KERATOMETRY &

AUTOREFRACTOMETRY

PRESENTER:Presenter
DR. PAVITRA
- Dhivya.G K.PATEL
 CONTENTS

KERATOMETRY
Definition
History
Principle
Types of keratometer
Procedure of keratometry
Interpretation of findings
Clinical uses
Limitations
Sources of error
Surgical keratometer
Automated keratometer
KERATOMETRY

“Kerato”- cornea
“metry”-measurement of
 DEFINITION:

Keratometry is measurement of curvature of the anterior

surface of cornea across a fixed chord length, usually 2 -
3 mm, which lies within the optical spherical zone of
cornea.

Expressed in Dioptric power.

Keratometer also called as Ophthalmometer.

 HISTORY

YEARS INVENTORS
1691 Christoph Scheiner –Description of corneal
curvature
-Compared size of the bars in a window-
lens & cornea
1796 Jesse Ramsden- Inventor of 1st model of
keratometer with 3 essential elements
1854 Helmholtz improved Ramsden’s design for
laboratory use
1881 Javal & Schiotz modified Helmholtz’s
instrument for clinical use
1980 Development of autorefractometer
 PRINCIPLE

 Keratometry is based on the fact that the anterior

surface of the cornea acts as a convex mirror & the size
of the image formed varies with its curvature.

Greater the curvature of cornea, lesser is the image size.

 Therefore, from the size of the image formed by the

anterior surface of cornea (1 st Purkinje image) , the
radius of curvature of cornea calculated as below:
 Optical principle involved is the relationship between the size of
an object and size of the image of that object reflected from
surface.

 Radius of curvature is determined by the apparent size of the

image of bright object (mires) viewed by the reflection from
anterior corneal surface which acts as a convex mirror.

r = 2 x h1/h
r= radius of curvature, h=height of object, h1=height of the image

D= (n1-n) /r x 1000

n1= refractive index of cornea (1.337),n=refractive index of

medium from which light originates (air=1)
Principles of Keratometry AB is the object and A' B' is the image. By measuring
the size of the object and image, curvature of the convex surface can be
calculated
 Keratometer is based on 2 concepts:

Fixed object size Fixed image size

with variable image with variable object
size size
(Variable doubling) (Fixed doubling)

Eg. Bausch and Lomb Eg. Javal- Schiotz

keratometer keratometer
 Doubling principle:

Because of involuntary eye movement image formed on

cornea would be constantly moving.
To overcome this Ramsden devoloped Doubling
technique.
A prism is introduced into the optical system so that 2
images are formed .
The prism is moved until the images touch each other.

Depending on the position of prism, if distance doubling

 Basically, there are two types of keratometer:

Manual Auto
keratometer keratometer
 BAUSCH AND LOMB KERATOMETER

 PRINCIPLE:
“Constant object size and variable image size”.
 PARTS:
OPTICAL SYSTEM OF KERATOMETER
 OPTICAL SYSTEM AND OTHER PARTS:
1. Object: Circular mire with two plus & two minus
signs.
o Lamp illuminates the mire by means
of a diagonally placed mirror.
o Light from the mire strikes the
patient’s cornea & produces a
diminished image behind it.
o This image becomes the object for the remainder of
optical system.
2. Objective lens:
o Focuses light from the image of the mire (new object)
along the central axis.

3. Diaphragm and doubling prisms:

o 4 aperture diaphragm is situated near objective lens.
o Beyond the diaphragm are two doubling prisms, one
with its base up & other with its base out.
o Prisms can be moved independently, parallel to the
central axis of instrument.
 Light passing through
Light passing through left
right aperture is deviated
aperture of diaphragm is
by base –out prism,
made to deviate above
placing the second image
the central optical axis by
to the right of the central
a base-up prism.
axis.

Light passing through

upper & lower apertures
does not pass through
either prism & an image
is produced on the axis.
 Total area of upper & = Area of each of
lower apertures the other two apertures

Therefore, brightness of the images is equal.

 Upper and lower apertures also act as Scheiner’s disc

doubling the central image, whenever the instrument is
not focused precisely on central mire image.

 Thus, image-doubling mechanism is unique in Bausch

and Lomb keratometer, in that double images are
produced side by side as well as at 90 0 from each other.
 This allows the measurement of the power of cornea in
two meridia, without rotating the instrument.

Therefore, it is also known as ‘one-position keratometer’.

