Corneal topography using the Holladay Diagnostic Summary

Jack T. Holladay, MD

Purpose: To describe new software developments in videokeratography and illustrate their application in patients with corneal disease or patients who have had keratorefractive ~urgery. Methods: The Holladay Diagnostic Summary provides 4 maps and 15 corneal parameters for the clinician. The maps include 2 refractive power maps on standard and auto scales, a profile difference map for determining the corneal shape relative to normal asphericity, and a distortion map to display the optical quality of the cornea. The 15 corneal parameters provide quantitative information about the cornea for a 3.0 mm pupil; e.g., effective refractive power, regular astigmatism, asphericity, and predicted corneal acuity. The maps and parameters are used to analyze a calibration ball and five clinical examples. Results: Patients with diseases such as keratoconus or patients who have had keratorefractive surgery have characteristic changes in the 4 maps and the 15 corneal parameters. Conclusion: When true refractive power maps, a profile difference map, a distortion map, and 15 corneal parameters are analyzed, characteristic changes are found that can help clinicians recognize and monitor corneal disease and refractive surgery and correlate these changes with patients' visual symptoms. J Cataract Refract Surg 1997; 23:209-221

he Holladay Diagnostic Summary (HDS) is intended to provide the clinician with a single report that contains information about (1) the true refractive power of the cornea at every point, (2) the shape of the cornea compared with normal at every point, (3) the optical quality (distortion) of the corneal surface at every point, and (4) 15 specific corneal parameters, such as effective refractive power used in intraocular lens (IOL) calculations and refractive procedures, to quantitatively describe the cornea. Although these maps and features were unique to the EyeSys topography unit 3 years ago, the use of Snell's law, shape maps, distortion maps, and
Dr. Holladay has been a consultant to EyeSys Technologies,Inc. Reprint requests to Jack T Holladay, MD, Houston Eye Associates Building, 2855 Gramercy, Houston, Texas 77025, USA. J CATARACT


effective refractive power can be found on most topography units manufactured today. The description of the map features and the examples should provide the clinician with valuable information about the current state of corneal topography.

General Features
As seen in HDS 1, the "key" giving the value for the color "green" and the "step" size is in the upper left or upper right corner of each map. The black mark at the center of all maps is the center of the rings. It is often referred to as vertex normal since the reflected image must be perpendicular at this point. The small white circle, usually near the black mark, is the pupil center. The medium white circle has an average diameter of
MARCH 1997



. Rpar:riv(' bln. or J CAT A. indicating th presence f mild irregular asrigrnacisrn nd pan-iaII)' plaining [he BCVA 0 20/30. n thi calc we ee that [be P wet widlin the central 3. The ticity would be expected foUowing PRK because [be paracentral region is far roo uoep fOT [be central po .p-A1lto calc. indicaring hell i5 7. his vision.ACTIUJ1RArrSlJI~G-Yt). Th diffi renee i mall c:cai e the 4.50 + 1.lall-.5 rnrn flnp and a 6.. his visual acuity was 201 O.OI quite perfect. Arph Ilea (Q) ind lcates rhe cenrral 3.0 mm PlJ. ne of tbe Or- ls sreepening more than a. The auto scale has chosen green as 4] . This asphe- LASH The pari n is a 0.50 0. The simulated keraromerry varie from '11 [0 I B degre fr m (he refined e power uxes but is ve close (0 (he poww·/i.50 D.! ablation is outside the 3. indicating there is n irregular asngmarisrn.0 mm excirner trearmenr in the bed wirh umrnit Apex laser 5 weeks pri r t this exarninati n.spherical ball. caus an' signillcanr pr blem . -0 + ..CQrllf!ll1 1'(lr(l.0 rnm 7. The gil sring of hcadliglus at: night is most likel ' due [0 till! edge of'rhe . er.l1111lrrJ for 3.. The U Index and the P .2 mm perimerer sampledby the standard kerat meter. The hl.-year-old man \ It had..S hap y wid.Ll).MI\]l.p. and be WIl.0() X 90.-0 X S .Ql i<:l'r .~ The Eff RP is approximarel 3.00 fh. The pupil is almost cnncenrric with (he ffillp. Tb_eRcgktig i~ almost identical to the T cAstig. visual acul 201.(l D fL'ln~ rhan normal.5 111 m zone of thl. mm the central cor- with an 8. A uiry indlcate 3 uniform central 3..00 and a rep iz~ O.1:0· uncorrect ·d vi ual acuiry was 20/30.5 rum optical zone iliac can be teen . Tilt! pesroperarive refra (jon was -0.0 rnrn is nonunif em and varie less than . 11B zone is uniFormly dArk hlue. bur they dld nor.( [hac the opri I zone i slightly dccenrered to nhe right (na ally) may also be Q cornplicating faaor. He:noriced sorne "halos" around lighes ac nighc.w::r[han normal w~hhalmost no astigrnatlsm present. LASII HD 5 ernea Rifracriu~/l. but n. The patient's precperarlve refraction VYa~ -5.0 mm zone with e cellenr opti ·1 quality. 11 [he di Ii n:ion m p. mflrimd colt: Th cenrral S..

