Chapter 17 Photokeratos PDF

PHOTOKERATOSCOPY 17
M. Guillon and A. Ho
17.1 INTRODUCfION ogy or in surgical cases of surgical opera

tions, to ensure that any procedures
used do not create any unacceptable/
17.1.1 AIMS AND APPLICATIONS adverse effects.
The aim of photokeratoscopy is to measure 3. To assess the duration of the post
and describe accurately the shape of the surgical stabilization period in order to
corneal front surface in all meridians. establish the optimum period before
Although a difficult task due to the complex prescribing follow-up treatments (e.g.
shape of the cornea, photokeratoscopy has optical appliances).
numerous useful applications. These can be
classified as follows: Contact lens fitting
Corneal topography influences the choice of
Monitoring of corneal changes the posterior contact lense surface geometry,
e.g. radii of curvature. This is particularly
A number of eye surgeries (both corneal important in the fitting of rigid lenses (Moss,
and intraocular) are accompanied post 1959; Von Fieandt 1965; Brungardt, 1965;
surgically by changes in the shape of the Kemmetmuller, 1984; Kivayev et al, 1985). In
cornea. These changes to the corneal topog routine practice, clinicians assess the fit of
raphy may be unintentional; as in the case contact lenses by subjective assessment of
of cataract extractions (Smith, 1977), or the fluorescein pattern of the tear layer situ
intentional; in the form of refractive sur ated between the contact lens and the cornea
gery (McDonnell & Carbus, 1988). Changes (Phillips, 1980). An exact knowledge of the
in corneal topography are also seen in patient's corneal surface shape would render
certain corneal diseases such as keratoco this choice less empirical (Amiard & Cochet,
nus. The close monitoring of any changes is 1972). Similarly, lens designers can benefit
essential to patient management for three frem the knowledge of the corneal shape of
main reasons: large patient populations when designing
lenses to provide optimal fitting characteris
1. In baseline (pre-surgery) examinations tics (Bibby, 1976b).
as a reference for further/future mea
surements. This is also important as a
Corneal optical modelling
safe-guard in any possible legal devel
opments. The front surface of the cornea is the most
2. To monitor the progress of any pathol powerful ocular refractive surface and a
Contact Lens Practice. Edited by Montague Ruben and Michel Guillon.
Published in 1994 by Chapman & Hall, London. ISBN 0 412 35120 X
314 Photokeratoscopy
major determinant of the optical perfor The methods used to convert measure
mance of the eye. A knowledge of its exact ments of image size to local corneal radii,
geometric form is therefore essential to any and subsequently corneal topography,
modelling of the optical system of the eye (EI involves the application of geometrical
Hage, 1971; Lotmar, 1971; Klyce, 1989). optics. However, when we consider the
complexity of the contour of the anterior
surface of the cornea and the limitations of
17.1.2 MEASUREMENT PRINCIPLES
the photokeratoscopic system it is possible
Photokeratoscopy and keratometry are based to understand the many problems associ
on a similar principle, making use of the ated with photokeratoscopy.
reflective property of the corneal front sur The problems, and the instrument designs
face (Duke-Elder, 1970; Borish, 1975). In both and special features employed to overcome
techniques, information regarding corneal or minimize these problems will be dis
shape is obtained by measuring the size of cussed in this chapter.
the image of the target formed by corneal
reflection. In keratometry the central corneal 17.2 INSTRUMENTAnON
radii are calcvia ted from measurements
made with a single target (Clark, 1973b). In 17.2.1 GENERAL FEATURES
keratoscopy a series of targets, usually circu
lar, are used. This arrangement of targets
Introduction
allows both the central and peripheral cor
neal curvature, and consequently the corneal
Historical notes
topography, to be assessed (Clark, 1973c).
Keratoscopy may be carried out qualita The invention of photokeratoscopy cannot
tively with the use of equipment which be attributed to any particular individual. A
involves nothing more than a Placido disk review of the literature points to a series of
(Klein, 1958; Levene, 1962). However, it is developments that have evolved into modem
when a recording of the image created by the photokeratoscopy.
cornea of the target is made and subse Scheiner, in the seventeenth century, and
quently used for quantitative measurements Senff (1846) in the nineteenth century, were
of corneal topography that the true potentia! apparently the first to analyse the shape of
of keratoscopy is realized. the cornea and compare ~t to an ellipsoid
Photokeratoscopy hence involves the mea (Bonnet & Cochet, 1962).
surement or estimation of the sizes of the The invention of the concentric ring target
optical images of a series of targets created which is the basis of modem keratoscopes is
by corneal reflection. Traditionally, a photo variously attributed to Amsler (Bonnet &
graphic record is made using a flash tube Cochet, 1962) and to Goode (1847) (Clark,
light source in order to eliminate eye move 1973c).
ments. The measurements and calculations Placido, 1880 is thought to be the first to
are then made from the photographs. have produced a photokeratoscope; this
Recently, the advances made in micropro instrument was used for qualitative analysis
cessing have made it possible for the kerato of keratoconic corneas by [aval (Holden,
scopic image to be captured electronically 1970; Clark, 1973c).
and analysed on line using high-speed, mod Gullstrand in 1896 (translated by Ludlam,
em personal computers with dedicated pro 1966; Ludlam & Wittenberg, 1966a) was the
grams. The new instruments are known as first to achieve quantitative photokeratos
video keratoscopes. copy. He analysed the data obtained using a
Instrumentation 315
flat target instrument consisting of four con The photokeratoscopic target The photok
centric rings that covered a diameter of eratoscopic target is the object which is
approximately 4 mm. By the judicious choice imaged by the cornea. The measurement of
of additional fixation points he was able to the image of this target is the basis for the
obtain information covering the whole cor determination of corneal parameters.
nea (Ludlam & Wittenberg, 1966b).
From these early instruments further The optical system The role of the optical
improvements have been made resulting in system is to focus the image of the target
the sophisticated instruments of today. produced by the cornea onto the recording
These improvements will be discussed in the plane. The optical system also enables the
ensuing sections. operator to focus the instrument correctly.
The recording system The recording system

Photokeratoscope subsystems creates a permanent record (photographic,
Photokeratoscopes are basically composed of electronic/digital signal, etc.) of the image of
three sub systems (Fig. 17.1): the target produced by the cornea and the
optical system. It is this permanent record
Observation system
eye piece
ler:s
objective
Figure 17.1 Photokeratoscope main component systems.

which is used for analysis. never more than 60% of the cornea (Aan De
Kerk et al., 1973). Second, curvature of field of
We will describe and assess the general fea the image produced by the cornea for a plane
tures of the photokeratoscope according to object makes it impossible to attain correct
the above three subsystems. focus for the entire target (Knoll et al. 1957).
Targets Hemispherical targets In order to increase

corneal coverage by the target, Berg (in 1929)
Photokeratoscopic targets can be classified proposed a hemispherical target (Bonnet &
according to three major features: (1) target Cochet, 1962; Holden, 1970; Clark, 1973c) that
locus; (2) target type; and (3) target illumina provides up to 80% corneal coverage
tion. (Donaldson, 1972). Such a target also tends to
Target locus describes the geometric sur decrease the curvature of field of the image.
face on which the individual targets are
positioned (e.g. hemispherical, cylindrical). Cylindrical target Dekking in 1930, pro
Target type refers to the geometrical shape posed that the curvature of the image surface
of the individual targets (e.g. rings, bars). of a flat target produced by the cornea was in
Target illumination refers to whether the the same direction as the cornea and sug
target's behaviour as a light source for the gested the use of a cylindrical target to over
recording system can be equated to a diffu come this problem. This design improved
sive or a directional source. results with regard to image focus and also
enabled full corneal coverage (Ludlam & Wit
tenberg, 1966c; Aan De Kerk et al, 1973).
Target locus
The target locus is the target feature that has Ellipsoidal target Further investigation of
the greatest influence on the instrument's per the problem of a flat field image led Ludlam
formance because it controls the extent of cor (Ludlam & Wittenberg, 1966c) to suggest the
neal coverage by the target and also affects the use of an ellipsoid of revolution for a target
shape of the image field (e.g. plane, curved) locus to obtain a plane image. Such a target
formed by the optical system. Therefore, clas locus, however, can only truly provide a flat
sification of photokeratoscopes may be based image field for a cornea with a specific pro
on the target locus, the geometric surface on file.
which the target is built.
Target loci can be classified into five Other targets Two other targets have been
groups: (1) plane; (2) hemispherical; (3) described which give good results: a car
cylindrical; (4) ellipsoidal; and (5) others. dioid (Amiard, 1972, 1973) and projected
targets (Westheimer, 1965; El Hage, 1971;
Plane targets Plane targets are often referred Clark, 1972; Fujii et al., 1972).
to as flat targets (Table 17.1). A flat target is
the simplest target locus to produce and the
Target type
earliest used. Its invention has been attrib
uted to Amsler (Bonnet & Cochet, 1962). A Two types of targets have been used: (1)
review of the literature showed an abun rings; and (2) lines, bars and points.
dance of instruments built with such a target
(Clark, 1973c). However, it has the greatest Ring targets These offer the greatest advan
number of limitations. First, only limited tages and are the most commonly used pho
corneal coverage is possible; practically tokeratoscopic targets. In particular, each
Instrumentation 317
Table 17.1 Classification of photokeratoscopes according to target locii