4. Eyepiece lens:
o Enables examiner to observe magnified view of the
doubled image.
 PROCEDURE OF KERATOMETRY:
1. Instrument adjustment:
Instrument is calibrated before use

White paper held in front of objective lens & a

black line is focused sharply on it

Keratometer is then calibrated with steel balls

Steel ball of known radius of curvature is placed

before keratometer & its value is set on the scale
or dial
 Mires are focused by clockwise & anticlockwise
movement of eyepiece through trial & error

When mires are in focus, the calibration is

complete.

2. Patient adjustment:
o Seated in front of the instrument.
o Chin on chin rest & head against head rest.
o Eye not being examined is covered with occluder.
o Chin is raised or lowered till patient’s pupil & projective
knob are at the same level.
3. Focusing of mire:
o Mire is focused in the centre of cornea.

First view seen by the examiner.

Patient’s view of mire Note that the central image is
doubled, indicating that instrument is
not correctly focused on the corneal
image of the mire.
4. Measurement of corneal curvature:
o Instrument is correctly focused on corneal image so that
central image is no longer doubled.
 To measure curvature in
horizontal meridian, plus
signs of central & left
images are superimposed
using horizontal measuring
control.
To measure curvature in
vertical meridian, minus
signs of central & upper
images are coincided with
the help of vertical
measuring control.

In presence of oblique
astigmatism, two plus
signs will not be Corneal radius of
aligned.Entire instrument Power is then
measured.
rotated till they are
aligned.
OBLIQUE ASTIGMATISM
 RECORDING OF THE CORNEAL CURVATURE:
 INTERPRETATION OF
FINDINGS

Remember that it is the power meridian, NOT the axis,

being recorded in keratometry.
 Spherical cornea
• No difference in power b/w 2
principal meridia
• Mires seen as perfect sphere.
Irregular anterior corneal
surface
• Irregular mires.
• Doubling of mires.
Astigmatism
• Difference in power b/w 2 principal meridia.
• Horizontally oval mires in WTR
astigmatism.
• Vertically oval mires in ATR astigmatism.
• Oblique astimatism principal meridia b/w
300-600 & 120-1500.
Keratoconus
• Pulsating mires(Inclination & jumpimg
of mires on attempt to adjust the
mires).
• Minification of mires in advanced
cases (K >52 D) due to increased
amount of myopia.
• Oval mires due to large astigmatism.
• Irregular,wavy & distorted mires in
advanced keratoconus.
RANGE OF KERATOMETER:

 Range  36.00 to 52.00 D

 Normal values  44.00 to 45.00 D
 To increase the range  Place +1.25 D lens in front of
the aperture to extend range to 61 D.
 ADD 9 D
 Place -1.00 D lens in front of the aperture to extend
range to 30 D.
 SUBTRACT 6 D
 JAVAL –SCHIOTZ KERATOMETER

 PRINCIPLE:
“Variable object size and constant image size”.
 OPTICAL SYSTEM OF KERATOMETER

 OPTICAL SYSTEM AND PARTS:

1.Object:
o Consists of two mires (A & B), mounted on an arc on
which they can be moved synchronously.
o Since the two mires together form the object, the
variable size is attained by their movement.

One mireStepped, Other mire Rectangular,

has green filter has red filter
o Mires divided horizontally through the centre.
o They are illuminated by small lamps.
o Image of these mires formed by patient’s cornea (1 st
Purkinje image) acts as an object for the rest of the
optical system of the keratometer.

2.Objective lens & doubling prism:

o Forms double image of the new object.
o Doubling prism used  Wollaston type.
o Produces fixed image doubling by birefringent (double
refracting) characteristic of material of which it is
made.

3. Eyepiece lens:
o Enables examiner to observe magnified view of the
doubled image.
 PROCEDURE OF KERATOMETRY:
1.Instrument adjustment:
o White paper held in front of the objective piece & black
line focused on it.
o Then instrument is calibrated to make it ready for use.

2.Patient adjustment
3.Adjustment of mires:
o Mires are focused in the centre of patient’s cornea.

Patient’s view of mires Examiner’s view of

doubled mire image
4.Recording of keratometric readings:
o Only central pair of images is used when measurements
are made.
o When two control images just meet, the scales
associated with the mire separation indicate the correct
corneal radius & dioptric power of the cornea.
 Measurement of radius of
Radius of curvature Then entire optical curvature in second
first found in one system rotated 900 meridian which is
meridian. about its central axis. perpendicular to 1st one is
then made in similar way.
 When corneal astigmatism is
present  Overlapping of
mires or they may move
further apart.
 Since stepped mire (staircase
pattern) is green &
rectangular mire is red, area
of overlap appears whitish.
 Each step of mire  1 D of
corneal power ,thus the
number of steps overlapped
gives approximate degree of
astigmatism.
 When oblique astigmatism is present

Scale associated
with instrument
Mires are
Instrument is rotation
horizontal,central
rotated until the indicates, in
bisecting lines of
control lines are degrees, one
images are not
aligned. meridian of
aligned.
oblique
astigmatism.

