zernike aberrations
measured with and without RGP lenses for each kerato-
conic patients right eye. Each patients anterior and pos-
terior corneal topographies are illustrated in Figure 1.

Table 1. A summary of the corneal parameters (Oculus Pentacam), visual acuities and Zernike aberrations (IRX-3 for a 4-mm pupil) evaluated for
each keratoconic patients right eye. The corneal and aberration measurements shown are the mean of 4 repeated measurements

Corneal parameters

Keratoconus severity Mild Moderate Severe

Flat K (D) 41.0 43.8 47.0

Steep K (D) 44.2 47.9 53.1
Corneal thickness (lm) 476 432 410

Spectacle refraction and acuities

Spectacle refraction )2.75/)1.25 75 )5.00/)1.75 85 )4.00/)4.50 90

Visual acuity (log units) 0.20 0.36 0.52

RGP lens powers and acuities

RGP lens power )3.00/DS )5.50/DS )6.50/DS

Visual acuity (log units) )0.10 0.08 0.14

Ocular aberrations (in lm)

Zernike coefficient terms RGP lens No lens RGP lens No lens RGP lens No lens
Oblique astigmatism 0.175 0.461 )0.223 )0.966 0.064 0.066
Defocus )0.022 1.221 0.661 2.408 )0.208 0.955
Regular astigmatism 0.068 0.504 0.153 )0.153 )0.543 )1.412
Oblique trefoil 0.042 0.100 0.065 0.123 0.132 0.471
Vertical coma 0.054 )0.409 0.054 )0.536 0.049 )0.881
Horizontal coma 0.044 )0.025 0.023 )0.176 0.067 0.055
Regular trefoil )0.006 0.104 )0.044 )0.111 )0.003 0.004
3rd-order RMS error 0.082 0.434 0.098 0.588 0.156 1.000
Oblique tetrafoil )0.004 )0.025 )0.013 )0.010 )0.004 )0.020
Oblique secondary cylinder )0.025 0.032 0.024 0.077 )0.011 )0.021
Spherical aberration 0.029 )0.074 0.052 0.004 0.064 )0.053
Regular secondary cylinder 0.000 )0.018 )0.005 )0.039 0.000 )0.005
Regular tetrafoil 0.017 0.037 0.002 0.020 0.031 0.095
4th-order RMS error 0.042 0.093 0.059 0.089 0.072 0.112
Oblique pentafoil )0.001 )0.005 0.000 0.001 0.000 )0.001
Oblique secondary trefoil )0.001 )0.003 0.000 )0.003 )0.011 )0.014
Secondary horizontal coma )0.003 )0.012 0.000 0.022 0.013 0.028
Secondary vertical coma )0.001 0.012 0.001 0.016 0.000 )0.002
Regular secondary trefoil 0.000 )0.006 0.003 0.004 0.000 )0.003
Regular pentafoil 0.000 )0.005 0.000 0.001 0.000 )0.003
5th-order RMS error 0.003 0.020 0.003 0.028 0.017 0.031
Total HORMS error (3rd- to 5th-order) 0.092 0.445 0.114 0.596 0.173 1.007

K, keratometric reading; LogMAR, logarithm of the minimum angle of resolution; RMS, root mean square; HORMS, higher-order RMS error.

Ophthalmic & Physiological Optics 32 (2012) 200212 2012 The College of Optometrists 203
Simulating customised corrections for keratoconus patients A Jinabhai et al.

Slit-lamp examination found that all three patients dis- with severe keratoconus, the residual total HORMS error
played Fleischers ring, with the moderate and severe of 0.173 lm when wearing the habitual RGP lens was
cases also showing Vogts striae. None of the patients comparable to the RMS error for an aberration-free eye
showed any apical scarring detectable upon slit-lamp suffering from 0.25 D of pure defocus (0.144 lm for the
examination. Note that the spectacle refraction of all the 4-mm pupil studied). Levels of RGP-corrected visual acu-
eyes included a significant cylindrical component. ity in all three cases were reasonable (<0.15 logMAR, i.e.
In agreement with the literature,3,37,38 uncorrected better than 6/9 Snellen acuity). This emphasises the opti-
HOA were dominated by the 3rd-order terms. All three cal advantages of RGP lenses in the visual rehabilitation
patients showed abnormally large magnitudes of vertical of patients with keratoconus. A spectacle or soft lens cor-
coma. The patient with severe keratoconus also showed a rection would not be expected to have as much of an
large magnitude of oblique trefoil. Other aberration coef- effect on ocular HOA.
ficients made only minor contributions to the overall The HOA wavefront maps and point-spread functions
total higher-order root-mean-square (HORMS) wavefront (PSFs) for the uncorrected and RGP lens-corrected cases
error. As anticipated, there were also high levels of 2nd- are illustrated in Figure 2: the wavefront aberrations
order aberration in all eyes. shown are for the 3rd- to 5th-orders inclusive, it
Table 1 shows that the conventional spherical RGP lens being assumed that 2nd-order aberrations were optimally
was quite successful in reducing HOA, even for the corrected. Note again, that the dominant HOA for all
patient with severe keratoconus. In all three cases, total three uncorrected keratoconic patients approximates to
HORMS with the RGP lens correction was approximately vertical coma; however, the RGP lens reduces the wave-
a fifth of that for the uncorrected eye. For the patient front aberration to a relatively low level. The RGP lens-