Target Qualitative Quantitative Qualitative Quantitative
experimental experimental commercial commercial
instrument instrument instrument instrument
P Streiff J, 1900 Gullstrand, 1896 Zeiss Nidek Sun
L Hartinger, 1930 AIM Keratograph, 1956 Reflectograph,1930 PKS-1oo0
A Von der Heydt, 1932 Keeler Keratoscope, 1958 Photokeratoscope,1980 Photokeratoscope
N Howard, 1936 Photo-Electronic
E Kokott,1938 Keratoscope (PEK)
Streiff EB, 1938 of Reynolds, 1959
Fincham, 1953
Phillips &: Hansell, 1954
Hansell, 1956
Stein, 1958
Reynolds &: Kratt, 1959
Perth Photokeratoscope, 1961
Norton &: Sullivan, 1962
Zingara, 1963
Brown, 1969
H Berg, 1929 Corneascope
E Lenoble, 1952 photokeratoscope
M Knoll, Stansson of International
I & Weeks, 1957 Diagnostic
S Stone, 1962 Instruments
P Donaldson, 1972
H
E
R
E
C Dekking, 1930 Knoll Bausch & Lomb Bausch & Lomb
y Eye Hospital Rotterdam Photokeratoscope,1961 Photokeratoscope,
L Photokeratoscope Ludlam & Wittenberg, 1%3
I 1966
N Mandell, 1968
D EI Hage
R Photokeratoscope
I (EHP),1976
C Photokeratoscope
A (EHP),1976
L
E Holden Wesley Jessen
L Photokeratoscope,1970 Photokeratoscope, 1967
L Computed Anatomy
I TMS-1 corneal
P modelling system
S EyeSys ES100 corneal
a topography and
I analysis system
D Visioptic EH-270
computerized
corneal topographer
a Cardioid target
T keratoscope of
H Amiard, 1972.
E Projected target
R keratoscope of
Westheimer,1965
The date indicates the first reference to the instrument in the literature. The instruments are divided into
experimental and commercially available instruments and are further divided into instruments that only produce
photokeratoscopic images for observation and those that produce a numerical representation of the cornea.
318 Photo keratoscopy
ring, being an infinite number of points, the rings will provide a greater accuracy.
carries information in any meridional direc
tion. This is particularly important when
analysing distorted corneas (e.g. keratoco Nature of the target illumination
nus) where the information required for the The nature of the light produced by the
analysis cannot be limited to two perpen target rings can either be: (I) diffuse; or (2)
dicular meridians (Cohen et al., 1984). directional. These two types of illumination
Further, with ring targets there is no need can be achieved by either frontal illumina
to determine the direction of the principal tion of the target surface (e.g. Brown photok
meridians by keratometry prior to undertak eratoscope (Brown, 1%9)} or by transmission
ing photokeratoscopy. through a transparent or translucent target
Following Gullstrand's suggestion (Lud medium (e.g. Nidek PKS-1000 photokerato
lam & Wittenburg, 1966a) the target rings are scope).
sometimes constructed with a thin black line
at the centre of the illuminated ring to Diffusive illumination Diffuse target illumi
improve the focusing accuracy. The Wesley nation is used in the majority of photokera
Jessen Photoelectric Keratoscope (PEK) was toscopes. Light rays emanating from such
the first commercial instrument incorporat objects are multi-directional so that at least
ing such a feature. some rays will pass through the nodal point
of the optical system (assuming a standard
Line, bar and point targets arrangement of optical components in the
Small thin line (or bar) and point targets, photokeratoscope). With this optical
usually situated on two perpendicular arms arrangement, the image size of the photo
which can be rotated, are found in a few graphic record is generally proportional to
photokeratoscopes (Berg photokeratoscope, the location and size of the photokerato
Ysoptic Keratometre, Holden photokerato scopic target.
scope). However, due to their limitations of
measuring only two meridians (usually at 90 Directional illumination Three types of
degrees), they are not included in any mod photokeratoscope fall into this category:
em instrument. externally illuminated, collimated and pro
jected focal targets. Externally illuminated
Two other parameters to consider when targets were proposed and assessed by EJ
assessing photokeratoscopic targets are the Hage (l971). However, no instrument of this
diameter of the central ring and the distance design is known. Collimated targets are
between successive rings. found in a few instruments: (Amiard, 1972;
The central ring should be as small as 1973; Fuji et al., 1972). The only photokerato
possible in order to give accurate informa scope to feature a projected focal (autocolli
tion on the central radii of curvature of mating) target is the Clark Photokeratoscope
non-spherical surfaces. (Clark, 1972).
The distance between successive rings The general aim of the use of these types of
should be as small as practicable in order to target illumination is to reduce the effect of,
maximize the number (density) of data or to eliminate certain parameters during
points. This is important when fitting curves analysis.
to any meridional section. In addition, some
methods of analysis are based on determin The design of the light source for illuminat
ing the mean value between successive ing the target will depend upon the nature of
rings. In those cases, smaller separations of that target. Obviously, the source must illu
Instrumentation 319
minate the whole target and must ensure that Working distance and magnification The
at least some of the light rays produced by working distance is usually defined by the
the target will pass through to the recording target location, the latter of which is gener
system after reflection at the cornea. For the ally designed to give as large a corneal
diffusive targets such a condition is always coverage as possible, while taking into con
met, but precautions must be taken when sideration the patient's facial anatomical
designing light sources for instruments with features.
reflective targets. The magnification is usually chosen to
give optimal coverage of the recording sys
tem by the target images. In general, the
Optical system
highest magnification fulfilling the require
The optical system of the photokeratoscope ment is chosen in order to maximize resolu
has two functions: tion.
Both above requirements are dependent
1. To bring the image of the target pro upon the focal length of the optical system.
duced by the cornea into focus in the Typically the optical system is d long focus
recording plane (target imaging system). ing microscope with a working distance of
2. To enable the operator to focus the instru S cm to 30 em and a linear magnification of
ment accurately on to the image produced xi to XS.
by the cornea (viewing system).
Depth of focus and depth of field For accu
Target imaging system rate focusing, the optical system must have a
narrow depth of focus. However during
Three general types of target imaging sys recording, the depth of field in the image
tems are encountered in photokeratoscopy. It plane must be maximal to compensate for the
is essential to know the exact nature of any non-aplanatic nature of the image. These
optical arrangement used as the choice of the conflicting requirements can be met by using
method of data analysis depends in part a wide aperture optical system to which a
upon the nature of the optical system itself. small aperture is automatically incorporated
The three optical systems encountered are: during image recording.
1. The non-telecentric systems that are
found in the majority of instn.:.ments built Aberration control The off-axis monochro
and in all those commercially available. matic aberrations are the major aberrations
2. The telecentric system, which has the affecting the quality of photokeratoscopic
advantage of eliminating errors in recordings (Amiard & Cochet, 1972).
results otherwise introduceable by Curvature of field is the most problematic
errors in focusing (EI Hage (EHP) photo of these aberrations. In practice, curvature of
keratoscope, Ysoptic Photokeratometre field can be minimized in two ways. First,
and Westheimer photokeratoscope). the optical system can be designed to pro
3. Other systems are mainly of the autocol vide a flat image of the target. This requires
limating type, of which the autocollimat consideration of both the target locus and the
ing system of Clark appears to have the curvature of field of the image of the target
best potentiaL created by the cornea and the optical system
of the photokeratoscope. (Systems delivering
Regardless of the type of target imaging flat image fields generally can only be
system used there are a number of common achieved with some degradation in astigma
requirements: tism.) Second, a small aperture size can be
used in the recording system in order to rect choice of aperture size, and film expo
improve the depth of field. sure and development.
Coma is another prominent aberration in The major effect of the other off-axis aber
the optical system of the photokeratoscope. rations (astigmatism, distortion) is to alter
Although the effect of this aberration the linear magnification of the different tar
appears severe through the view finder get rings. Their effects can be minimized by
(especially in instruments which do not use appropriate calibration and measurement
ring targets), experience of the authors sug procedures (Amiard & Cochet, 1967).
gests that the effect of coma on the accuracy
of data collection is minimal. This is true
Viewing system
provided that the estimation of ring sizes is
made at the head of the coma flare; among The photokeratoscope viewing system has
most the accuracy of the resultant measure several features that are common to other
ment is generally not affected. Because of the ophthalmic instruments.
skewed comatic distribution of light, this can The light source is usually a fluorescent
be accomplished readily. Further, the tail of tube, and is often annular.
the coma flare can be reduced with the cor A fixation system is incorporated in order
Subject's eye
0--
Photokeratoscopic
target
Photographic film
Figure 17.2 Zeis reflectograph keratoscopic optical principle.

Instrumentation 321
to locate corneal features accurately and However, we will limit our discussion to a
repeatably. number of features that are known to opti
With some instruments, vignetting by the mize the performance of such a system.
nose is a problem. A fixation point situated
temporally to the main optical system of the
Light source
photokeratoscope is habitually used to over
come that problem (Amiard, 1972, 1973). An All modern photokeratoscopes utilize an
alternative procedure to avoid vignetting is electronic flash as a light source. These
to keep the fixation coaxial with the photok flashes deliver as much light as necessary
eratoscope's main optical system and posi (keeping in mind other limits including the
tion the patient slightly side-on to the target. maximum safety level to light exposure of
A number of focusing aids such as ametro various ocular tissues) and, through their
pia correction, magnifying eye piece, split short duration (111000 s or less), they elimi
prism, ground glass focusing screen and nate all problems associated with eye
alignment cross have been used. In all cases, movements. The videokeratoscopes incor
the viewing system should operate at full porate CCD video cameras; in two out of
aperture in order to allow critical focusing. the three systems commercially available,
these are sensitive enough to respond to
the constant white light source also used
Recording system for focusing (The Visioptic Corneal Topog
rapher EH-270 utilizes an electronic flash).
As its name suggests, photokeratoscopy The eye movement problems are elimi
involves the photographic recording of the nated by instantaneous electronic image
keratoscopic image. However, in at least three capture.
experimental instruments (Westheimer, 1965; Optimally the peak emission wavelength
EI Hage, 1976; Gormley et al., 1988) and in all of the illumination system should be chosen
the latest commercial instruments (Topo to match the peak sensitivity of the recording
graphic Modeling System lMS-1, EyeSys medium.
video keratoscope, Visioptic EH-270 Comput
erised Corneal Topographer) an electronic
recording system has been incorporated. Filters
The advantages of electronic recording are In some instruments filters are incorporated
obvious. Such systems offer immediate avail to improve the image quality by transform
ability of results and enable direct data analy ing the system to a near monochromatic
sis. Only technological limitations, not system (Clark, 1972). However, filters must
permitting as high a resolution as the photo be chosen carefully, with a spectral band
graphic system, have hindered its wider use in width matching the emission peak of the
the past. But as demonstrated by the current light source. Further, if interference filters
instruments, advancements in technology (and are used, the direction of all possible light
particularly in the area of computing and elec paths must be considered.
tronics), has remedied this problem:
A wide range of photographic systems has
been used to record photokeratoscopy data. Recording media
• The accuracy of the recently developed Corneal Modeling Photographic film