 Corneal radius or power is then measured in this

meridian & also in the meridian 90 0 to it as usual.
 CLINICAL USES OF KERATOMETERS

1. Helps in measurement of corneal astigmatic error.

o Difference in power between two principal meridians is

the amount of corneal astigmatism.
o In Optometry, astigmatism is corrected by minus
cylinder lens.
o From K readings, meridian of least refracting power
indicates the position of minus axis of the correcting
cylinder.
Eg 1. OD 42.50D at 180 / 44.50D at 90
 Corneal astigmatism = 2.00D
 Correcting cylinder = -2.00DC x 180
 WTR astigmatism

Eg 2. OD 42.75D at 180 / 42.00D at 90

 Corneal astigmatism = 0.75D
 Correcting cylinder = -0.75DC x 90
 ATR astigmatism
2. Helps to estimate radius of curvature of the anterior
surface of cornea  Use in contact lens fitting.
3.Monitors shape of the cornea  Keratoconus
Keratoglobus
4.Assess refractive error in cases of hazy media.
5.IOL power calculation.
6.To monitor pre- & post-surgical astigmatism.
7.Used for differential diagnosis of axial versus
curvatural anisometropia.
 LIMITATIONS OF KERATOMETRY

Measurements of
keratometer based
on false assumption Measures Loses accuracy
that cornea is a
symmetrical refractive when
spherical or status of small measuring very
spherocylindrical central cornea flat or very
structure,with 2
principal meridia (3-4 mm) steep cornea
separated from each
other by 900
 Small corneal
Distance to
irregularities One-position
focal point is
preclude use of instruments
approximated
keratometer assume regular
by distance to
due to irregular astigmatism.
image.
astigmatism.
SOURCES OF ERROR IN KERATOMETRY

Improper
calibration
Improper
Faulty
focusing of
positioning
corneal
of patient
image

Improper
Abnormal
fixation by
lid position
patient

Accomodat
-ive
Excessive
fluctuation
tearing
by
examiner
Localized
corneal
distortion
SURGICAL/OPERATING KERATOMETER

 Attached to operating microscope.

 Helpful in monitoring astigmatism
during corneal surgery.
 Accuracy limited:
1. Difficulty in aligning patients
visual axis & keratometer ’s
optical axis.
2. Calibrated for a fixed distance
from anterior cornea.
3. Different microscope objective
lenses result in different focal
lengths & therefore different
working distance.
4. External pressure on globe
results in change in a corneal
curvature.
AUTOMATED KERATOMETER

• Focuses reflected corneal image on

to an electronic photosensitive
device, which instantly records the
size & computes the radius of
curvature.
• Target mires are illuminated with
infrared light, & an infrared
photodetector is used.

 ADVANTAGES:
• Compact device
• Very short time consuming
• Comparatively easy to operate
 Availability of autokeratometer:
o Either available alone or more commonly in association
with autorefractometers as autokeratorefractometers.
Eg: Nidek ARK 2000-S autokeratorefractometer

o Automated keratometry can be performed using

following instruments:
1. The IOL master
2. Pentacam
3. Orbscan
4. Corneal topographer
AUTO-REFRACTOMETRY-CONTENTS

AUTO-REFRACTOMETRY
Definition
Principle
Types of refractometers
Portable autorefractors
Advantages of automated over manual
Wavefront technology
AUTOREFRACTOMETRY

 Refractometry (optometry) is
an alternative method of
finding out the error of
refraction by the use of an
optical equipment called
refractometer or optometer.
 OPTICAL PRINCIPLES

