CORNEAL TOPOGRAPHY

Suraj Chhetri
B. Optometry
16th batch
 The word topography derived from Greek word : ‘topos’
(place) and ‘graphein’ (to draw)

 Corneal topography corresponds to the graphic

representation of the geometrical properties of corneal
surface

 Tomography

Derived from Greek word : Tomos (slice/

section) and grapho (to write )
Topographic reprsentation of nepal Saggital section of human head
 Dimensions of cornea
Diameter Thickness Radii of curvature

Anterior Surface Center- 0.52mm Human corneal

Dh- 11.5mm Periphery- 0.67mm surface is aspheric.
Dv- 10.6mm Limbus- 1.2mm Central optic zone
radii of curvature
Posterior surface Anterior- 7.8mm
Dh=Dv- 11.5mm Posterior- 6.8mm
 OPTICS OF CORNEA
 Cornea is the most powerful refractive element of the eye

 Contributes about 43D(70%) of refractive power of eye

 Even a minor modification on its surface can lead to a

significant alteration of the images formed on the retina

 The most critical element to preserving corneal optics is the

status of the corneal surface and tear film
 The swelling properties of the cornea( Mild epithelial edema)
can produce the symptoms of halos around bright lights or
Sattler’s veil,…

 While moderate stromal edema can also decrease visual

acuity( VA) primarily through light scatter, although this does
not become significant until swelling of 70 % is achieved.
 Causes of irregular corneal surface

 Corneal pathologies Ectatic degenerative diseases

Basement Membrane Keratoconus

Dystrophy Pellucid marginal
Bullous Keratopathy degeneration
Infectious Keratitis Terriens marginal
Trauma degeneration
Corneal ulcer Keratoglobus
 Corneal topographers have emerged as a powerful tool with
which to assess the etiology of factors that degrade vision by

 producing irregularities on the corneal surface that lead to

optical aberrations

 Any distortion in the corneal surface leads to reduced

quality retinal image.
• Direct examination of the corneal surface with the
biomicroscope does not provide enough resolution to detect
vision-reducing irregular astigmatism

• Although retinoscopy provides a greater sensitivity to

irregular astigmatism, the distortion seen in the retinal reflex
(e.g., scissoring and distorted shadows) Does Not Always
Indicate the nature or the location of the irregular
astigmatism
• Keratometers and Ophthalmometers have proven to be useful
when one limits the measurement of corneal power in
spherocylindrical notation

• Assumes the normal pupil to be approximately 3 mm in

diameter.
• Clinicians have long sought a device that
the entire surface of the cornea

• Issues of corneal regularity, symmetry, and the general nature

of the peripheral cornea are important for the understanding
of corneal optics.
• Reflection techniques, such as the Placido disk, keratometry,
photokeratoscopy, and corneal topography all arise from this
principle

• However, it was not until the development of corneal

topography that clinicians were provided with easily under-
stood color-coded maps of corneal curvature as well as
quantitative indices of irregular astigmatism that correlate
with potential visual acuity
 Indications & uses
• Preoperative and post operative assessment of refractive
patient

• Preoperative and post operative assessment of penetrating

keratoplasty

• Irregular astigmatism

• Corneal dystrophy and bullous keratopathy

• Keratoconus (diagnostic and follow-up)

• Follow-up of corneal ulceration and abscess

• Contact lens fitting

• Evaluation of tear film quality

• To study unexplained low visual acuity after any surgical

procedure:( trabeculectomy, extracapsular lens extraction,….)