System (Gonnley et al, 1988; Hannush et al, 1989) is a clear
indication that the photographic media will soon be ren 1. Film type. Black and white negatives
dered obsolete by fully electronic/digital instruments. and prints, and colour prints, have all
322 Pholokeraloscopy
been used in photokeratoscopy. We per per recording cell in the horizontal and verti
sonally favour the direct use of black and cal directions are suitable. In one instrument
white negatives during measurement (Computer Anatomy TMS-1 keratoscope)
and analysis as they afford a high con 1500 pixels are used. The dynamic (bright
trast and require no further steps which ness) range and resolution of each pixel is of
can introduce additional sources of consideration. Localization of image peaks
errors (e.g. enlargement magnification and target edges is more accurate with a
errors and dimension instability of the higher dynamic range. It is also possible to
medium). One-step prints such as utilize amplitude interpolative algorithms to
Polaroid print films can also provide localize image peaks or target edges between
these advantages. pixels, provided a sufficiently high dynamic
All current instruments use Polaroid resolution is available. The CCD camera can
type instant processing films or plates. either be colour or black and white, the latter
Clinically, this is essential as it gives the however suffices as the information used only
operator instant feed back on the suit needs to be monochromatic. The image
ability of the record. For this reason formed on the recording cells is then captured
commercial photokeratoscopes utilize via a dedicated electronic digitizing board.
fine grain Polaroid films originally
designed for landscape and aerial pho 17.2.2 SPECIFIC INSTRUMENTS
tography.
2. Film size. It is preferable to use large or
Introduction
medium format systems (such as 6 em X
9 cm) rather than the conventional 35 em As we have seen, photokeratoscopes can be
format, With the larger formats, a greater systematically divided into three sub
overall magnification is possible. For systems, the main classification being con
example, the Wesley-Jessen negative cerned with variations in targets and the
image on a 6 cm X 9 cm format has a associated imaging system. This section
linear magnification of approximately gives a listing of all known instruments
X 5, while the Nidek photokeratoscope according to these two classifications.
using an 8.5 em X 10.8 cm format (two
records per frame) has a magnification of
Research and experimental instruments
approximately X 2.6. This improves
resolution, thus reducing percentage A review of the literature (Morris, 1956; Knoll
error of measurement. et al, 1957; Holden, 1970; EI Hage, 1971;
3. Film speed. The main concern regarding Amiard & Cochet, 1972; Clark, 1973c)
the high film speed req uired in some revealed a plethora of photokeratoscopes.
cases is the accompanying larger film The majority of these instruments remained
grain that may limit resolution. How experimental prototypes and were never dis
ever, film grain is not usually a limiting tributed commercially. Some, however, had
factor with modem films. unique features worthy of mention. For clar
ity, we have classified them according to
Video recording The recording media for their target design (Table 17.1) and have
the video system is the CCD camera. Because listed them in chronological order with
of the high resolution required to obtain regard to the first reference of the instrument
sufficient accuracy when determining the appearing in the literature.
corneal topography only high or very high Of the instruments listed, some no longer
resolution systems with at least 512 pixels available are worthy of special comment. The
lnstrumentation 323
discussion of these instruments will be pre enabled stereoscopic corneal shape repro
sented according to their target types: duction.
Plane target instruments Cylindrical target instruments

1. The Zeiss reflectograph, 1930 (Morris, The Knoll, Bausch and Lomb Photokerato
1956; Clark, 1973c) was in fact a reverse scope (Knoll, 1961) was the basis of the
flat target (Fig. 17.2). The target was Ludlam and Wittenberg, the Mandell's and
situated where the plane of the film is EI Hage (El Hage, 1972b) photokeratoscopes
normally positioned and vice versa. The and gave full cornea! coverage by the target
light reaches the cornea via a central with the exception of vignetting by the nose.
aperture through the film plate. Excellent results have been reported with
2. The photokeratoscope of Kokott 1938 this type of instrument.
(Clark, 1973c) used a pair of cameras
which gave a stereoscopic pair of photo
graphs of the corneal images. Ellipsoidal target instruments
3. The Fincham Photokeratoscope 1953 The Holden Photokeratoscope (Holden, 1970)
(Fincham, 1953) has been the bench was fairly large in construction in order to
mark for flat target photokeratoscopes enable the precise location of individual tar
since its introduction and has been the get rings. It also incorporated a relocatable
subject of several copies: the Hansell fixation light which enabled the operator to
Photokeratoscope in 1956 (Brown, 1969); locate the position of the corneal apex.
the Perth Photokeratoscope (Plummer &
Lamb, 1961); the Brown Photokerato
scope (Brown, 1969); and one which Other instruments
became commercially available: AIM The Clark Photokeratoscope (Clark, 1972) uti
Keratograph (Morris, 1956). lized a projected target system whereby an
4. The Norton-Sullivan Photokeratoscope image of the actual target was projected onto
(Norton & Sullivan, 1962) was the first to the cornea. The 'photokeratometre' of Ysop
incorporate a Polaroid camera back. tic (Amiard, 1972, 1973) used a cardioid tar
5. A compact (and therefore portable) pho get surface (closely approaching an ellipsoid)
tokeratoscope based on a 35 mm camera which purportedly provided an optimally
with extension bellows and readily flat corneal image.
available components was designed and
constructed by Sivak (1977).
6. A device for converting a Topcon photo .Commercial instruments
slit-lamp to a photokeratoscope was
Six instruments are presently available com
designed and constructed by Cotran and
mercially:
Miller (1987). A modification unit of this
kind may be a cost and space efficient 1. The PEK photokeratoscope from
method of attaining corneal topographi Wesley-Jessen Incorporated of Chicago,
cal examination in the clinical practice. Illinois (Bibby, 1976a).
2. The PKS-1000 Photokeratoscope from
Nidek Incorporated of Palo Alto, Califor
Hemispherical target instruments
nia; previously distributed as the Sun
The Donaldson photokeratoscope had two Photokeratoscopy (Sun Contact Lens
photographic systems (Donaldson, 1954) that Company of Kyoto, Japan).
Table 17.2 Commercially available instruments

Features Instruments
Corneascope PEK PKS
Commercial photokeratoscope instruments
Target shape Hemispherical Ellipsoid Elliptical
Target type Reflective Diffusive Diffusive
Corneal coverage Model 900 7 mm 9mm 10mm
Model 1200 10.9 mm
Centre ring 3 mm 3mm 2mm
Number of rings 9 (model 900) 9 10
U (model 1200)
Recording system Polaroid Type Polaroid-High Polaroid Type 667
108 or 699 Contrast Land (possible computer storage)
(possible computer Projection
storage) Film 146
Output of results Local 'power or Apical radius and Local 'radii' of principal
'radii' for each shape factor for meridians and
ring in 8 major each principal 3D graphics display
meridians meridian
Claimed accuracy Same as Repeatability Precision
keratometer ± 0.18 D central K ± 0.03 mm for
±0.25-().50D ± 0.05 shape factor central cornea
at 95% confidence 0.07/0.08 mm for
level peripheral cornea
Corneal modeling Eye Sys Visioptis

system TMS ES-100 EH-270
Commercial videokeratoscopic instruments

Target shape Conical Conical Conical
Target type Diffusive Projected Diffusive
Corneal coverage 11 mm X 14 mm 9.6mm >10.0 mm
Centre ring O.7mm 0.31 mm
Number of rings 25 (standard model) On the Eyesis, the 22
32 (contour model} analysis is based on
the edges between
rings. Hence corneal
points are obtained
for each half meridian
Recording system Super resolving High resolution High resolution
ceo video camera CCD video camera CCD video camera
1000 X 1500 pixels
Output of results Digital information Digital information Digital information
and colour coded and colour coded and colour coded
topographic maps topographic maps topOgraphic maps
Claimed accuracy Accuracy ± 0.2 D Resolution 0.01 D Resolution ± 0.2 D
Reproductibility ± 0.25 D
Methods of analysis 325
3. The Corneascope from International
Diagnostic Instruments Ltd of Broken
Arrow, previously distributed by the
Kera Corporation of Santa Clara, Califor
nia (Rowsey et al, 1981; Petricciani et al,
1985).
4. The Corneal Modeling System TMS 1
(Fig. 17.3) from Computed Anatomy
Incorporated, New York, NY (Gormley et
a, 1988).
5. The ES100 Corneal Topographic System
(Fig. 17.4) from EyeSys Laboratories,
Houston, Texas.
6. The EH-270 Computerised Corneal
Topographer from Vision Optics Inc.
(Fig. 17.5) Houston, Texas.
Figure 17.3 Computer Anatomy Incorporated
Each photographic instrument is also avail Corneal Modeling System TMS-l video kerato
able as a part of a package for which the scope.
manufacturer undertakes the analysis of the
photokeratographs and provides the practi
tioner with a mathematical representation of images formed by corneal reflection and is
the patient's corneal shape. Analysis systems completed with a description of the corneal
for on-site data analysis are also available. shape. The steps include: (1) data collection;
The analysis systems are the Kerascan from (2) computation; and (3) presentation of
the International Diagnostic Company, the results.
System 2000 from Wesley-Jessen and the Pal
250 from the Nidek Corporation. All the
video systems incorporate an on-line PC 17.3.1 DATA COLLECTION
based data analysis system that gives both There are two steps in data collection; ini
graphic representation of the corneal topog tially the obtention of a record (photographic
raphy and numerical values. or electronic) of the image given by' the
The features of these six instruments are cornea of the instrument's target followed by
summarized in Table 17.2. the measurement of this record to obtain
data values for the analytical parameters.
17.3 METHODS OF ANALYSIS There are two types of parameter: (1) fixed;
and (2) variable. Those of relevance will be
The single most complex phase in photokera considered in Table 17.3.
toscopy is data analysis. The rapidity of
development and the intensity with which
Fixed parameters
improvement is sought in all facets of data
analysis (including algorithm, hardware and The fixed parameters are the instrument speci
software) bears witness to this (Townsley, fications. The values of the fixed parameters
1970; Oark, 1973a; Klyce, 1984; Gormley et al. (for the purpose of data analysis) are assumed
1988; Busin et al., 1989). to remain constant. For example, the locations
Analysis begins with the measurement of of the target rings are considered to be fixed
photographic or electronic records of target parameters as they are relatively fixed with
-~'o'r
-•
m... " "., p
>
Figure 17.5 Visioptics Incorporated, Computer

ised Corneal Topographer EH-270 video kerato
scope.
Figure 17.4 Eye5ys Laboratories E5100 video

keratoscope. these variable parameters in order to calcu
late the corneal topography.
respect to the subject's eye and the optical These measurements may involve either
system of the photokeratoscope. Typically, analysis of photographic records or electronic
these fixed parameters are measured or are output. In the former case, the records may be
known accurately during the construction of measured using a travelling or projection
the instrument (Ludlam et al., 1967). microscope (Wesley-Jessen) or an image
Some fixed parameters may vary during analyser (Nidek Corporation). In the latter
instrument use. However, because these case, the output from electronic photo-arrays is
variations are small or not estimable, the directly transmitted to a computer for analysis
parameters are assumed to be constant. For (Westheimer, 1965; EI Hage, 1976).
example, the magnification of the photo Two examples of variable parameters are
graphic system, although theoretically fixed the recorded size of the corneal image of the
by the focal length of the photographic lens target and the direction of light rays follow
and the subject's eye to film plane distance, ing reflection at the cornea.
may change by a minute amount due to
focusing errors.
17.3.2 COMPUTATION
Variable parameters
During computation measured parameters are
In a valid measurement system, the variable processed mathematically or graphically (Man
parameters are related to corneal topography. dell & York, 1%9; York, 1969) to derive a
The purpose of data collection is to measure description of the topography of the measured
Table 17.3 Parameters included in keratoscopic data analysis
Fixed parameters Variable parameters
Instrument Location, diameter,
target reflected/diffused target
Optical system Lens focal length, Fixation direction/
aperture size, angle, corneal apex
magnification, centration, corneal
film/photocell/plane curvature topography
distance
Measurement Calibration constants,
system magnification
Subject's eye Object's focus plans
cornea. The choice of computational method is incorrect or inappropriate computational