Scheiner Optometer
principle(1619) principle(1759)
1. SCHEINER PRINCIPLE:
o Scheiner in 1619 observed that
refractive error of the eye is determined by using double
pinhole apertures before the pupils.
 Parallel rays of light from a distant object are reduced
to two small bundles of light by the Scheiner disc.
 These form a single focus on the retina if the eye is
emmetropic; but if there is any refractive error two
spots fall on the retina.
By adjusting the position of the object (performed optically by the
autorefractor) until one focus of light is seen by the patient, the far
point of the patient’s eye and the refractive error can be determined.
2. OPTOMETER PRINCIPLE:
o Porterfield, in 1759 coined the term optometer to
describe an instrument for measuring the limits of
distinct vision.
o Principle permits continuous variation of power in
refracting instruments.
o It involves a convex lens placed in front of the eye at its
focal length from the eye (or the spectacle plane) and a
movable target is viewed through the lens.
 Light from the target on the far side of the lens enters
the eye with vergence of different amounts, depending
on the position of the target.
 If the target lies at the focal point of the lens, light from
the target will be parallel at the spectacle plane, and
focused on the retina of the Emmetropic eye.
 Light from the target when it is within the focal length
of the lens will be divergent in the spectacle plane while
light from a target outside the focal length of the lens
will be convergent.
 The vergence of the light in the focal plane of the lens
is linearly related to the displacement of the target from
the focal point of the lens.
 A scale can thus be formed which would show the
number of diopters of correction according to the
position of the target.
 Development of optometers grouped as follows:

Early Modern
refractometers autorefractors

 Both are subdivided into subjective & objective optometers.

 EARLY REFRACTOMETERS
1. EARLY SUBJECTIVE
OPTOMETERS:
o Patient is required to adjust
the instrument for best focus.
o Unsuccessful due to
instrument accomodation.
o Examples: 1.Badal
Optometer
2.Young’s Optometer
1. EARLY OBJECTIVE
OPTOMETERS:
o Rely on examiner ’s decision on
when the image is clearest.
o Thus, they were objective only
in sense that the patient’s
subjective choice had been
replaced by the choice of an
experienced examiner.
o Based on optometer principle, &
most of them incorporated
Scheiner principle as well.
 LIMITATIONS OF EARLIER OPTOMETERS:
1. Alignment problem:
o As per Scheiner ’s principle, both pinhole apertures must
fit within the patient’s pupil.
o If patient’s fixation wanders, reading is invalid.
o Thus, considerable patient cooperation required.

2. Irregular astigmatism:
o In a patient with irregular astigmatism, best refraction
over whole pupil may be different in contrast to two
small pinhole areas of pupil.
3. Accomodation:
o On looking into the instrument, patient tends to
accommodate  Instrument Myopia.
o Alters actual refractive status of patient.
o Factors affecting accomodation:
Attention
Fatigue
Direction of gaze
Illumination
Image detail
Blur of retinal image
Psychological factors
 MODERN REFRACTOMETERS

 General comparison of subjective & objective

instruments:
Features Objective Subjective
refractometers refractometers
Source of light Low levels of invisible Visible light
infrared light to perform
refraction
Time required for 2-4 mins 4-8 mins
refraction(BE)
Information provided Do not provide this Supply more
information EXCEPT information & corrected
Humphrey Automatic VA obtained as a part of
Refractor which refracting procedure.
provides VA capability.
Features Objective Subjective
refractometers refractometers
Patient cooperation Requires less patient Patient should be able to
factors cooperation turn a knob to focus
(>5 years) various targets or
answer simple questions
about appearance of
target.
(>8 years)
Ocular factors Give better results in Less better
presence of macular
diseases with clear
ocular media.
Performance is equal in presence of hazy ocular
media with vision upto 6/18
Do not function Rough refraction may
properly in presence of be obtained.
hazy ocular media with
drop in VA of >6/18
Features Objective Subjective
refractometers refractometers
Over-refraction Over-refraction in pts No such problem
capability using spectacles,
contact lenses/IOL
difficult
Expected results Provides preliminary Provides refined
refractive findings. subjective results
Eg. Vision Analyser
 COMMERCIALLY AVAILABLE OBJECTIVE
AUTOREFRACTOMETERS:
Based on one or more of the following working principles
1. The Scheiner principle
2. The optometric principle (retinoscopic principle)
3. The best-focus principle
4. The knife-edge principle
5. The ray-deflection principle
6. The image size principle
 Autorefractors based on Scheiner principle:

1. Acuity Systems 6600 (NA)

2. Grand Seiko (RH Burton’s BAR 7 in the USA; BAR 8
with AutoK)
3. Nidek (Marco’s AR-800 & 820 in the USA; ARK -900
with AutoK)
4. Takagi (not available in the USA)
5. Topcon (NA)
 Auto refractors based on retinoscopic principle:

 Based on one of the following 2 characteristics of

retinoscopic fundus reflex

Speed of motion of the

Direction of motion of observed fundus reflex with
observed fundus reflex with respect to speed of motion of
respect to direction of motion insident radion.
of incident radiation
Eg. Nikon NR-5500, Nikon
Eg.Baush & Lomb Retinomax, Tomey TR-
1000,Nidek OPD-Scan
 SUBJECTIVE AUTOREFRACTORS:
1. Vision analyser:
o Uses innovative optical system & equally innovative
methods for subjective refraction.