• Post traumatic corneal scarring

• Reference instrument for IOL-implants to see the corneal

difference before and after surgery
 Background

• In 1619 Father Christopher Scheiner

realized that one could estimate
corneal curvature by comparing the
reflection of a window on the corneal surface to that on a series
of different sized marbles.
 The Placido disk, introduced in 1880 by Antonio Placido

 Consists of a circular target of alternating white and black

rings or mires with a central aperture through which one can
view its virtual image

Example of a Placido disk pattern. It includes a series of

spaced circular segments centered around a central point.
Distortion of the Placido mires images reflected on a
surface S with spherical (a) and toroidal (b) surface
geometry.
 These days, a resurgence of interest in corneal
topography has occurred, mainly due to

 The increasing use of keratorefractive procedures

and contact lens fitting in patients with corneal surface
abnormalities
 Topography:
Technique

Keratoscopy Keratometry Rastersterography Interferometry

Placido- Photo- Video-

disc keratoscopy keratoscopy
Topography: principle
 Optical principle and techniques

 Keratometry
 r= (-2d h’)/h
Where,
r = radius of curvature
d = distance between object
and 1st Purkinje image
h’= image height
h = mire separation

Keratometer mires
 Keratoscopy
– Is a general term that refers to the evaluation of
topographic abnormalities of the corneal surface by direct
observation of the images of mires reflected from the
surface of the cornea

Videokeratoscopic mires are closer together in the axis of steep curvature (arrow),
and farther apart in the flat axis (arrowhead) in this post-penetrating keratoplasty
patient.
Major axes are not orthogonal. (Courtesy of John E. Sutphin, MD.)
 Disadvantages
Small degrees of abnormalities of corneal shape go
undetected.

Could not be used in cornea with epithelial defects and

stromal ulcers because cornea cannot reflect the target

Placido disc is used only as a gross method of qualitative

assessment of the corneal surface
 Photokeratoscopy

 When a photographic film camera is attached to a

keratoscope, it is a photokeratoscope

 In the technique, the keratoscopic image is photographed

and the size of the images on the photographic film can be
changed to change the size of the corneal image
 The image of most photokeratoscope rings covers the
paracentral, overlapping into the central and peripheral
zones but leaving the optically important central 2-3 mm
as well as the peripheral cornea

 Current photokeratoscopes ( eg., Nidek PKS-1000 or

Keracorneascope) have 9-15 rings which cover 55-75% of
the corneal surface

 The corneal cylinders of up to 3 D can escape detection

by use of photokeratoscopy
 Videokeratoscopy
 When a television camera is attached to a keratoscope,
it is a videokeratoscope

 With the advent of computers, the

videokeratoscopy has been computerised

 A portrayal of the video recording of the corneal surface

is called a videokeratography
 Videokeratoscopy

• Presently,
the computer-assisted videokeratoscopy

corneal topography.

It covers approximately 95% of the corneal surface

 Rastersterography

 It uses a direct image on the corneal surface

 It projects a caliberated grid

pattern of horizontal and
vertical lines (spacing of 0.2 mm
is used) onto the fluorescein

 Stained tear film, takes a

photograph and uses computer
algorithms to analyse the pictures
 Rasterserography
 The accuracy of the system is
0.30 D for a diameter of 7
mm.

The advantage of this system

is that it includes all of the
cornea, including a part of the sclera.
 interferometry

 It uses the technique of light wave interference.

 This method has become obsolete and is of no concern to

present-world study of corneal topography.
 Computer Topography Systems

 Presently the term corneal topography system (CTS), or

videokeratography, implies computerised, video-
assisted technique that provides detailed information
about the shape of the corneal surface

 The technique has an excellent accuracy and

repeatability.

 Most corneal topographers evaluate 8000-10000

specific points across the entire corneal surface.
 Computer topography system
• Basic unit of CTS primarily consists of
– A projection device
– Video Camera
– Digital computer attached to a slit-lamp chin rest
 Different types of CTS
1.Placido-disc topography systems

Makes use of 8-32 concentric rings on the cornea

 Commercially available Placido-disc topography systems

Corneal Modeling System( CMS)

Computerised Corneal Topographer EH 270
EyeSys 2000 Corneal Analysis System
TMS-1 Topographic Modeling System
 2. Slit-imaging topography systems
 CTS based on this technology uses scanning slits that step
over the corneal surface to acquire topographic information