important as the accuracy and validity of the method or due to numerical computational
photokeratoscopic results depend upon it. errors. Other sources of data distortion include
A large number of analytical techniques the use of inappropriate assumptions, and
(Ludlam & Wittenberg, 1966b: Townsley, 1970; systematic errors which may occur during any
Clark, 1973a; Klyce, 1984; Gonnley, 1988; Busin part of the data acquisition phase.
et a1., 1989) are available to determine the
corneal surface topography. The choice of ana Assumptions
lytical techniques are, to some extent, limited
by the type of instrument used (EIHage, 1971). The use of inappropriate assumptions will
For each instrument type, however, it is pos lead to data distortion (Ludlam & Witten
sible to account for any number of parameters berg, 1966b; Mandell & York, 1969; York,
in order to increase the accuracy (albeit at the 1969; Edmund, 1986). Generally, the greater
expense of increasing the complexity) of the the number of assumptions made, the more
analysis. Conversely it is possible to omit or probable the computed description of cor
make assumptions for other parameters in neal surface will deviate from the true cor
neal surface. The number of assumptions
order to simplify the analysis at the cost of
reducing the accuracy. also determines the scope of a computational
method. The greater the number of assump
tions the more limited will be the applicabil
Requirements
ity of the computation method.
For these reasons, the introduction of any
An appropriate computation system must:
assumption must be assessed critically

(1) minimize data distortion; and (2) employ
before incorporation into an analysis
minimal and only valid assumptions.
method. Obviously, any assumption made
must be consistent with the data acquisition
Data distortion system, the instrument type and the corneal
model used (Ludlam & Wittenberg, 1966b).
Data distortion refers to the loss of validity of
the computed results as a true representation
General analysis methods
of the actual corneal shape. Data distortion
mainly occurs as a result of the choice of an Computational methods found in the
literature fall into the following categories: cornea. For photokeratoscopy, where up to
(1) calibration with reference spheres; (2) 32 rings have been used as targets, each ring
slope of the surface method; (3) curve match may be used to obtain a separate 'local'
ing; and (4) others. radius of curvature.
This method is acceptable near the geo
metric axis but is inappropriate for the other
Calibration with reference spheres
regions of the corneal surface. From geomet
Calibration with reference spheres is the ric principles the centres of the spheres rep
earliest method used to analyse photokerato resenting each local radius of curvature must
scopic data; it is similar to the method used lie on the geometric axis. This assumption is
to derive keratome try results by Scheiner inappropriate for the cornea for which the
(Wittenberg & Ludlam, 1966). Basically, the centres of curvature of the peripheral surface
recorded corneal image is compared to the do not lie on the axis but form an evolute
reflected image of the same target produced away from the axis (Bennett, 1968) (Fig. 17.6).
by a reference sphere. The radius of curva Further, the method assumes that the
ture of the sphere with the same size image forming property of the cornea at the
reflected image as the corneal image is point of reflection is similar to that of a
recorded as the radius of curvature of the sphere at the same point (Mandell & York,
Target
Incident light rays
Actual corneal surface
Reflected light rays
Radius of
sphere (local '.
sagittal radius. Actual local radius of
f mea) . cornea (tangential radius)
~ -.
______ '. '
Geometrical/optic
axis of cornea
------------~
Centre of best '.
------------------
matching sphere
Centre of corneal curvature
Figure 17.6 Geometric principle of peripheral corneal image formation assuming local reference sphere.
1969; Edmund, 1986). This assumption is also curve along a meridian of the corneal surface
unacceptable as the true surface shape at the is representable by a (or a series of) differen
region near the point of reflection is different tiable mathematical function (the topo
from the curve of the reference sphere (Wit graphical function) then the first derivative
tenberg & Ludlam, 1%6). In particular, the of this function represents the slope of the
tangential" radius of curvature of the cornea tangent to the surface (Westheimer, 1965).
at any point is different from the radius of Therefore, by numerical integration of a set
the matching reference sphere (Bennett, of data containing the slope of the tangent at
1968). each point of reflection with respect to the
In fact, with this method, the only param position of the point of reflection, the topo
eters which are identical between the corneal graphical function describing the corneal
surface measured and the matching reference shape can be obtained.
sphere are the ray height and the slope of the This procedure may be applied to different
tangent to the surface at the point of reflec corneal sectional curves belonging to differ
tion. These parameters can be used as the ent meridians until a three-dimensional rep
basis for a computational method. resentation of the entire corneal surface is
obtained.
With this method of computation, if a
Slope of surface method single topographical function is used, one
major assumption made is that the corneal
This is the most frequently described and curve can be represented by a continuous
employed computational method (Westhe function. Generally, this assumption is
imer, 1965; Wittenberg & Ludlam, 1966; El appropriate provided the measured cornea is
Hage, 1972a; Fujii et al., 1972). relatively free from any severe distortions as
When a ray travels from a target to the may be present in some abnormal corneal
cornea and after reflection passes through conditions, such as keratoconus. In the cases
the optical system of the photokeratoscope, where this assumption may be suspected not
its path can be traced by applying optical and to be robust, it can either be made valid or be
geometric principles (Fig. 17.7). If the posi eliminated altogether in the following ways.
tion of the cornea, the angles of the incident Being a physical structure with no sharp
and the reflected rays to the optical axis, and edges (except perhaps immediately follow
the location of the target are known, then the ing corneal surgery) the anterior cornea is a
angles of incidence and reflection to the continuous surface in the mathematical
cornea can be calculated. From these param sense. Any apparent discontinuities in any
eters, the slope of the normal at the point of resultant topographical function is a result of
reflection, and therefore the slope of the the limited number of target rings used.
tangent to the surface, may be calculated. By Therefore, for even a severely distorted cor
repeating this calculation for each point of nea, a continuous mathematical function to
reflection for the different target rings, a set describe the topography can be achieved
of data containing the position of the point of provided a sufficient number of target rings
reflection and the corresponding slope of the are used.
tangent may be generated. If, due to the instrument's limitation, a sig
If an assumption is made that the sectional nificantly large number of target rings cannot
be incorporated, the assumption of continuity
• The geometrical descriptions 'tangential radius' and 'sag can be eliminated. by using a series (many) of
gital radius' are used throughout this chapter. In some
texts, the corresponding descriptions 'instantaneousllocal mathematical functions (e.g. polynomials) to
radius' respectively are used. fit the surface. In this variation, the topo
Figure 17.7 Geometric principle of peripheral corneal image formation by surface slope determination
method.
graphical function which describes the corneal solved by numerical methods to obtain a
surface is the super-function containing the mathematical description of the sectional
series of functions used. corneal curve.
Many variations of this method have
been published. One notable variation
Curve matching
illustrates the level of sophistication that
this computation method may attain (Wit In many cases, computation can be simpli
tenberg & Ludlam, 1966; £1 Hage, 1972a). In fled by adopting a reversed procedure. A
this variation, a formal relationship includ general model for a series of reference sur
ing the position of each target ring, the faces is adopted incorporating all parameters
points of reflection and the slope of the considered relevant (Mandell and St Helen,
tangent is derived by considering the rela 1971; Himi et a!., 1981; Edmund & Sjontoff,
tionship between various parameters (Wit 1985). Idealized photokeratoscopic results
tenberg & Ludlam, 1966). To compute the (image sizes) for these reference surfaces are
topographical function, polynomials were calculated for different combinations of val
used to relate the distance of the points of ues for the different parameters. The mea
reflection from the optic axis, to the loca sured corneal image sizes are then compared
tion of each target ring (£1 Hage, 1972a). to the calculated image sizes of the reference
During computation, the polynomials surfaces. Values of the parameters of the
describing the differential function were closest matching reference surface are
obtained by least squares curve fitting to recorded as the values of the parameters of
the data. The differential function was then the measured cornea.
The advantages of this method are speed measurements along any meridian are
and simplicity. These advantages, however, recorded as ellipses.
are now negated by the availability of high With such a model, all departures of the
speed computers; although the method may true surface from the ellipsoid will be lost.
retain a place in clinical applications for Further, if the model is simple, with few
which accuracy is not necessarily a greater parameters, then it is possible to obtain the
consideration than simplicity. One advan same set of resultant corneal descriptive
tage of this method is that look-up tables can parameters from measured corneas which
be generated before measurements take have different actual surface shapes (Fig.
place thus allowing quick assessment of 17.8). Of course, the degree to which this
results in situ. loss of information may be tolerated will
The simplicity of this method is gained at depend upon the accuracy required of the
the expense of making certain assumptions method.
regarding the corneal surface. The general
model adopted is assumed to be a good
Others
approximation of all corneas to be measured.
Because of this generalization of the surface Many variations of the computational meth
description, finer details of the measured ods have been devised (Clark, 1973a).
cornea may be lost. For instance, the general Generically, almost all of these methods are
model most commonly adopted is an ellip related, or are sophisticated variations of one
soid (Edmund & Sjontoft, 1985) or an ellipse or more of the methods described. However,
of revolution (Townsley, 1970; Mandell & St all published methods have some common
Helen, 1971) in which results for all corneal alities. All methods treat the three dimen-
Actual corneal surface
Profile derived from
theoretical parametric
Two different corneal profiles
model of comea which may be "best fitted" with "',
the parametric model on the left
Figure 17.8 Geometric principle of determination of corneal profile by curve matching.