Mild KC no lens With RGP lens Mild KC no lens With RGP lens
2 2
1.5
1.5 1.5 5 5
1
Y-pupil co-ordinate

Y-axis (minutes)

1 1

Y-axis (minutes)
0.5 0.5 0.5

0 0 0 m 0 0
0.5 0.5 0.5
1 1
1
1.5 1.5 5 5
1.5
2 2
2 1.5 1 0.5 0 0.5 1 1.5 2 2 1.5 1 0.5 0 0.5 1 1.5 2 5 0 5 5 0 5
X-pupil co-ordinate
Moderate KC no lens With RGP lens Moderate KC no lens With RGP lens
2 2
1.5 5 5
1.5 1.5
Y-axis (minutes)
Y-pupil co-ordinate

1
Y-axis (minutes)

1 1
0.5 0.5 0.5
0 0 0
0 0 m
0.5 0.5 0.5
1 1
1
1.5 1.5 5 5
1.5
2 2
2 1.5 1 0.5 0 0.5 1 1.5 2 2 1.5 1 0.5 0 0.5 1 1.5 2 5 0 5 5 0 5
X-pupil co-ordinate
Severe KC no lens With RGP lens Severe KC no lens With RGP lens
2 2
1.5
1.5 1.5 5 5
1
Y-pupil co-ordinate

1 1
Y-axis (minutes)

Y-axis (minutes)

0.5 0.5 0.5

0 0 0 m 0 0
0.5 0.5 0.5
1 1
1
1.5 1.5
1.5 5 5
2 2
2 1.5 1 0.5 0 0.5 1 1.5 2 2 1.5 1 0.5 0 0.5 1 1.5 2
X-pupil co-ordinate 5 0 5 5 0 5
X-axis (minutes) X-axis (minutes)

Figure 2. (Left) The higher-order wavefront aberration maps for each uncorrected keratoconic patients right eye and the aberration map with
their habitual RGP lens correction. Each wavefront map represents the aberrations from the 3rd- to the 5th-order. All aberrations were calculated
using a 4-mm pupil diameter. The darker shades represent negative aberrations, whereas the lighter shades represent positive aberrations. The
scale bar shown is in lm. (Right) The corresponding point-spread functions.

204 Ophthalmic & Physiological Optics 32 (2012) 200212 2012 The College of Optometrists
A Jinabhai et al. Simulating customised corrections for keratoconus patients

corrected PSF for the patient with mild keratoconus has a moderate keratoconic eyes but there is already noticeable
form close to that of the aberration-free Airy diffraction blurring for the eye with severe keratoconus at 5. For
pattern; however, for all three uncorrected keratoconic the 10- and 15-degree rotations, considerable magnitudes
eyes, the angular spread of the PSF is significantly broader of positive coma are induced in all three cases, particu-
than the ideal Airy disc pattern. larly in the severe case. This induced coma is predomi-
nantly horizontal, whereas the original, uncorrected coma
was predominantly vertical. However, a comparison of
Effects of a simulated customised correction: rotational
Figure 3 with Figure 2 suggests that, even with the 15-
displacements
degree rotation of the customised correction, the PSF is
With an ideal, correctly-aligned, customised HOA cor- always more compact than that of the corresponding ori-
rection (from the 3rd- to the 5th-order), the wavefront ginal, uncorrected eye, although not that for the RGP
error is zero across the full pupil and the PSF is an Airy lens-corrected eye. Broadly similar effects are produced by
diffraction pattern. Figure 3a) to 3d) displays the calcu- rotations in the opposite direction (Data S1).
lated residual HOA wavefront maps and PSFs generated Figure 4 shows the magnitude of some of the induced
for each patient (using a wavelength of 780 nm) when HOA. As the ideal HOA correction rotates, the aberrations
their ideal HOA correction is rotated (but not decentred) increase almost linearly with the angle of rotation. In all
from the correctly aligned position, in a clockwise direc- three cases, the overall 3rd- to 5th-order HORMS error is
tion, by 1, 5, 10 and 15 respectively. Rotations of up to dominated by the 3rd-order contribution. Induced coma
5 produce little degradation in the PSF for the mild and RMS and trefoil RMS aberrations are similar for the mild

(a) 1 of clockwise rotation (b) 5 of clockwise rotation

2
Mild KC 2
Moderate KC Severe KC Mild KC Moderate KC Severe KC
2 2 2 2
1.5 1.5
1.5 1.5 1.5 1.5 1.5 1.5
1 1
1 1 1 1 1 1
Y-pupil co-ordinate
Y-pupil co-ordinate