 This is similar to the slit-lamp in principle. Two slits are used,

positioned at 45 deg angles to the right and left of the
instrument axis
 Slit-imaging topography systems
 Twenty slit images are captured from each direction
with overlap in a 7-mm diameter central area

 Total corneal coverage is up to 10 mm, depending on

the individual corneal shape

 All images are captured within approximately 1.5

seconds.
 Advantage Disadvantage

Measure all surfaces of Relatively long

anterior segment. scanning time.
Data regarding the
accuracy and
reproducibility of
Pentacam are not
available yet.
Commercially available ‘slit-imaging’
topography systems

orbsacn pentacam
 Orbscan
 Most recent of the commercially available topography
systems.

 It combines a slit scanning system and Plasido’s disk

 Measures elevation and curvature of anterior and

posterior surfaces of cornea along with full
pachymetry map.

 It uses the principle of back-scattered reflection,

unlike the specular reflection employed in
keratometry.
Specular reflection. This is Back-scatter reflection. This is
used in keratometry and is used in Orbscan. This is omni-
angle dependent. directional.
 Orbscan
 Orbscan uses slit-beams and back-scattered light to
triangulate surface shape. The derived mathematical
surface is then ray traced using a basic keratometer
model to produce simulated keratometer (Sim K)values
 Orbscan
 Orbscan II, the improved model is an integration of the Slit
scanning technology into the Placido-disc system
OR
 Orbscan + Placido-disc = Orbscan II
 HOW IS RECORDING MADE?

 40 slit images (40 slits limbus to limbus)are acquired in

two 0.7 second periods.

 During acquisition, involuntary saccades typically move

the eye by 50 microns.

 Eye movement is measured from anterior reflections of

stationary slit beam and other light sources.

 Eye tracking data permit saccadic movements to be

subtracted form the final topographic surface.
 Orbscan
 If we were doing topography with a machine, which
does not have slit scan imaging facility, we would not
be able to see the topography of the posterior surface
of the cornea

 If any abnormality in the posterior surface of the

cornea, for example as in primary posterior corneal
elevation this would not be diagnosed
 Orbscan
 Then if we perform Lasik on such a patient we would
create an iatrogenic keratectesia. The orbscan helps us
to detect the abnormalities on the posterior surface of
the cornea.

 Colour meanings in the spectral direction ( from blue

to red)
 Red = high, steep, sharp, shallow, thin, or focused
 Blue = low, level, flat, deep, thick, or aberrated.
General quad map of a primary posterior corneal elevation. Notice the upper right map has
an abnormality whereas the upper left map is normal. This shows the anterior surface of
the cornea is normal and the problem is in the posterior surface of the cornea.
 Pentacam
 Images the anterior segment of the eye, using a rotating
Scheimpflug camera, and pictures in these dimensions of the
anterior segment are shown by this rotating process

 The images captured are then used to construct the anterior

corneal surface (corneal topography), posterior corneal
surface and anterior axis and anterior lens surfaces

 The Scheimpflug is modification of slit- lamp camera.

 Has modified geometry to improve depth of focus and include

distortion correction algorithms.
The image in the ordinary camera. The main disadvantage is
limited depth of focus because the picture plane, objective plane
and the film plane are parallel.
The Scheimpflug camera. Higher depth of focus, sharp image but
distorted. The picture plane, the objective plane and the film plane cut
each other in one line or one point of intersection.

Scheimflug
intersection
 A two-dimensional cross-sectional image results.
When performing A scan, cameras are used to
capture the image.
 One centrally located camera detects pupil size and
orientation, and controls fixation.
 The second rotates 180 degrees to capture 25 or 50
images of the anterior segment to the level of the iris,
and through the pupil to evaluate the lens.
 Pentacam
 500 true elevation data points are generated per image to
yield up to 25,000 points for each surface.