sional corneal surface as several two If the photokeratoscope does not have a
dimensional meridional sectional curves. telecentric stop (Fig. 17.9b), rays which are
Also, the .results of these analyses are given reflected from the cornea do not travel paral
either in the form of a continuous curve or lel to the optical axis. Generally, the ray angle
surface, or in terms of a set of co-ordinates is dependent upon the position of the nodal
which lie on the corneal surface (Clark, point of the optical system of the instrument
1974a). The relative merits of these two and the positions of the eye and of the target
approaches will be discussed further in the rings. Because the reflected rays form a finite
next section. angle with the optical axis, computation for
the corneal point of reflection becomes
slightly more difficult. Nevertheless, once
Instrument constraints
the incident and reflected ray angles are
Although there is apparently a large number known, the angle of the normals and hence,
of usable computational methods, the choice the tangents to the corneal surface are readily
of an appropriate method will in part be calculable. From this point, the course of the
limited by the characteristics of the photok analysis follows that used for an instrument
eratoscope from which the data will be col with a telecentric stop.
lected. The major characteristics of a
photokeratoscope which can influence the
Target and image location
computational methods are: (1) location of
aperture stop; (2) target and image location; Although the longitudinal (x) positions of
(3) target size and distance; and (4) target the corneal image are not known, they may
illumination. be calculated from the object (distance
between first nodal point and corneal image)
and image (distance between second nodal
Location of aperture stop
point and recording plane) distances of the
Perhaps the simplest computational method optical system (Fig. 17.10). Note that image
is afforded by the use of a photokeratoscope in location is not required to be known in the
which the aperture stop is placed at the analysis for instruments with telecentric
second focal plane of the optical system, stops.
becoming a telecentric stop (Fig. 17.9a). The two requirements needed in order for
Under this condition, the majority of rays image location to be calculated are:
which pass through the optical system must
1. The image formed by corneal reflection
have travelled parallel to the optical axis after
must lie approximately on a flat field.
reflection from the cornea. The advantage of
2. The entire photographic image must be
this condition is that the lateral height (per
in focus in the recording plane.
pendicular to the optical axis) of the point of
reflection is independent of the longitudinal The latter requirement can be met by using a
location (along the optical axis) of the image photographic lens designed for negligible
(Westheimer, 1965; Amiard & Cochet, 1972). amount of curvature of field. The former
Further, the slope of the tangents to the requirement can be met by the correct loca
corneal point of reflection can be found tion of individual targets. Here, the target
directly from the location of the target and locus is the determining factor. The target
the eye and therefore, is directly related to locus which produces a plane set of corneal
the ray height. Consequently, only the ray reflected images for an average cornea
height, which can be directly calculated from appears to be a cardioid (Arniard, 1972),
the photographic record, need be measured. although an ellipse of revolution is a good
\-------.....- 0
lmege height
(independent of
po.ilion)
Photoll"~hic
film
Figure 17.9a Location of aperture stop for telecentric system (aperture stop at focal plane).
approximation. In any case, the target locus tangent at the point of corneal reflection may
can be correct only for the corneal shape for be calculated (Doss et al, 1981). In instru
which the locus was specifically designed. ments for which the target size and or dis
Therefore, some degree of approximation tance are not relatively large, considerations
must be accepted during computation for the must be given to these two parameters in
normal range of corneas. order to obtain valid estimation of the vari
ous ray angles.
Target size and distance
Target illumination
The size of the target and the distance
between the target and the eye affects com Most photokeratoscope targets have diffusing
putation. For most instruments, the target surfaces. When illuminated these targets act as
size and distance are both much greater than secondary sources propagating rays in all
the radius of curvature of the corneal con directions. Under this condition, the angle
tour. Hence the angle with respect to the relative to the axis of the incident ray is depen
optical axis of rays directed from the target to dent only on the position of the target rings
the eye, regardless of the location of the point and the position of the point of reflection at the
of reflection, may be considered fixed. Given corneal surface. As described previously, most
the angles of the incident rays from the target computational methods rely implicitly on the
and of the reflected rays, the slope of the accurate estimation of this angle.
Image height
• • • •
. . .. O lldependent
ita positionl
on
.' I
Photogrephie
film
--- ~~~< 0_"-"
- - - photokeret08COP"
Figure 17.9b Location of aperture stop for generalized non-telecentric system.
For some photokeratoscopes, the angle of tokeratoscope of Clark also implicitly kept
the ray for each target ring may be fixed, as the ray angles of each ring constant (Fig.
for those with collimated or focused target 17.11c) by using an optical arrangement
illumination. On these instruments no angle which resembles a Twymann-Green inter
measurement is required (El Hage, 1971). ferometer (Clark, 1972).
Consequently, the computation is simplified Mathematical considerations show that
and a greater accuracy attainable. computation of the corneal surface for instru
A few instruments and corresponding ments with fixed ray angles need not involve
methods have been described which pro integration or differentiation as is necessary
duce this condition. One system (El Hage, for instruments with diffuse illumination (El
1971) was concerned with reflective target Hage, 1971).
ring surfaces such that the angle of the beams
of each target ring were defined by the
Discussion
location of the target ring and the light
source, and the angle of inclination of the It is clear that assumptions must be made at
target ring surface (Figure 17.11a). A second some stage regardless of the choice of com
method of keeping constant the direction of putational methods.
the target rays was by using collimated Some assumptions or approximations are
sources for each target point (Fujii et al., direct consequences of the instrument con
1972) (Fig. 17.11b). The autocollimating pho straints, or are implicit in the computational
C..,vetur. of field of
com. . ,.ftectlon
.' •• 1•
O~..
O~ ;:e:.:: 'Of
k• •toacopic , • •ta
X_
__________ G.. xi, _
axie of cornea
1nwI;> _t...,.
photolt. .toocopic
of Objec:. di._ of
photoltwetoocopic
llyatem IYlt.-n
Figure 17.10 Location of target object and keratoscopic image.
methods and therefore could be avoided by analysis using meridional sections in two
the appropriate choice of instruments or dimensions is that the ray incident on the
methods. cornea, the normal to the surface at the point
Because the analysis is concerned with of reflection and the optical axis all lie in the
depicting a three-dimensional surface by same plane. This condition is only true if the
multiple meridional representations in two corneal surface is a radially symmetrical sur
dimensions, some assumptions are unavoid face of revolution. For instance, if any
able. One of these assumptions is that the amount of corneal astigmatism is present,
location of the corneal apex is at the visual then the normals to the surface of any points
axis in all mendians. This assumption is not not on one of the two principal meridians
usually met as the typical corneal apex lies will not lie in the same plane as the optical
eccentrically (Tomlinson & Schwartz, 1979; axis. This departure (or skewness of rays)
Wesley, 1982; Edmund, 1987), and conse increases as corneal astigmatism or surface
quently, most meridional sections will not irregularity increases (Clark, 1973a).
contain the corneal apex. Regrettably, until a method is devised for
One way to minimize this error is to shift analysing the cornea in the three
the patient's direction of fixation until the dimensional space, all computational meth
image of the central target ring is concentric ods must accept these assumptions.
with the optical axis of the instrument. This
technique can be facilitated by the addition
Calibration
of variable fixation targets (Holden, 1970).
However, this can only minimize the error as Due to the presence of assumptions and
there is no certainty that the apex is at the approximations, the only method of assess
geometric centre of the central image. ing the validity of a computational method is
Another assumption directly related to the by calibration using known standards. Cali
Targets with angled