0.5 0.5 0.5 0.5 0.5 0.5

0.5 0.5

0 0 0 0 0 0 0 m
0 m
0.5 0.5 0.5 0.5 0.5 0.5
0.5 0.5
1 1 1 1 1 1
1 1
1.5 1.5 1.5 1.5 1.5 1.5

2 1.5 2 2 1.5
2 2 2
2 1.5 1 0.5 0 0.5 1 1.5 2 2 1.5 1 0.5 0 0.5 1 1.5 2 2 1.5 1 0.5 0 0.5 1 1.5 2 2 1.5 1 0.5 0 0.5 1 1.5 2 2 1.5 1 0.5 0 0.5 1 1.5 2 2 1.5 1 0.5 0 0.5 1 1.5 2
X-pupil co-ordinate X-pupil co-ordinate X-pupil co-ordinate X-pupil co-ordinate X-pupil co-ordinate X-pupil co-ordinate

5 5 5 5
5 5
Y-axis (minutes)
Y-axis (minutes)

0 0 0 0
0 0

5 5 5
5 5 5

5 0 5 5 0 5 5 0 5 5 0 5 5 0 5 5 0 5
X-axis (minutes) X-axis (minutes) (minutes) X-axis (minutes) X-axis (minutes) X-axis (minutes)
X-axis

10 of clockwise rotation 15 of clockwise rotation

(c) (d)
Mild KC Moderate KC Severe KC Mild KC Moderate KC Severe KC
2 2 2 2 2 2
1.5 1.5
1.5 1.5 1.5 1.5 1.5 1.5
1 1
1 1 1 1 1 1
Y-pupil co-ordinate

Y-pupil co-ordinate

0.5 0.5 0.5 0.5 0.5 0.5 0.5

0.5

0 0 0
0
m 0 0 0 0 m
0.5 0.5 0.5 0.5 0.5 0.5
0.5 0.5
1 1 1 1 1 1
1.5 1 1.5 1
1.5 1.5 1.5 1.5
2 2 2 2 1.5
2 1.5 1 0.5 0 0.5 1 1.5 2 2 2
2 1.5 1 0.5 0 0.5 1 1.5 2 2 1.5 1 0.5 0 0.5 1 1.5 2 2 1.5 1 0.5 0 0.5 1 1.5 2 2 1.5 1 0.5 0 0.5 1 1.5 2 2 1.5 1 0.5 0 0.5 1 1.5 2
X-pupil co-ordinate X-pupil co-ordinate X-pupil co-ordinate X-pupil co-ordinate X-pupil co-ordinate X-pupil co-ordinate

5 5 5 5 5
5
Y-axis (minutes)

(minutes)

0 0 0 0 0
0
Y-axis

5 5 5 5
5 5

5 0 5 5 0 5 5 0 5 5 0 5 5 0 5 5 0 5
X-axis (minutes) X-axis (minutes) X-axis (minutes) X-axis (minutes) X-axis (minutes) X-axis (minutes)

Figure 3. The residual higher-order wavefront aberration maps (upper half) and PSFs (lower half), generated when the ideal aberration correction
is rotated from the aligned position by 1 (a), 5 (b), 10 (c) and 15 (d) in a clockwise direction for all three keratoconic patients. Each wavefront
map represents the aberrations from the 3rd- to the 5th-order. All aberrations were calculated using a 4-mm pupil diameter. The darker shades
represent negative aberrations, whereas the lighter shades represent positive aberrations. The scale bar shown is in lm. The left-hand images in
each block display the aberrations induced for the mild keratoconic patient, the central images for the moderate keratoconic patient and the
right-hand images for the severe keratoconic patient.