 Data points are captured for the center of the cornea, an area
that placido disc topographers and slit scanning devices are
unable to evaluate.
(Based on an elevation map)
Formats for display of data on color maps

1. Corneal Power Map (Axial or Sagittal)

– 24-colour representation of dioptric power at various
points on the cornea

What is the axial curvature then???

The sagittal (axial method). The curvature power of the measured
surface in point “a” is calculated using a tangent line in this point, the
normal in this point intersects the reference axis at point b, ab is the
radius (r) of point “a”, finally the equation is applied to calculate the
power (K) at point a.
Corneal Power Map (Axial or Sagittal)
Axial curvature closely approximates the power of the
central 1-2 mm of the cornea but fails to describe the true
shape and power of the peripheral cornea.

 For almost sphere cornea… the curvature is almost the

same from the centre to the periphery.
In fact, cornea are not always spherical.

 This is not a good descriptor

in corneal topography.
 2. Tangential or Intanstaneous map
– A better geographic representation of the cornea
than the axial/saggital map.

The tangential (local method). The Please notice the

principle depends on tangent circles difference…
rather than straight lines. this is an axial map…
3. Elevation map

 Elevation is not measured by Placido-based

topographers, but certain assumptions allow the
construction of elevation maps

 Elevation of a point on the corneal surface

displays the height of the point on the corneal
surface relative to a spherical surface.

 The reference surface is mostly considered to

be a sphere, or, to be precise, a Best Fit Sphere ( BFS)
 Calculates corneal elevation data from a reference
ellipse/sphere

 In case of topographical land

maps, elevations are measur-
ed from a reference plane at
sea level,
for example..the
height of Mt Everest is 8848 m
( from sea level)
The BFS (green) is the closest sphere to the corneal surface. Once
the sphere radius and location are positioned, elevation is plotted
as the distance from the surface to the sphere.
The relationship between the reference body and the
cornea. Corneal surface (yellow) has steep center and flat
periphery in accordance to this particular reference body.
4. Refractive Power Map

 Optical power maps (or ‘refractive maps’) are

functional maps and should not be confounded
with curvature maps.

 Since the cornea suffers aberrations, the

refraction varies along the meridians even if the
curvature does not change….owing to spherical
aberration..esp…positive spherical aberration.

 Why????
These light rays near the center of the cornea have a small angle of
incidence relative to the surface normal, and thus the refracted
angle is also quite small. Contrarily, light rays in the paracentral and
peripheral cornea have a larger angle of incidence relative to the
surface normal, and thus the refracted angle is larger.
Color codes
 Absolute

Adjustable Normalized

SCALES

Maguire/waring Klyce/wilson
 Absolute scale

• Scale range: 9.0D to 101.5 D

• Average value 43D

• Central area divided into 11 graduations

1.5D interval

• Beyond 11 graduations interval of 5.0 D

 Normalized scale

• Divided into scale of 11

• Displays the max and min

refractive power of
examined eye
 Adjustable scale

• 26 graduations

• Max and min value can be

selected by examiner
 Klyce/Wilson scale

• Scale range: 28.0D to 65.5D

• Interval of 1.5D
 Maguire/waring scale

• Scale range: 32.0D to 57.0D

• Interval of 1.0D
Topographic display in
Pentacam
Statistical indices employed in
videokeratoscopy
 SimK: Simulated keratometry

 It is obtained from the greatest power observed on

the corneal surface from an average of rings 12-16
along every meridian

 The power and axis orthogonal to the highest power

are also reported as they are in traditional
keratometry

 Higher than normal values are often associated with

keratoconus, penetrating keratoplasty, and the
occasional steep normal. Lower than normal values
occur with myopic refractive surgical corrections and
the rare flat normal.
 SimK2: Simulated keratometry.

– SimK2 is the power of the flat meridian orthogonal (90°) to

SimK1.
 MinK: Minimum Keratometry Value

 Often the meridians of highest and lowest power are

not orthogonal.

 It is useful to know the meridian for which the actual

minimum power occurs, particularly in the planning of
astigmatic keratotomy.