reflective surfaces
o
~
Light source
Subject's cornea
Targets with
point light sources
Incident co!limated
light rays with
fixed angle
-------------------------------
Figure 17.11a b Photokeratoscopic target image arrangement for (a) EI Hage system, (b) Fujii system.
~
Light source
•
~
Incident light
rays with
• ~
fixed angles
i SUbject's cornea
•
- -
-•'"
- - - - - - - -- - -
- ~
•
I ~
~
•
~
Figure 17.11c Photokeratoscopic target image arrangement for Clark System.
bration is also important in establishing the The ideal standards should be made from
accuracy of both the instrument and the dimensionally stable, scratch-proof, glossy
computational method used. Regular calibra materials such as pyrex or zerodur. Their
tion also ensures minimum data distortion dimensions should be measured regularly
and checks on changes or drifts in the param using methods such as interferometry to
eters of the instrument. guard against dimensional variations. These
Although calibration is most commonly reference surfaces should be kept and mea
carried out on glass or steel spheres, for sured under constant environmental condi
maximum validity, calibrators with the tions.
shape of a typical cornea should be used.
Therefore calibration should be carried out 17.3.3 PRESENTATION OF RESULTS
on ellipsoid standards with central radii and
eccentricity resembling those of the eye
General comments
(Mandell & York, 1%9; York, 1969). If the
computational method adopts a general At the end of computation, a decision needs to
mathematical model for the eye (e.g. a cat be made concerning the method of presenta
enary), then the surface of the calibration tion of results. This decision is not a trivial one
standard should match that general model. as the method of results presentation must:
1. Provide a quick and easily recognizable presentation (Clark, 1974a). At least this
description of the measured corneal method cannot introduce any misleading
topography. information: falsely fitting continuous sur
2. Provide the maximum amount of infor faces when the corneal surface may be a
mation regarding the cornea measured. discontinuous one or ignoring fine topo
3. Facilitate further analysis of corneal graphical details. Certainly this method
topography as required. makes no assumption about the nature of the
surface in between the measured points.
Regardless of the method of presentation
One such method is to record the depar
chosen, consistency must be kept within any
ture of the corneal surface from a standard
study to allow the comparison of results of
surface, for example, a reference sphere (Pul
different corneas. Given the conflicting
vermacher & Rott, 1972; Clark, 1974a; Doss et
requirements in (1) and (2) above, it is obvi
ous that no single method of presentation of
a.. 1981) or an ellipse (Bibby, 1976b).
However, with this method there is neces
results can satisfy all requirements.
sarily a larger amount of data to process to
obtain useful comparisons between corneas,
Description of methods the number of data points to process
The methods of presentation of results can be depending upon the number of target rings
categorized loosely as: (1) surface/curve fit and meridians used.
ting to data points; (2) distinct data points; Variations of this method of data descrip
and (3) parametric descriptions. tion include the presentation of a topo
graphical map of either the local radius of
curvature or the local refractive power (Fry,
Surface/curve fitting to data points 1975a, b; Klyce, 1984; Maguire et al., 1985).
This method initially provides the locations
of the corneal surface points measured. By Parametric description
assuming that the cornea has a continuous
surface the method attempts to interpolate In these methods of presentation, a math
between points, which renders the corneal ematical model is adopted for the corneal
topographical results easy to visualize. For shape. Individual corneas are then described
this reason, this method lends itself well to by the set of parameters which approximates
representation by computer graphics (Din that cornea under the mathematical model.
geldein & Klyce, 1988). The main difference between this
However, by making this assumption, approach and surface/curve fitting to data
information presented may be misleading in points are that in the curve fitting interpola
that discontinuous surfaces, as for a post tive method, the values of the individual
surgical cornea, may be falsely displayed as data (surface) points are retained (or at least
being continuous. The validity of this are not altered) so that the accuracy of any
method thus depends on the type of instru subsequent analysis required does net suf
ment used and the degree of sophistication fer. Mathematical interpretation of surface
of the curve/surface fitting algorithm. details is limited to the intervals between
points. In the parametric description
method, the general mathematical model is
Distinct data points
fitted to the corneal surface. For this reason,
Validity of information is retained by keep the value of each surface point is replaced
ing the measurement points unjoined rather (implicitly) by the expected value of that
than producing a visual, contour map-type of point under the adopted/assumed model.
Accuracy and repeatability 339
Certainly this method greatly simplifies to be carried out, then the relative advan
data recording and any subsequent analysis tages of keeping all topographical data points
since the follow-up analysis may be applied must be weighed against the relative sim
to the individual parameters (as compared to plicity of employing a general corneal model.
the much large number of surface points). The parametric descriptive method may be
This may be an important consideration in the better choice in this case (Guillon et al
epidemiological applications. This method, 1986).
however, in order to achieve a simplified If the aim of photokeratoscopy is to anal
analysis necessarily ignores a large amount yse the corneal topography of individual
of information regarding the corneal topog corneas as, for example, in designing the
raphy. optimum back surface shape of a contact
Many mathematical models have been lens, then it may be preferable to keep all
described and used, ranging from the ellipse measurements in the form of topographical
to more complex functions including a cat co-ordinates. In this way, lens fitting param
enary and an Ignesi curve (Himi et al., 1981). eters such as surface clearance, tear layer
This method of presentation may be thickness and shape can be calculated
extended by employing published abstract directly from the data. If this method of data
mathematical/geometrical concepts in order presentation is employed, a further decision
to facilitate subsequent data handling and will need to be made in selecting the
analysis. One such method for describing the co-ordinates system of measurement to use,
corneal topography has been proposed by e.g. longitudinal/axial or with respect to a
Cohen et al., (1984), which eliminates the reference surface. For instance, in examining
need for recording large numbers of corneal the tear layer thickness, the deviation of a
surface co-ordinates and which also does not surface along the normals to a reference sur
assume any general model for the corneal face would have greater validity than the
surface. A number of indices describing vari equivalent longitudinal measurement (Tom
ous features of the corneal surface measured linson & Bibby, 1977).
are calculated. These indices can then be For optical analysis (e.g. in trigonometrical
used for parametric or non parametric statis ray tracing of the eye), the important infor
tical analysis. mation includes the topographical
The main drawback of parametric methods co-ordinates of the surface points and the
of presentation is that the descriptive angle or slope of the tangent and normal to
parameters/indices may not define a unique any point along the surface. Because in many
corneal surface in that a number of different cases a continuous refracting surface is
corneal topographies may have the same assumed, there is no other choice but to fit a
descriptive parameters. Because of this, the continuous surface to the measured points.
original corneal shape cannot be recon However, even given this constraint, the
structed from the parameters. type of surfaces fitted will still depend upon
the level of sophistication required in the
optical model.
Discussion
Applications of the photokeratoscopic results
17.4 ACCURACY AND REPEATABILITY
play a major role in the selection of the
method of presentation. For instance, if the
17.4.1 GENERAL PRINCIPLES
results are to be used in a numerically
descriptive form (e.g. epidemiological sur The usual method to assess the overall accu
vey) for which statistical analyses may need racy and repeatability of a keratoscopic sys
Table 17.4 Summary of sources of errors
Type of Parameter Oass Source of error Method of error
error prevention/detection/
minimization
Instrument Magnification Systematic Object and image Careful accurate
construction, assessment
measurement, check of
instrument, specifications
Target rings Systematic Roundness,
concentricity,
alignment of rings,
diameter position
Data Focus Random Interobserver Train observers
acquisition differences Implement rigid criteria
Focus Random Depth of focus Focus using the wide
aperture exposure with
smal! aperture
Focus Both Curvature of field Improve optical system,
of corneal image optimize target locus,
implement rigid criteria
Focus Random Eye movement Electronic flash exposure
Alignment Random Interobserver Train observers,
implement rigid criteria
Alignment ? Corneal assymetry/ ?
astigmatism
Alignment Random Eye movement Electronic flash exposure
Corneal records Random Resolution of Use slow fine grain
photographic/ medium halation film with thin film base
electronic of denser photocell arrays
Corneal records Random? Location of film plane Careful checks film,
photographic/ photocells pressure plates/
electronic transparent fil slide
Random Diffraction aberrations Use optimum aperture,
and improve optical system
systematic
Data Photographic Random Dimension stability/ Test film stability per film
storage record and standardize type and batch
dimensions systematic temperature and
humidity during
measurement
Data retrieval Measurement Random Interobserver Train observers,
of records standardize record
measurement procedures
Random and Accuracy of Use accurate/calibrated
systematic measurement equipment only,
device calibrate regularly
Random Determination of Obtain good quality
actual centre photographs, use dark
of lines lines on rings as guide,
improve optical system
Type of Parameter Class Source of error Method of error
error prevention!detection!
minimization
Random Defining ?
centre
of cornea for
semi-meridian
Data Computation Systematic Method of Use appropriate method
computation computation
and analysis
Random and Incorrect Use appropriate
systematic assumptions, assumptions and
approximations general models
Random and Numerical Double precision,
systematic operations, check accuracies of
EG truncation mathematical functions
Random and Integration! Check numerical analytic
systematic differentiation
e.g. quadrature vs
spline fit
Systematic Type of general Select reference surface
model or with similar parameters
reference surface to cornea and model
adopted
tem is to compare the results from a number true value of the parameter measured. The
of photographs of one or more reference repeatability of a measurement (often
surfaces and corneas. called reliability or precision) indicates the
Numerous claims have been made in the ability of the instrument to duplicate its
literature regarding mainly the accuracy, but own results (ISO 3534, 1982). In other
also, the repeatability of photokeratoscopic words 'the accuracy is a measure of an
systems. However, with perhaps a few instrument's ability to tell the truth,
exceptions (Ludlam et al., 1967), the informa whereas repeatability is a measure of its
tion given was either incomplete and/or was ability to stick to the same story' (Hayward,
derived in a manner which departed from 1977). From the definitions it is obvious
standard methods, making it difficult and that in order to determine the accuracy of
sometimes impossible to calculate the instru an instrument one must first know the
ment's true accuracy and/or repeatability. 'true' value of the parameters measured.
Some authors, often the instrument's design Hence, the accuracy of a photokeratoscope
ers, depart from accepted metrological tech can only be determined for reference sur
niques in the determination of accuracy and faces such as steel balls or glass spheres of
repeatability and, in so doing, tend to over known radii. Repeatability on the other
estimate the performance of the instrument hand can be measured for both reference
tested. surfaces and the in vivo corneas.
The accuracy (sometimes called validity) Most papers quote the standard deviation
of an instrument indicates the closeness of a series of measurements as the repeatabil
between the mean measured value and the ity of an instrument. It is, however, the usual
convention in metrology to report accuracy column. The accuracy quoted is the best
and repeatability of an instrument at the 95% and worst case claimed in the published
confidence level; this is obtained by multi works in which the method was first
plying the standard deviation by the corre applied to corneal topography. Where no
sponding Student t value: quantitative estimates of accuracy were
As this is not the place to detail the meth found, the most reasonable subjective esti
odology to measure accuracy and repeatabil mate was given.
ity, the interested reader should consult A number of comments can be made about
metrology texts (e.g. Campion, 1973; the information in Table 17.5. Some authors
Dietrich, 1973). However, it is useful to be quoted instrumental errors. In these cases we
familiar with the two types of uncertainties assumed that the results obtained referred to
which affect measurements; namely ran the instrument accuracy. In many cases no data
dom and systematic uncertainties. Repeat was given to support the claims made for the
ability refers only to random uncertainties, accuracy (Knoll, 1%1; Clark, 1973c, 1974a; EI
while accuracy is concerned with both. Hage, 1976; Doss et al., 1981) and also for
Hence the accuracy of an instrument can repeatability (Oark, 1973c; Klyce, 1984).
never be better than its repeatability. It In a number of cases where data are given
should be noted that some authors describe and claims made, the two did not agree and
instrument performance in terms of resolu we have subsequently recalculated the rel
tion, which should not be confused with evant parameters as follows:
accuracy nor repeatability. Resolution
describes the smallest difference that the 1. Doss et al. (1981) reported for the mea
instrument can detect. Accuracy can never surement of a reference sphere of nomi
be better than resolution but can be signifi nal radius 9.52 mm an average measured
cantly worse. radius of 9.663 ± 0.2385 mm for the nine
The accuracy achievable with any instru rings. The standard deviation alone
ment depends upon both the hardware avail gives an instrument repeatability of
able and the various steps taken from image ± 0.477 mm on the radius. The data thus
acquisition to its analysis. The various types gave an accuracy of «9.663 - 9.52f +
of errors encountered and their sources arc (0.477)2)lh = 0.498 mm.
summarized in Table 17.4. 2. Ludlam et al. (1967) did not analyse their
data fully. By meaning in quadrature the
standard deviations reported for the two
17.4.2 INFORMAnON CURRENTLY reference steel balls measured we obtain a
AVAILABLE repeatability at 95 % confidence level of
For comparison, the information reported ± 0.008% mm (SO ± 0.00448 mm) for the
in the literature on accuracy and repeatabil image of the first ring and ± 0.04016 mm
ity is given in summarized form in Table (SO ± 0.02008 mm) for that of the sixth
17.5. The references cited for each method ring. A similar computation for a cornea
in Table 17.5 are the earliest published gives repeatability of ± 0.0122 mm (SO ±
works in which the basic method was first 0.0061 mm) for the first ring and ± 0.044
applied to corneal topography. A brief out mm (SO ± 0.0472 mm) for the sixth ring.
line of the method is given in the second 3. Klyce (1984) reported for a reference
sphere of 8.100 mm nominal radius,
and measured radii of 8.137 ± 0.015
• The 95% confidence level calculated gives a range
approximately X2 the range obtained by taking the stan mm and 8.138 ± 0.020 mm. This data
dard deviation. gives a mean systematic uncertainty of
Table 17.5 Summary of published data on accuracy and repeatability of specific photokeratoscopes
Instrument Reference Accuracy Repeatability
Gullstrand (E) Gullstrand,1896 Claim: Average
± 0.0025 mm for image
of photokeratograph of
steel balls
Sun PKS - 1000 Sun Contact Lens Claim: 1 % error on
Photokeratoscope (C) radii 7.Q0-8.00 mm. No
supporting evidence
Klyce, 1984 Measurement: n = 2
photographs, no
difference between
mean for reference
sphere
Berg Clark, 1973 Measurement: ± 0.2 D
Photokeratoscope (E) error (equivalent to
± 0.04 mm radius) on
glass lens
Corneascope or Doss et a.. 1981 Measurement: ± 2.7 to
Photokeratoscope 4.7% on power.
(International Claim: Overall
Diagnostic accuracy ± 2 to 5%
Instrument) (C) with possible
improvement to an
accuracy of ± 0.5%
Measurement:
reference steel balls
nominal radius =
9.52 mm measured
radius = 9.663 ±
0.2385 mm
Knoll Bausch & Lomb Knoll, 1961 Claim: approximately
±0.2mm
Photokeratoscope (C) Ludlam et a; 1967 Measurement:
± 0.030 mm for central
ring ± 0.036 mm for
periphery for 95%
confidence level for
reference sphere
Mandell Mandell and Measurement: + 1 % Measurement:
Photokeratoscope (E) St Helen, 1968 on ring diameter of 1) ± 0.12% (on average
Mandell and photokeratographs of change 0 to 0.53%) on
St Helen, 1971 reference steel balls ring diameter from 5
Claim: ± 0.25% photokeratographs of a
possible if careful steel reference ball
focusing applied 2) ± 0.21 % (range
0.21% (range 0.02 to
0.58%) as above for
corneal surface
344 Photo keratoscopy
Instrument Reference Accuracy Repeatability