Ophthalmic & Physiological Optics 32 (2012) 200212 2012 The College of Optometrists 205
Simulating customised corrections for keratoconus patients
Figure 4. The magnitude of the trefoil RMS, coma RMS, 3rd-order
RMS and higher-order RMS aberrations induced by rotating the ideal
aberration-controlling correction (from the aligned position) in a
clockwise direction by up to 15 for the three keratoconic patients.
Higher-order RMS aberrations were calculated from the 3rd- to the
5th-order. All data were calculated using a 4-mm pupil diameter.
With the conventional RGP lens correction the HORMS values were
0.09, 0.11 and 0.17 lm for the mild, moderate and severe KC eyes
respectively. For a 4-mm pupil, an equivalent defocus of 0.25 D corre-
sponds to an RMS aberration of 0.144 lm, as shown by the horizon-
tal green line.
and moderate keratoconic patients but substantially larger
magnitudes of 3rd-order aberrations are induced with
rotation for the patient with severe keratoconus. Note,
however, that the total uncorrected HORMS values for a
4-mm pupil diameter were (Table 1) 0.45, 0.60 and
1.01 lm for the mild, moderate and severe cases respec-
tively, so that even for rotations of 15, the aberrations of
all the customised lens-corrected eyes are smaller than
those of the corresponding uncorrected eyes (or the eyes
206 Ophthalmic & Physiological Optics 32 (2012) 200212 2012 The College of Optometrists
A Jinabhai et al.
when corrected with a spectacle lens). On the other hand,
with a conventional RGP lens the total HORMS values
were 0.09, 0.11 and 0.17 lm respectively (Table 1), so
that only when the rotation is less than around 6 does
the customised correction begin to offer advantages over
the conventional RGP lens. Note that the tolerances on
rotation based on comparison with the RGP lens-cor-
rected case are about the same for all three eyes, even
though the absolute levels of total HORMS are different.
It is, of course, to be expected that the aberrations mea-
sured with the conventional RGP lens will also vary
slightly as the lens moves.
To set the magnitude of the residual aberrations into
context, the Marechal criterion39 suggests that the PSF is
almost perfect if the wavefront aberration is <1/14 of a
wavelength, i.e. around 0.04 lm at the middle of the visi-
ble spectrum. Figure 4 shows that this is almost the case
for customised lens rotations of up to approximately 4 for
the patients with mild and moderate disease, but not the
patient with severe keratoconus. Alternatively, a criterion
based on the magnitude of spherical blur which gives a
similar level of RMS wavefront aberration could be used.
For the 4-mm pupil diameter used, a wavefront aberration
of about 0.144 lm corresponds to an equivalent defocus of
0.25 D.40 Assuming that this magnitude of RMS wavefront
error is tolerable, it can be seen that the PSF for the
patients with mild and moderate keratoconus may be
acceptable even if their corrections rotate through 10,
whereas rotation should not exceed about 5 for the eye
with severe keratoconus. The HORMS error measured with
a conventional RGP lens (about 0.09, 0.11 and 0.17 lm
respectively for the mild, moderate and severe cases) all
satisfy, or are close to, the equivalent defocus tolerance.
Effects of a simulated customised correction:
translational displacements
Figure 5 displays the residual HOA wavefront maps and
PSFs generated for each patient by translating an ideal
aberration correction (from the correctly aligned posi-
tion) horizontally, in the nasal direction by (a) 0.1, (b)
0.5 and (c) 1.0 mm. Note that, even with 1 mm of decen-
tration, the PSFs are still more compact than the corre-
sponding uncorrected PSF images displayed in Figure 2.
Figure 6 shows the corresponding effects obtained when
the translation is in the vertical direction (superiorly).
Both Figures 5 and 6 suggest that, in all three eyes, the
PSFs remain reasonably compact for displacements up to
0.5 mm. It is again helpful to examine the corresponding
changes in the individual aberrations (Figure 7). As in the
case of rotations, the HORMS error induced by transla-
tion are dominated by 3rd-order errors. Vertical transla-
tion, in general, induces greater residual errors than
A Jinabhai et al. Simulating customised corrections for keratoconus patients

(a) 0.1 mm of horizontal translation (nasally) (a) 0.1 mm of vertical translation (superiorly)
2
Mild KC Moderate KC Severe KC Mild KC Moderate KC Severe KC 1.5
2 2 2 2 2
1.5
1.5 1.5 1.5 1.5
1.5 1.5 1
1 1 1 1 1
1 1

Y-pupil co-ordinate
Y-pupil co-ordinate

0.5 0.5 0.5

0.5 0.5
0.5 0.5 0.5
0 0 0
0 0
0 m
0
0 m 0.5 0.5 0.5
0.5 0.5 0.5 0.5
1 1 1
1 0.5
1 1
1.5 1.5 1.5 1
1.5 1.5 1
1.5 2 2 2
2 1.5 1 0.5 0 0.5 1 1.5 2 2 1.5 1 0.5 0 0.5 1 1.5 2 2 1.5 1 0.5 0 0.5 1 1.5 2 1.5
2 2
2 1.5 1 0.5 0 0.5 1 1.5 2 2 1.5 1 0.5 0 2 X-pupil co-ordinate X-pupil co-ordinate X-pupil co-ordinate
0.5 1 1.5 2 1.5
2 1.5 1 0.5 0 0.5 1 1.5 2
X-pupil co-ordinate X-pupil co-ordinate
X-pupil co-ordinate
5 5
5
5 5 5

(minutes)
(minutes)

0 0
0

Y-axis
0 0 0
Y-axis

5 5

5 5 5 0 5 5 0 5 5 0 5
5
(minutes) (minutes) (minutes)
X-axis X-axis X-axis
5 0 5 5 0 5 5 0 5
(minutes) (minutes) (minutes)
X-axis X-axis X-axis

0.5 mm of horizontal translation (nasally) 0.5 mm of vertical translation (superiorly)