 This situation most often occurs with keratoconus,

penetrating keratoplasty, and trauma, although it may be
present after cataract surgery as well.
• SAI: Surface Asymmetry Index

– The SAI measures the difference in corneal powers at

every ring (180° apart) over the entire corneal surface.

– The SAI is often higher than normal in keratoconus,

penetrating keratoplasty, decentered myopic refractive
surgical procedures, trauma, and contact lens warpage.

– Adequate spectacle correction is often not achieved when

SAI is high.
• Cyl: Simulated keratometric cylinder

– The simulated keratometric cylinder of the corneal surface

is obtained from the Sim K readings.

– Higher than normal values of Cyl are associated with

several pathologies, trauma, and surgery.
• SDP: Standard Deviation of corneal Power

– The SDP is calculated from the distribution of all corneal

powers in a videokeratography.

– SDP is often high for keratoconus corneas, transplants,

and trauma - all situations in which there is a wide range
of powers occurring in the measured topography.
CVP: Coefficient of Variation of corneal Power

 The CVP is calculated from the Standard Deviation of

corneal Powers (SDP) divided by the grand average of
corneal powers.

 High values are found in Keratoconus, corneal transplants.

• IAI: Irregular Astigmatism Index

 The IAI is an area-compensated average summation of

inter-ring power variations along every meridian for the
entire corneal surface analyzed.

 The IAI increases as local irregular astigmatism in the

corneal surface increases. IAI is high in corneal transplants
shortly after surgery; persistence often sub optimal best
spectacle corrected vision.
EDP: Elevation/Depression Power

 EDP calculates the average power of apparent islands and

valleys for those areas of the cornea that are within the
demarcated pupil.
 SRI: Surface Regularity Index

 The SRI is a correlate to potential visual acuity and is a

measure of local fluctuations in central corneal power.

 When SRI is elevated, the corneal surface ahead of the

entrance pupil will be irregular, leading to a reduction in
best spectacle-corrected visual acuity. High SRI values are
found with dry eyes, contact lens wear, trauma, and
penetrating keratoplasty
 PVA: Potential Visual Acuity

 Irregularities in corneal topography ahead of the

entrance pupil reduce the visual potential of the
eye.

 The consequence of these irregularities are

assessed by the calculation of the Surface
Regularity Index which has been correlated to PVA
in a published clinical study.

 The PVA is given as the range of best spectacle-

corrected Snellen visual acuity that might be
expected from a functionally normal eye with the
topographical characteristics of the analyzed
cornea.
 ACP : Average Corneal Power

 The ACP is an area-corrected average of the corneal power

ahead of the entrance pupil.

 It is generally equal to the keratometric spherical

equivalent except for decentered refractive surgical
procedures.

 Abnormal values occur for the same reasons as for

keratometry
 CEI: Corneal Eccentricity Index

– The CEI is a measure of corneal eccentricity, a global shape

factor.

– A positive (normal) value is obtained for a prolate surface,

a nil value for a sphere and a negative value is used to
indicate an oblate surface.

– Out of range values include keratoconus (higher than

normal) and negative values often found with contact lens
wear and myopic refractive surgical corrections.
 EDD: Elevation/Depression Diameter

 EDD is the equivalent diameter of the area found to

contain powers within the pupil 1 Diopter or more from
the mode.

 It is calculated from twice the square root of this area

divided by Pi.

 The units are mm.

LogMAR: Log of the Minimum Angle of Resolution

 LogMAR is a standard unit for expressing high contrast (Snellen)

visual acuity.

 It relates directly to how well the eye can discriminate between

two points of light.
 KPI: Keratoconus Prediction Index

 The Keratoconus Prediction Index is less than 0.225 for

normals.

 It is obtained by discriminant analysis of corneal statistical

indexes.