EI Hage El Hage, 1976 Claim: Less than ± 0.01
Photokeratoscope (EHP) (E) mm at the extreme
corneal periphery
Wesley-Jessen Bibby and Measurement:
Photokeratoscope Townsley, 1976 1) ± 0.0036 to ± 0.0122
mm on saggital values at
the 95% confidence level
2) ± 0.18 0 on central
curvation and ± 0.08 on
shape factor at the 95%
confidence level
Holden Holden, 1970 Measurement:
Photokeratoscope 1) ± 0.0009 mm SO on
central ring and ±
0.0032 mm SO on
peripheral ring of steel
ball photokeratograph
(equivalent to ± 0.022
mm±0.26%)
2) ± 0.0012 mm SO on
diameters of central ring
and ± 0.0052 rnm 50 on
peripheral ring of
corneal
photokeratograph
(equivalent ± 0.023 mm
0.25%)
Photokeratometre Clark, 1973 Claim: ± 0.01 mm (SO) Claim: Precision ± 1 %
Ysoptic (C) error
Computer Computer Claim: ± 0.2 D Claim: Resolution
Anatomy TM51 Anatomy Inc. ± 0.20 D
EyeSys ESl00 EyeSys Claim: Resolution
Laboratories ± 0.010
Reproducibility
± 0.25 0
Visioptics EN270 Visioptics Inc. Claim: Resolution
± 0.20 0
± 0.075 mm and a random uncertainty photokeratograph. They claim this to be

of ± 0.045 mm, hence an accuracy of equivalent to an error of an accuracy of
«0.045)2 + (0.075)2)Y.l = 0.0875 mm. 0.3 0, for a 40 0 surface, This 0.3 0 is
4. Maguire et al. (1985) reported that their probably the instrument resolution in
instrument achieved a video digitizer equivalent dioptric units. Their paper
resolution of 2000 pixels per frame corre has no information from which accuracy
sponding to a resolution of 7.5 urn in the could be calculated.
Non-photokeratoscopic methods 345

17.4.3 ACCURACY REQUIREMENTS In this case, the two controlling variables
are location of surface points and surface
The usefulness of photokeratoscopic infor slope at those points. For the second vari
mation in any application is limited by its able, the cornea has typically a 10° slope
accuracy. For example, one important (normal with respect to the geometrical
application is the determination of the cor axis) at the mid-periphery. In order to
neal shape in view of designing optimally resolve a 0.25 D change in refractive power
fitting rigid lenses (Moss, 1959: Cochet & at this point, the slope of the surface will
Amiard, 1969; Amiard, 1972; Wilms, 1974, need to be measured with an accuracy of
1981; Bibby, 1976a, b; Muckenhirn, 1981; 0.05° (3 minutes).
Guillon et aI., 1983; Kemmetmuller, 1984; Based on the information in Table 17.4,
Kivayev et al., 1985; Manabe et aI., 1986). one may argue that photokeratoscopy will
For this application a useful system will need further improvement before either of
need to have an accuracy commensurate the two applications described can be tackled
with this task. with confidence.
The most critical aspect in rigid lens
fitting is the distance between the contact
lens back surface and the corneal front 17.5 NON-PHOTOKERATOSCOPIC
surface at the apex, often called the central METHODS
tear layer thickness (TLTc). Experienced
practitioners by subjective assessment of 17.5.1 GENERAL COMMENTS
fluorescein patterns can differentiate
between the fit of two lenses differing by as There are a number of noteworthy methods
little as 0.05 mm in back optic radius of corneal topographic analysis which do
(BOR). Thus, arguably, any photokerato not involve photokeratoscopy (Table 17.6).
scopic system intended for this purpose Although this chapter deals only with pho
should have an accuracy in radius of curva tokeratoscopy, by examining the accuracy,
ture equivalent to (or finer than) 0.05 mm. validity and practicality of non
In terms of linear dimensions, this corre photokeratoscopic methods the relative
sponds, for a typical lens with an 8.00 mm merits of both photokeratoscopy and non
back optic diameter, to a difference in TLTc photokeratoscopy techniques can be
variation of 10.0 urn to 6.8 urn over the assessed.
normal range of BOR from 7.20 mm to 8.40 One point which must be borne in mind
mm, respectively. Therefore, the required is that although many of the listed methods
system will need an accuracy of approxi can purportedly record the cornea in three
mately 0.025 mm radius determination. dimensions, problems still exist as to how
Note that, in this application, the accu quantitative data can be extracted from the
racy required depends greatly on the clini resultant topographical records. for
cally significant difference for the control example, holographic recordings or cast
variables. For example, although practitio impressions of several test eyes can be
ners can detect differences of 0.05 mm BOR, made. However, comparisons between
this difference in contact lenses may cause these eyes cannot be made unless topo
little difference in performance. The above graphical data in some quantitative form
calculations were greatly simplified and (e.g. sag heights or local radii of curvature)
were intended solely for illustration. can be obtained from the recordings. The
In another example, the application may discussion concerning methods of data pre
be for optical ray-tracing of an eye model. sentation for photokeratoscopy should also
Table 17.6 Brief notes on non-photo and video keratoscopic methods
Methods Advantages Disadvantages Accuracy
Peripheral keratometry Relatively simple Equivalent radii at
instrumentation periphery not
necessarily true, local
radii of curvature,
computation very
involved
Autocollimation No calculation of Symmetry about Depends upon
results required-direct optical point assumed, aperture size, lens
reading of 'local only one radius aperture, define area of
radius' measurement per surface used. As good
aperture, eye or better than
movement a problem keratometer?
Interferometry Less affected by Needs diffusing Potential wavelength
(common path) movement surface? accuracy
Interferometry Needs diffusing
(projected dual beam) surface, must be very
stable
Holography Three dimensional Subject must be very Potentially very
recording and stable, needs further accurate
presentation work before data
usable
Moire fringes No integration in Needs diffuse surface, ± 5 urn for 7.50 mm
(toposcope) analysis, valid for very field of view depends radius
uneven surfaces on aperture, less
accurate at corneal
apex
Stereo Good at recording Needs diffuse surface ± 30 urn for 8 mm
photogrammetry severe departures from radius
normality e.g.
keratoconus
Profile method (direct) Simple analysis Horizontal meridians Depends on recording
difficult to evaluate medium, potentially
accurate
Profile methcd (optic Slit lamp or special ± 5!lm on sag
section) camera ± 12.5 urn on radius
Profile method Specialized instrument Need to reconstruct
(Schiempflug) actual curvation from
apparent curvation
Casting/moulding Only gross irregulari ty Poor repeatability
detectable,
deformation of cornea
shape by mould
material- shrinkage,
needs further work
before data usable.
Methods Advantages Disadvantages Accuracy

Fluorescein methods Shows up small Lens must not distort, Subjective judgement
irregularities well sensitivity depends on better than ± 0.05 mm
reference contact lens radius
shape
be considered for the non-photokerato spherical (or is _at least symmetrically

scopic methods. disposed about the point of measure
A number of methods have been described. ment). Because the cornea approximates
Most of these are optical (peripheral keratom an ellipse (Holden, 1970; Guillon et al.,
etry, autocollimation, corneal profile, moire 1986), this assumption can only be met
fringes, stereophotogrammetry, interferometry at the corneal apex and therefore is inap
and holography, and fluorescence methods propriate in general.
(Stone, 1962; Clark, 1973d; Berish, 1975; Smith, 2. If the surface is described by a math
1977», while one is physical/mechanical (casts/ ematical function, the local radius of
moulding, although the use of fluorescein may curvature is a composite variable con
also be classified as being a physical method as sisting of the first (slope) and second
contact is made with the eye). As one impor (acceleration) derivative of that function
tant criteria of corneal topographical assess (Thomas, 1975). Because the two deriva
ment is that test cornea must not be distorted, tives have been reduced to a single
the physical methods may not be suitable. quantity, it is impossible mathemati
cally to extract the exact parent function
17.5.2 PERIPHERAL KERATOMETRY
describing the corneal surface from the
local radii of curvature. An approxima
Peripheral keratometry involves the mea tion of the corneal surface, however, can
surement of local radii of curvature (Douth be obtained (in polar co-ordinates) pro
waite, 1987b; Grosvenor, 1961; Wilms, 1974, vided certain assumptions about the
1981; Wilms & Rabbetts, 1977; Campbell, geometry of eye movement are accepted
1982; Kemmetmuller, 1984). To facilitate this, (Fry, 1975b). Analysis of data from
a series of peripheral fixation points are peripheral keratometry can be simpli
added to the keratometer (Grosvenor, 1961; fied if a general model (e.g. ellipse) for
Mandell, 1961, 1962). The validity of the the corneal shape is adopted (Douth
measurement can be improved with this waite & Sheridan, 1989).
method by using a small mire keratometer
(Fry, 1975b; Douthwaite, 1987b). From the set
of measured local radii of curvature and their 17.5.3 AUTOCOLLIMATION
angular positions relative to the primary
Autocollimation uses the Drysdale method to
visual axis, the approximate corneal topogra
measure the radius of curvature of a surface
phy can be reconstructed (Borish, 1975).
(Bennett, 1964; Douthwaite, 1987a) (Fig.
However, there are a number of limitations
17.12). Basically, the local radius of curvature
that affect the validity of this method. In
at a given point of reflection is measured as
particular, two major limitations imposed
the distance between the focal plane of the
are:
optical system and the corneal apex when
1. An assumption is made that the actual autocollimation is achieved.
surface at the point of measurement is For different aperture sizes used, different
348 Photokeraloscopy
--- ---
Light source and
image plane
--- --- ---
. - -----
Light source and
image plane
--- --- ---