(b) (b)
Mild KC Moderate KC Severe KC Mild KC Moderate KC Severe KC
2 2 2 1.5
2 2 2
1.5
1.5 1.5 1.5
1.5 1.5 1.5
1
1 1 1 1
1 1 1

Y-pupil co-ordinate
0.5 0.5 0.5 0.5
Y-pupil co-ordinate

0.5 0.5 0.5 0.5

0 0 0
0 0 0 0 m
0 m 0.5 0.5 0.5
0.5 0.5 0.5 0.5
0.5 1 1 1
1 1 1
1.5 1.5 1.5 1
1.5 1.5 1.5 1
2 2 2
2 1.5 1 0.5 0 0.5 1 1.5 2 2 1.5 1 0.5 0 0.5 1 1.5 2 2 1.5 1 0.5 0 0.5 1 1.5 2 1.5
2 2 2 X-pupil co-ordinate X-pupil co-ordinate X-pupil co-ordinate
2 1.5 1 0.5 0 0.5 1 1.5 2 2 1.5 1 0.5 0 0.5 1 1.5 2 2 1.5 1 0.5 0 0.5 1 1.5 2 1.5
X-pupil co-ordinate X-pupil co-ordinate X-pupil co-ordinate
5 5 5
5 5 5
(minutes)
(minutes)

0 0 0
Y-axis

0 0 0
Y-axis

5 5 5

5 5 5
5 0 5 5 0 5 5 0 5
(minutes) (minutes) (minutes)
5 0 5 5 0 5 5 0 5 X-axis X-axis X-axis
(minutes) (minutes) (minutes)
X-axis X-axis X-axis

1.0 mm of horizontal translation (nasally)

(c) (c) 1.0 mm of Vertical translation (superiorly)
Mild KC Moderate KC Severe KC Mild KC Moderate KC
2
2 2 2
Severe KC
2
1.5 2 1.5
1.5
1.5 1.5 1.5 1.5 1.5
1 1 1
1 1 1 1 1
Y-pupil co-ordinate

Y-pupil co-ordinate

0.5 0.5
0.5 0.5 0.5 0.5 0.5 0.5

0 0
0 0 0 0
0 m 0 m
0.5 0.5
0.5 0.5 0.5 0.5
0.5
1 0.5 1
1 1 1 1

1.5 1.5 1
1.5 1.5 1.5 1.5
1
2 2
2 2 2 1.5 1 0.5 0 0.5 1 1.5 2 2 2
2 1.5 1 0.5 0 0.5 1 1.5 2 2 1.5 1 0.5 0 0.5 1 2 1.5 1 0.5 0 0.5 1 1.5 2 2 1.5 1 0.5 0 0.5 1 1.5 2 1.5
1.5 2 2 1.5 1 0.5 0 0.5 1 1.5 2 1.5 X-pupil co-ordinate X-pupil co-ordinate X-pupil co-ordinate
X-pupil co-ordinate X-pupil co-ordinate X-pupil co-ordinate
5 5 5
5
5 5
(minutes)
(minutes)

0 0 0
0
Y-axis

0 0
Y-axis

5 5
5 5
5 5
5 0 5 5 0 5 5 0 5
5 0 5 5 0 5 (minutes) (minutes) (minutes)
5 0 5 X-axis X-axis X-axis
(minutes) (minutes)
X-axis X-axis (minutes)
X-axis

Figure 6. The residual higher-order wavefront aberration maps

Figure 5. The residual higher-order wavefront aberration maps (upper
(upper half) and PSFs (lower half), generated when an ideal correction
half) and PSFs (lower half), generated when an ideal correction is trans-
is translated from the aligned position by 0.1 (a), 0.5 (b) and
lated in a horizontal direction, nasally from the aligned position by 0.1
1.0 mm (c) vertically upwards (superiorly) for all three keratoconic
(a), 0.5 (b) and 1.0 mm (c) for all three keratoconic patients. Each
patients. Each wavefront map represents the aberrations from the
wavefront map represents the aberrations from the 3rd- to the
3rd- to the 5th-order and includes a sphero-cylindrical correction. All
5th-order. All aberrations were calculated using a 4-mm pupil diame-
aberrations were calculated using a 4-mm pupil diameter. The darker
ter. The darker shades represent negative aberrations, whereas the
shades represent negative aberrations, whereas the lighter shades rep-
lighter shades represent positive aberrations. The scale bar shown is in
resent positive aberrations. The scale bar shown is in lm. The left
lm. The left hand images display the aberrations induced for the
hand images display the aberrations induced for the mild keratoconic
mild keratoconic patient, the central images for the moderate kerato-
patient, the central images for the moderate keratoconic patient and
conic patient and the right-hand images for the severe keratoconic
the right-hand images for the severe keratoconic patient.
patient.