 This numerical estimator is used to indicate the presence

of a keratoconus pattern in corneal topography1
1 (Invest Ophthalmol Vis Sci 35:2749-2757, 1994)
• KSI: Keratoconus Severity Index

– Keratoconus suspect is interpreted when KSI reaches 0.15

– Clinical keratoconus is triggered at a KSI of 0.30 2

2 (Invest Ophthalmol Vis Sci 38:2290-2299, 1997)

 DSI: Differential Sector Index

 The DSI reports the area-compensated greatest difference

between any two (out of eight) sectors of a given cornea.

 Here it shows a DSI of 10 D.

 OSI: Opposite Sector Index

 The OSI is higher than normal in keratoconus. It represents

the maximum difference between an area-corrected
corneal powers between any two opposite sectors of the
cornea.
 CSI: Center/Surround Index

– The CSI is the area-corrected difference in average

corneal power between the central 3 millimeters of
analyzed area and an annulus surrounding the
central area from an inner radius of 1.5 mm to an
outer radius of 3 mm.

– The CSI is higher than normal with centrally

located keratoconus and refractive surgical
correction of hyperopia. It is subnormal for myopic
refractive surgical corrections.
 Corneal Topogaphic patterns in
NORMAL CORNEAS
 The normal cornea flattens progessively from the centre to
the periphery by 2-4 D, with the nasal area flattening more
than the temporal area
 Two corneas of an
individual
show mirror-image
asymmetry.
 Variations are common in
nature.
 Corneal Topogaphic patterns
in NORMAL CORNEAS

• Depending on the corneal curvature, Rabinowitz et al. in

1996 described 10 different corneal topographic
patterns in normal eyes.
Corneal Topogaphic patterns
in NORMAL CORNEAS
Round: 22.6%
Symmetric bow-tie: 17.5%
Asymmetric bow-tie: 32.1%
Irregular:7.1%
 Clinical Applications of Corneal
Topography
Corneal Topography in Ectasias

Mires lie closest together in

the inferiocentral region
where the cornea is
steepest and furthest apart
superiorly where the cornea
is flattest.
 Keratoconus

Keratoconus is almost always bilateral, and one cornea is more

involved than the other (in this case OD). Note that, while OS at first
impression looks fairly normal, the ‘lazy eight’ astigmatic pattern is a
common characteristic of keratoconus.
 keratoconus

Keratoconus suspect is diagnosed in curvature maps Also diagnosis:

when the central corneal power or Sim K is greater than Mean central
47.2 D or I-S value greater than 1.4 D. thickness: < 500μ;
Keratoconus…48.7 D and I-S value > 1.9 thinnest point <470
μm; difference of >100
I-S = difference between the powers in the superior and μm from thinnest
the inferior paracentral regions point to 7 mm zone
Pellucid marginal degeneration
 Pellucid marginal degeneration

The topographical findings in PMD include high against-the-rule

corneal astigmatism and inferior mid-peripheral steepening at 4
and 8 o’clock. This pattern in creates a “kissing pigeon” or
“butterfly wing-like” or “crab claw” pattern diagnostic of PMD.
 Terriens degeneration

In Terriens degeneration when the thinning is restricted to the

superior or inferior area of the peripheral cornea, there is relative
steepening approximately 90 deg away. ATR Astigmatism..with
vertical flattening….The diagnosis always requires a pachymetry map.
 Pterygium

Asymmetrical nasal flattening of the right eye of a patient with

pterygium. This is marked with-the-rule toricity.
Clinical Applications of Corneal Topography

• Photorefractive keratectomy (PRK) and Laser-assisted in-situ

keratomileusis (LASIK)

– Information about the quality, diameter and centration of

the ablated zone along with its stability over a course of
time.
–
Decentration---halos or glare effect
Irregular ablation zone---decreased visual acuity
Videokeratography of the left eye of a myopic patient after laser in
situ keratomileusis (LASIK). Upper left, preoperative eye. Follow-up:
lower left, 2 weeks; upper right, 2 months; lower right, 6 months
after surgery. This format is useful to study topographic stability.
References