Optical system
Figure 17.12 Drysdale autocollimating principle for measurement of corneal shape for (a) focusing at
corneal centre of curvature; (b) focusing at corneal apex.
points of reflection can be measured. If sev mating photokeratoscope (Oark, 1972; Oark,
eral rings are used simultaneously, instead of 1974).
a single aperture, the local radii at various
points on the cornea can be measured. This
17.5.4. CORNEAL PROFILE

in effect, although the measurement and
computational method are somewhat differ These methods involve the photographic or
ent, is the optical basis of Clark's autocolli- electronic recording of the corneal profile.
The profile can be obtained either by pho horizontal are difficult to measure.
tography of the contour of the centre of the
cornea (McMonnies, 1971; Wechsler, 1978)
(Fig. 17.13a) or by biomicroscopy using optic 17.5.5 MOIRE FRINGES
section (Brown, 1972). One variation of the Moire fringes methods involve the projection
latter is the Scheimpflug technique (Drago of two sets of optical patterns (e.g. parallel
mirescu et al., 1980; Richards et al., 1988) in lines) onto the cornea. From the resultant
which the direction of observation need not interference-like appearance, the corneal
be perpendicular to the direction of illumina topography can be computed (Ludlam &
tion (Fig. 17.13b). Kaye, 1966; Mandell, 1966; Chander et al.,
More recently, an opto-electronic instru 1976; Kawara, 1984).
ment has been designed which records the The major advantage of this method is that
profile of both the anterior and posterior no surface continuity needs to be assumed,
cornea (Bille et al., 1987). and therefore, it could be particularly useful
The main advantage of corneal profile for irregular surfaces (e.g. keratoconus). The
methods is that they are the only optical two drawbacks are:
methods that give a direct record of the
sectional corneal contour. However, one 1. The corneal surface needs to be rendered
major disadvantage is that in practice, sec diffusive.
tional meridians other than the vertical and 2. The accuracy is poor near the corneal
Light surface
for background
....
Camera or
video/digitiser
Light source
Figure 17.13a Corneal profile principle for measurement of corneal shape profile photography.
1\
~
Slit light source
Figure 17.13b Corneal profile principle for measurement of corneal shape biomicroscopic optic section.
apex (although this may be overcome by powder has in some methods been replaced
repeating measurements at different by the use of sodium fluorescein (Warnick et
directions of projection and observa al., 1987). Nevertheless, such procedures add
tion). to the duration and tedium of these methods
17.5.6 STF.REOPHOTOGRAMMETRY
The first step in stereophotogrammetry is to

-
which limit their use in clinical applications.
]7.5.7 INTERFEROMETRY AND

HOLOGRAPHY
render the cornea opaque and diffuse. Ste
reoscopic pairs of photographs of the cornea Interferometry employs the physical optics
are then taken. Corneal topography is phenomenon of interference to assess the
obtained by recombining the pair of photo corneal topography. Two experimental
graphs (Bonnet & Cochet, 1962). arrangements have been described: common
The advantage is that the surface need not path and dual beam interferometers.
be continuous. However, similar to the Holography is a special case of interferom
moire fringes method, stereophotogramme etry where the photographic recording of the
try methods require the test surface to be interference patterns is used to record and/or
optically opaque and/or diffusive. Because reconstruct the corneal surface in three
the cornea is reflective, measures need to be dimensions (Clark, 1973d).
taken to provide these characteristics. The The potential accuracy of these methods is
traditional procedure involving anaesthesia very high, of the order of wavelength of light
followed by dusting of the cornea by talcum but the rigid requirements of the methods, as
Corneal topography 351
yet, do not make them a practical technique to the contact lens fitter who can then best
for clinical use (Clark, 1973e). understand the concept of the tear layer
thickness. That concept relates directly to the
17.5.8 METHODS INVOLVING FLUORESCEIN relative sagitta of the contact lens back sur
face and corneal front surface. Information as
The fluorescein methods involve the use of a to normal variations such as age effects or
series of hard contact lenses with known racial differences will be given. However, no
back surface characteristics. The aim is to information will be given as to corneal topo
match the corneal front surface and the con graphic changes associated with surgical
tact lens back surface. Surface matching is procedures (e.g. corneal grafting) or eye dis
judged by observing the presence or absence eases (e.g. keratoconus), which are dealt with
of a fluorescein layer in a manner similar to in Chapters 35 and 36.
contact lens fitting. When no fluorescein can
be seen, the two curves are assumed to be
17.6.2 CLINICAL RESULTS
matching (Brungardt, 1965). A more objec
tive and accurate method can be obtained by Despite the extensive use of keratometry and
measuring the thickness of the tear layer photokeratoscopy over the years, relatively
using fluorophotometry (Furakawa et aI., few systematic studies have attempted to
1976). From the knowledge of the contact lens describe the normal cornea in detail by mea
back surface and the tear layer thickness suring large representative samples. Two
profile, it is possible to deduce the anterior photokeratoscopic studies, using in one case
corneal surface shape. the Clark photokeratoscope (Kiely et aI.,
The main drawback is associated with the 1982a, 1984), and the other case the Wesley
distortion of either the contact lens or the Jessen PEK photokeratoscope (Guillon et al.,
cornea. 1986) have studied the corneal shape for a
Caucasian population. Despite the different
17.5.9 CASTING AND MOULDING
instrumentation used, the two studies, both
adopted a conic section model to represent
Casting of the corneal shape is carried out in the cornea and arrived at very similar results.
a similar manner to casting undertaken with The main difference has been that in Kiely's
a view to fitting scleral lenses. The positive study the data was analysed for each half
cast of the cornea is used for topographical meridian, whereas in Guillon's study the
analysis. The drawbacks of casting are well analysis was for the whole meridian. The
known, in particular deformation of the cor results are presented with the notation sug
nea during application and material shrink gested by Bennett (1968) to describe conic
age during setting (Stone, 1962). This sections. In that notation the origins of
drawback renders the technique unsuitable co-ordinates are taken at the corneal apex
for accurate analytic corneal topography. and any meridional section is described by
two parameters, the apical radius of curva
17.6 CORNEAL TOPOGRAPHY
ture (ro) and the shape factor (p). A shape
factor, p = 1, corresponds to a sphere; 0 < p
17.6.1 GENERAL COMMENTS
< 1 to a flattening ellipse and p > 1 to a
steepening ellipse.
This section will report upon corneal topog The results (Table 17.7) indicate that the
raphy biostatics. The information will be central radii of curvature are normally dis
limited to normal corneas. This information tributed peaking at 7.79 mm in one study
is of particular interest to the lens designer or (Kiely et aI., 1984) and 7.87 mm in the other
Table 17.7 Central keratometric measurement for the normal Caucasian population
Mean ± SO 95% Range Absolute range
(mm) (mm) (mm)
Kiely et al. Horizontal meridian 7.27-8.31 7.10-8.75
(1984) 7.79 ± 0.26
(n = 196 eyes) Vertical meridian 7.12-8.24 7.06-8.66
7.69 ± 0.28
Guillon et al. Flat meridian 7.37-8.37 7.14-8.54
(1986) 7.87 ± 0.25
(n = 220 eyes) Steep meridian 7.16-8.24 7.03-8.46
7.70 ± 0.27
(Guillon et al., 1986) in the flattest meridian ence in shape factor between the flat and
and at 7.69 mm and 7.70 mm respectively in steep meridians (Table 17.8) shows that the
the steepest meridian. The difference flattening or steepening of the cornea is not
between those central meridional values, always the same in the two meridians of the
which represent the central corneal astigma same cornea. Neither of the two studies
tism, peaks at 0.1 mm but is highly patient report any systematic differences between
dependent, as illustrated by a standard males and females.
deviation of ± 0.15 mm, which indicates a The two characteristics of the peripheral
95% range of 0.00 mm to 0.45 mm (Guillon et cornea have significant implications. The
al., 1986). The corneal periphery is most often difference in peripheral flattening between
best represented by a flattening (oblate) corneas with identical central radii of cur
ellipse (Table 17.8) with mean shape factors vature explains why, to achieve a given
p = 0.80 (Kiely et al., 1984) or p = 0.83 fluorescein pattern (hence a given central
(Guillon et al., 1986). However, both studies tear layer thickness) for corneas that have
report a wide range of p values with a signifi- . identical central radii of curvature, one may
cant number of corneas that show no periph require in extreme cases rigid gas perme
eral change in radii of curvature and other able lenses with back optic radii that differ
corneas that are steeper at the periphery than by as much as 0.3 mm. The difference in
at the centre. The distribution of the differ peripheral flattening between two merid-
Table 17.8 Peripheral corneal asphericity (p value) for the normal Caucasian population
Authors Mean ± SO 95% Range Absolute range
(p) (p) (p)
Kiely et al. (1984) Horizontal meridian 0.50-1.10 0.48-1.13
(n = 196 eyes) 0.80 ± 0.15
Vertical meridian 0.36-1.24 -D. 11-1.52
0.80 ± 0.22
Guillon et al. (1986) Flat meridian 0.57-1.09 0.21-1.20
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designs to achieve a good peripheral fit. In some fluctuations but their samples are too
such a case, a cornea with a similar rate of small to be representative.
flattening in both principal meridians or a Finally, associations have been sug
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can usually be adequately fitted with a vature (Hovding, 1983) and between
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Japanese population study has shown that,
on average, they have a much steeper cen
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PHOTOKERATOSCOPY 17

17.1 INTRODUCfION ogy or in surgical cases of surgical opera­

Published in 1994 by Chapman & Hall, London. ISBN 0 412 35120 X

The recording system The recording system

Figure 17.1 Photokeratoscope main component systems.

Targets Hemispherical targets In order to increase

Table 17.1 Classification of photokeratoscopes according to target locii

Figure 17.2 Zeis reflectograph keratoscopic optical principle.

• The accuracy of the recently developed Corneal Modeling Photographic film

Plane target instruments Cylindrical target instruments

Table 17.2 Commercially available instruments

Corneal modeling Eye Sys Visioptis

Commercial videokeratoscopic instruments

Figure 17.5 Visioptics Incorporated, Computer­

Figure 17.4 Eye5ys Laboratories E5100 video

cornea. The choice of computational method is incorrect or inappropriate computational

assumption must be assessed critically

Incident light rays

Actual corneal surface

Reflected light rays

Centre of corneal curvature

Actual corneal surface

Profile derived from

Figure 17.8 Geometric principle of determination of corneal profile by curve matching.

Figure 17.9b Location of aperture stop for generalized non-telecentric system.

Figure 17.10 Location of target object and keratoscopic image.

Targets with angled

Instrument Reference Accuracy Repeatability

± 0.075 mm and a random uncertainty photokeratograph. They claim this to be

Non-photokeratoscopic methods 345

Methods Advantages Disadvantages Accuracy

be considered for the non-photokerato­ spherical (or is _at least symmetrically

--- --- ---

--- --- ---

eral rings are used simultaneously, instead of 1974).

a single aperture, the local radii at various

points on the cornea can be measured. This

17.5.4. CORNEAL PROFILE

Slit light source

The first step in stereophotogrammetry is to

]7.5.7 INTERFEROMETRY AND

You might also like

17.1 INTRODUCfION ogy or in surgical cases of surgical opera

Figure 17.5 Visioptics Incorporated, Computer

be considered for the non-photokerato spherical (or is _at least symmetrically