Ophthalmic & Physiological Optics 32 (2012) 200212 2012 The College of Optometrists 207
Simulating customised corrections for keratoconus patients A Jinabhai et al.

horizontal translation. However, the uncorrected HORMS
error values for a 4-mm pupil diameter were (Table 1)
0.45, 0.60 and 1.01 lm for the mild, moderate and severe
cases respectively, so that even for 1 mm of horizontal or
vertical decentration, the aberrations of the corrected eyes
were smaller than those of the uncorrected eyes.
Figure 7 shows that horizontal or vertical translations
of up to 0.1 mm meet the Marechal criterion,39 yielding
HORMS error values 0.04 lm for all three keratoconic
patients. Alternatively, if it is required that the induced
aberrations satisfy the equivalent spherical blur criterion
described earlier (HORMS error <0.144 lm), or that they
be lower than those for the RGP lens-corrected eyes, Fig-
ure 7 shows that horizontal decentrations of up to about
0.5 mm may be acceptable in all three cases, however,
vertical decentrations should be kept to <0.4 mm. This
implies that a tolerance of about 0.3 mm on lens dis-
placement might be required for customised corrections.
Simulating residual 2nd-order wavefront errors
Having discussed changes in HOA, it is equally important
to also appreciate how customised lens movements will
impact on 2nd-order aberrations. Rotation of either 2nd-
order astigmatic Zernike component will induce a resid-
ual error of the same azimuthal frequency within the
same radial order, as is well known with toric corrections
i.e. rotation (without translation) of a correction for
C(2,2) induces residual C(2,)2) error, but no change in
defocus. In contrast, rotation of the higher-order Zernike
components of a customised HOA correction (3rd-order
and above) does not induce a change in 2nd-order terms.
However, translation of the higher-order Zernike compo-
nents will, in general, induce 2nd-order (sphero-cylindri-
cal) errors.15,41 In particular, translation of the correction
of the dominant 3rd-order vertical coma of keratoconic
eyes (Table 1) will generate marked 2nd-order defocus
and astigmatism.15,42
Figure 8 displays the magnitude of 2nd-order astigma-
tism induced by rotating an ideal customised correction,
which is designed to correct HOA (3rd-order to 5th-
order), from the perfectly aligned position by up to 15
for all three keratoconic patients. The crossed-cylinder
astigmatismpis expressed as a correction J, in pdioptres
2 (D),
2
where J J02 pJ245 ,
2 with J 0 C 2  2 6=R and
40
J45 C22  2 6=R , where R is the pupil radius.
The 2nd-order crossed-cylinder astigmatic error shows a
quasi-linear increase in magnitude with increasing rota-
tional misalignment for all three patients. Using, as a
tolerance, the criterion that the induced 2nd-order aberra-
tion should not exceed 0.25 D, the results suggest that the
mild and moderate keratoconic patients may be able to
tolerate rotations of up to 8, but that rotations should
not exceed 4 to provide good vision for the patient with
severe keratoconus. Obviously, the principal factor here is
the original level of astigmatism for each individual eye,
which is a function of both disease severity and cone apex
location.43

Figure 7. The magnitude of some of the residual higher-order aberrations when translating the ideal aberration-controlling correction, from the
aligned position, horizontally (nasally) and vertically (superiorly), by up to 1 mm for all three keratoconic patients. The upper graphs display the
horizontal translations, whereas the lower graphs show the vertical translations. The left-hand graphs display the mild keratoconic patients data,
the central graphs the moderate keratoconic patients data and the right-hand graphs the severe keratoconic patients data. Higher-order RMS
aberrations were calculated from the 3rd- to the 5th-order. All data were calculated using a 4-mm pupil diameter. The uncorrected HORMS values
for a 4-mm pupil diameter were (Table 1) 0.45, 0.60 and 1.01 lm for the mild, moderate and severe keratoconic patients respectively; corre-
sponding values for the RGP-corrected eyes were 0.09, 0.11 and 0.17 lm. For a 4-mm pupil, an equivalent defocus of 0.25 D corresponds to an
RMS aberration of 0.144 lm, as shown by the horizontal green line.

208 Ophthalmic & Physiological Optics 32 (2012) 200212 2012 The College of Optometrists
A Jinabhai et al. Simulating customised corrections for keratoconus patients

1.00 1.00
0.90 J Mild J Mod J Severe

0.80
2nd-order aberration (D)

2nd-order aberration (D)

0.70 0.50
0.60
0.50
0.40 0.00
0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1.0
0.30
0.20
0.10 0.50

0.00
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
Rotation (degrees)
1.00 Horizontal decentration (mm)

Figure 8. The magnitude of the 2nd-order crossed-cylinder astigma- 2.50

tism, J induced by rotating the ideal aberration-controlling correction 2.00
(from the aligned position) in a clockwise direction by up to 15 for 1.50