2. SR-IV programmed subjective refractor:

o Uses optometer principle

3. Subjective autorefractor-7:
o Screening instrument
o Has spherical optics only
 AUTOREFRACTORS CURRENTLY IN USE

 Autorefractors are most commonly used to provide the

starting point for refraction to obtain an objective result
before performing subjective refraction.

 Most commercially available Autorefractors available

today come with an inbuilt Automated Keratometer &
are known as Auto Kerato-Refractometer.

 Recently new equipments with addition corneal

topographers have been developed in which Corneal
Topography can also be performed.
 PORTABLE AUTOREFRACTORS

 Portable autorefractor is
particularly helpful in
examining children as they
can easily adjust themselves
according to different
positions of the patient.
 The portable autorefractor holds great promise in the
future for better eye health, because it can also allow
optometrists to conduct preliminary eye examinations
for those who cannot get to a doctor ’s office.
 It is also ideal for vision screenings in community
groups or health fairs.
 With the advent of handheld autorefractors, it can be
used on patients with certain disabilities, such as those
who cannot hold their head up straight. Technicians or
doctors can position themselves to make them work on
bedridden patients.
Advantages of automated refraction systems vs. manual
refraction equipment are:
 less manual labour by the practitioner or technician
 more automation of repetitive and iterative tasks in the
refraction
 ability to present former and new values quickly for
validation
 reduced risk of human error
 direct transmission of results to Electronic Medical
Record(EMR) software
 Improved efficiency of practice
 RECENT ADVANCES IN AUTOMATED
REFRACTION

 Recently, a tool has been developed which works by

combining a simple optical attachment with software on
a smartphone which enables assessment of Refractive
Error.
 WAVEFRONT TECHNOLOGY IN
REFRACTION
 Additionally, some variations on the traditional
autorefractor have been developed.
 The aberrometer is an advanced form of autorefractor
that examines light refraction from multiple sites on the
eye.
 Aberrometry measures the way a wavefront of light
passes through the cornea & crystalline lens, which are
the refractive components of the eye. Distortions that
occur as light travels through the eye are called
aberrations, representing specific vision errors.
 Several types of visual imperfections, referred to as
lower and higher-order aberrations, exist within the eye
and can affect both visual acuity and the quality of
vision.
 Conventional examination techniques & autorefractors
only measure lower-order aberrations such as myopia,
hypermetropia, and astigmatism.
 However, these do not account for all potential vision
imperfections. Higher-order aberrations can also have a
significant impact on quality of vision and are often
linked to glare and halos that may cause night vision
problems.
 Wavefront technology, or aberrometry, diagnoses both
lower- and higher-order vision errors represented by the
way the eye refracts or focuses light.

 Wavefront analysis not "an upgraded" version of corneal

topography or autorefraction but a visual equity
measuring device that takes all elements of the optical
system into consideration i.e. the tear film, the anterior
corneal surface, the corneal stroma, the anterior
crystalline lens surface, the crystalline lens substance,
the posterior crystalline lens surface, the vitreous and
the retina.
 Wavefront analysis is approximately 25-50 times more
accurate than the autorefractometer.

 Now that higher-order aberrations can be accurately

defined by wavefront technology and corrected by new
kinds of spectacles, contact lenses & refractive surgery,
they have become more important factors in eye exams.
 AUTOREFRACTION IN IRREGULAR EYES

 Corneal shape post refractive surgery is clearly

modified in the majority of procedures .

 Furthermore, specific algorithms are used in lasers

which ablate the cornea to reduce aberrations .

 Most autorefractors (all Scheiner based) perform

refraction through a fixed pupil diameter.

 Therefore, the influence of overall refraction throughout

the pupillary plane will not be addressed.
 In eyes with a normal corneal shape, the results will not
be affected but in pathological eyes such as post graft,
keratoconus and post refractive surgery, the departure of
corneal shape from normality may induce significant
errors compared to subjective refraction.
 REFERENCES

 THEORY & PRACTICE OF OPTICS AND REFRACTION-3 rd

EDITION-A K KHURANA
 OPHTHALMOLOGY 3 rd EDITION-YANOFF DUKER
 CLINICAL OPTICS-3 rd EDITION-ANDREW R. ELKINGTON
 INTERNET
THANK YOU!!!