2nd-order aberration (D)

the three keratoconic patients. All data were calculated using a 4-mm 1.00

pupil diameter and are expressed as a correction in dioptres. The hori- 0.50

zontal dashed line shows a threshold of 0.25 D of refractive error. 0.00

0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1.0
0.50
1.00
Figure 9 displays effects of either horizontal or vertical 1.50
translation of an ideal HOA-controlling correction (i.e. 2.00
2.50 M Mild M Mod M Severe
3rd- to the 5th-order) on p the
induced dioptric 2nd-order 3.00
spherical defocus M 4 3C02 =R2 , in D,40 and crossed- J Mild J Mod J Severe

3.50 Vertical decentration (mm)

cylinder astigmatism term J (combined J0 and J45), again
in D. High levels of 2nd-order aberration are found for
the larger decentration values, particularly in the vertical
direction. For all three patients, the induced magnitudes
of M and J typically reached values in excess of 0.35 D
for horizontal translations approaching 0.5 mm in magni-
tude. Compared to horizontal decentrations, vertical
translations induced larger magnitudes of residual
2nd-order aberrations. Using the criterion of 0.25 D of
equivalent spherical blur, the results suggest that only
translations of no more than 0.1 mm could be tolerated.
Discussion
The present study has several limitations. It considers the
effects of rotation and translation of ideal customised
lenses only in terms of the RMS wavefront errors and the
form of the monochromatic PSF, rather than in terms of
the modulation transfer functions (MTFs) as used by
Guirao et al.15 Different aberrations with the same level of
RMS wavefront error may have different effects on the
MTF and visual performance.44,45 The calculations use
only a 4-mm pupil diameter and ignore the effects of
chromatic aberrations; the latter will cause additional blur
in all white-light images and tend to reduce the advantage
offered by a correctly-aligned customised correction.15,46
The dynamic nature of lens movements is also ignored; it
may be that although the maximum translation is, say
0.5 mm, the average translation is much smaller, allowing
periods of better vision.15,28,29 We note too that, in prac-
tice, ocular aberrations are themselves subject to change
Figure 9. The magnitude of the induced 2nd-order RMS aberrations
(astigmatism, J and defocus, M) when translating the ideal aberra-
tion-controlling correction, from the aligned position, nasally along
the horizontal meridian (upper graph) and superiorly along the vertical
meridian (lower graph) by up to 1 mm for the three keratoconic
patients. All data were calculated using a 4-mm pupil diameter and
are expressed as corrections in dioptres. Note the difference in the ver-
tical scales used in the two parts of the figure. The horizontal dashed
black and grey lines show a threshold of 0.25 D of refractive error.
with such factors as tear film changes after blinks, accom-
modation,47 and disease progression, and that fabricated
customised lenses may themselves not have the ideal
aberration characteristics as desired through manufactur-
ing limitations.22,23 Even with perfect correction of aberra-
tions, the visual performance of patients with keratoconus
is perhaps reduced due to neural factors such as adapta-
tion to the high magnitudes of ocular aberrations12,13: this
limits the utility of discussions based on improvements of
optical performance alone. Finally, we have used only
three representative keratoconic patients, although the
exact effects of lens movement will vary with the individ-
ual patient, particularly with disease severity and the cone
apex location. Nevertheless, in spite of these and other
limitations, we believe that the results give useful insights
into the relative merits of a conventional RGP lens correc-
tion and a customised correction for keratoconic eyes.
The results presented here, like those of many earlier
authors,14,15,17,2729,34,48 demonstrate that lower-order and
HOA become induced when an ideal, customised HOA-
controlling correction becomes rotated or decentred for

Ophthalmic & Physiological Optics 32 (2012) 200212 2012 The College of Optometrists 209
Simulating customised corrections for keratoconus patients
highly-aberrated, keratoconic eyes. The range of movement
evaluated in this study was chosen to be similar in magni-
tude to the small vertical, rotational and horizontal lens
movements characteristically seen between blinks and with
versional eye movements in toric soft contact lens wear-
ers,3133 although RGP contact lenses are likely to show
larger magnitudes of decentration upon blinking.
While typical amounts of rotation and translation of
the customised lens induces substantial levels of HOA, it
is striking that for the three keratoconic eyes investigated
here, the 2nd-order aberrations induced through transla-
tion are substantially larger than the induced HOAs
(compare Figures 4 and 7 with Figures 8 and 9). This was
found to be the case for both vertical and horizontal de-
centrations; therefore, the residual 2nd-order effects set
tighter tolerances on the permitted limits for such move-
ments. In general, too, the same RMS level of 2nd-order
aberration would have a greater effect on vision than if it
is found in the higher radial orders.44,45
A further striking aspect of the results for these kerato-
conic patients is that their conventional RGP lens correc-
tions reduced the total HORMS errors to around one-
fifth of the uncorrected values (Table 1). This sets much
tighter constraints on the tolerable values of rotation and
displacement for any customised lens if the latter is to
provide a useful improvement over the RGP lens-cor-
rected eye, rather than the uncorrected eye. Since there is
a quasi-linear relationship between total HORMS error
and the magnitudes of the angles of rotation and linear
translations (Figures 4 and 7 respectively), this effectively
implies that, in contrast to tolerances based on a compar-
ison with the naked eye, the tolerances for movement of
the customised correction need to be reduced by a factor
of around five if the customised optical performance is to
be superior to that with the RGP lens. The tolerances
then fall to values of around 2 of rotation and 0.10 mm
of translation. These tolerances may perhaps be too strin-
gent, since in studies restricted to patients with mild to
moderate keratoconus only, several authors6,9,10,38 found
somewhat smaller reductions (a factor of about 2) in the
HOA for keratoconic eyes when they were fitted with
conventional spherical RGP lenses. It may also be that
customised lenses offering partial correction of aberra-
tions may deliver better performance in the presence of
lens translation and rotation than lenses attempting to
fully correct HOA.14 Nevertheless, it appears that if custo-
mised contact lenses are to offer real visual advantages
over RGP lens corrections to keratoconic patients, their
movement must be very tightly controlled.
Only a few practical studies have been made of custo-
mised soft contact lenses as applied to real keratoconic
eyes,1820,22,23,34 although the effect of such lenses has also
been simulated using adaptive optics.12,13,49,50 The practi-
210 Ophthalmic & Physiological Optics 32 (2012) 200212 2012 The College of Optometrists
A Jinabhai et al.
cal trials suggest that the customised corrections fabri-
cated to date, yielded visual performances which differed
little from those obtained with conventional RGP lens
corrections. Sabesan et al.22 found that, when three kera-
toconic patients were fitted with aberration-reducing cus-
tomised soft lenses specially designed to also minimise
lens movement, the latter was reduced to about 0.30 mm
of translation and 10 of rotation, somewhat worse than
the levels suggested as desirable in our work. Mean high-
contrast visual acuity with these lenses was about 0.16
logMAR: a very similar level of visual acuity was achieved
by the one patient in the study who was also tested wear-
ing their habitual conventional RGP lens. This visual acu-
ity level is only slightly worse than that achieved by our
own RGP lens-corrected patients (Table 1). However,
Sabesan et al.s22 single patient who wore both types of
correction did have better low-contrast visual acuity with
their customised correction. Marsack et al.19,20 found that
their customised lenses gave comparable visual acuity per-
formance to RGP lenses when fitted on a small sample of
keratoconic patients. Katsoulos et al.18 found that, in four
keratoconic eyes, customised hydrogel lenses designed to
correct individual vertical coma aberration improved
monocular high-contrast visual acuity to an average of
about )0.04 logMAR.
Overall, these experimental results seem to be in broad
accordance with the predictions of our simulations allied to
the experimental measurements on our keratoconic eyes.
We interpret them as implying that current customised
corrections offer, at best, only marginal optical and visual
performance improvements over conventional RGP lens
corrections. This may be due to several factors in addition
to the problems of lens movement. The repeatability of
measurements of the aberrations of keratoconic patients
seems to be lower than those of normal patients,37 perhaps
because the high levels of aberration lead to misidentifica-
tion of the spots images when Shack-Hartman aberrome-
ters are used. This may lead to the wrong specification
being used for the aberrations of the correction. Further-
more, the customised corrections may either imperfectly
reproduce the required compensating aberrations or, as
already noted, assume the wrong position with respect to
the eye, due to rotation or translation. Advances in manu-
facturing technology may offer both better compensation
of HOA and a better stabilisation of lens position, particu-
larly through the use of back surface profiles which match
the corneal topography.23 Although relatively unpopular,
customised scleral lenses could reduce the problems of lens
movement. Certainly, if these various problems can be
overcome, laboratory studies in which the HOA are cor-
rected using adaptive optics suggest that aberration correc-
tion is capable of improving visual performance in patients
with keratoconus (e.g. to give high-contrast visual acuities
A Jinabhai et al.
of around )0.10 logMAR) although not quite to the levels
achieved by normal eyes when given the same type of aber-
ration correction, perhaps because keratoconic patients
may be adapted to their own normal high magnitudes of
aberration.12,13,49
Finally, we emphasise that these results relate to optical
quality only. Many patients find RGP contact lenses
uncomfortable and may therefore prefer customised soft
contact lenses5,22 even if they offer no advantages in visual
performance. Additionally, RGP contact lens wear has been
associated with corneal scarring and this, with epithelial
staining, may scatter light and reduce contrast sensitivity
and low-contrast visual acuity.51,52 Thus it may be that the
additional cost and complexity of customised corrections
will ultimately be justifiable for some keratoconic patients.
Acknowledgements
Amit Jinabhai is supported by a College of Optometrists
(UK) Ph.D. studentship. The authors would also like to
thank Patrick Y. Maeda for sharing his MatLAB code to
generate the PSF and wavefront map images.
Financial disclosures
The authors have no financial disclosures regarding any
of the equipment used in this investigation.
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