The red dlsrerticn m o'clock on this rillg corresponds ro the p rtion r the 6. indicating <I slightly vcrtictlly cUspt cd prical zone. Tlie U Index and the r Acuity indicnre a nonuniform central 3.0 mm pupil. 'rill: diB"eren I.n 111. ru~I~ lll) . lK nap. The Asph ( indicates the cc.5 mrn pupil correspoml to a ncenrri "wrinkle" in the Oap. extending :lJp ) ri rnately .lcl.5 111m ill diameter and corresponds to the irular temporal and inferior edge of the 8. he error of rhe 1m K' are on Iy in the range ero.s bur illustra te the liml • d n .irnarely 5.O nun pupil corresp nds to rhe edge 0 the ablation zone. The pupil is virrually courcnrric wirh rhe map. The halos [rom h ndlighrs at night are lue to the con entri dis(0 rti 0 ns wi thin the 6. isrent wirh 10/32 Be . r . Th f'a L til It th piic 1 di t rricn are not ex cl syrnrnerrical m. con. n r lilt! rJU. in curvature at the G.0 mm pupil char ClU] bt' seen uu the listonion rruLp.0 mill pupil ihar CUt best be soon on the Refinrrive Map-.:1'11 ral pupil 'l.':! issreepening more chan a spherical ball. "11\(. The simuls cc.! Is du [() he im:gul. rile incomplete 6.[ dj~t ributi n ncar rhe . TIle mea pr gl'(!.0 mm ablariou I.0 mm ring of eli t man rre ponds ro rh 6.which correlates willh rhe rin of optical di torti 1Il seen at the c. n nearest th nasa] "hinge" ftll·.1' rat infcriorgrcCIl and retlow arcs at 3. or me Cam rd Parl[lt1ttrrrfor 3. stc:cper ill the p -dphcl)' chan n irma] fj r till nrral puwcr.:ntral~. Th ·Iarg 1 incornplerc ring is 8. 50 and I d :grcc. nun 7.' 1. y b 3 ornplicaring facror. as we would expece \ ith an bl. su nd rd keran merry me uremenrs With irregular astlgmarism. ne L rrr stir blue.5 nun LASU( flap. bur there ure two small areas of rreen and yeU w dernensrraring a smal! amcunt dlsmnlon in rhe optical zone. III III pr ub ve rh 3. The abrupt hangc. sqrrn e afrer a myopi LA.:dkeJ1:Jromerry i~ L3 degrees di 1'1:111 From the refracrive power axes.uio Scale.0 mm e rcimer blarion zone.u pow . The Reg Asug is ielentical to rhc Tor Aseig.0 mrn zone with good but nor perfect 'ptJaJ quality. demonstrnting rhat this rnea is relariv I)' ml.'Ulivciy increases ill power peripherally by seven colors. no oblique-axes irreglllllr astigmatism.o rnm pupil on tilt: dIM rrrion mall. Dissortio« Mill': Tilt.0 nun pupil: 111' • P • RP iii appro . IF .0 D Darter than 11 rmal.Profil/' Dijfirem:£ Mnp: The enrral green area is sl ightly oval vertical Iy. IIlwrnnl1g u.

near distortion ate keratetomies SpOTI1 ere place I along the flat a:-il.. The auto scale bas chosen grecu as 1.~are 60 degrees apart (aonre nnglt!)~ indJc:ating rhe presence of obliqu .rd at the top (11 o'cl ck) and bottom.. Within the 6. Profi/~ Dif.0 mm Ptj.ttivf Map-SrJUuia. 0 nthis scale we see thar [he central 3.0 mrn pupil we ee up £0 a 2. refra ri n at 1!h. The red areas of ghosting of Images at night.0 mm diameter. arcuate areas of distortion ian. he h d a keratoren from 39. In astigmatism t! then stablllzed nrhs.5 and meridian. Three months later she had 4.ith AK Cornea lIDS 6 Th parienr is a 70~ ear-old w man wh was p eud phskic and had 8. FR.0 D 0 rnyopi agaln t-cbe-rul dSdgmadsm 1 year after cataract surgel·Y. The irregular.HoImlum LTK w.A J.Nfnp--Aum Scale.0 D (yellow) steeper than the rest oFthe central 3.0 rnrn zone.0 mrn. he patient wa me 6.. conSrming the presence of irreguLrr astigmatism.haped cenrral island mat is pproximerely 1. Because ch paricnr could nor tolemre the full asdgmaricprescripd in spectacles r wear a con cr lens •. indi ring <1 pr gressive increase in the irregularity wid) lncreaslng pupil fractive procedure wi.iJ agalnsr-the-rule asrigmatism. The central zone are a result the our holmium laser p rs placed ar 8.5 mm inro this region.0 mm area. The pad en r develo ped 11. 'orneal Pnrnmffm for 3.0 D Ilareer than normal. ThcReg Asrig ' 23. D of residual.fol'mct! M'1P: The central green area has a yellow.0 D of with-the-rule immediately a spherical after the laser treatment. URG-V .0 D. Disumion.0 rnrn diameters in the 90 degree is nonuniform dark and light blue. Map: The central 3.GORe shows light green and yellow dist rti ns encroaching approximately 0. . cecp axe. so rom holmium laser size.0 mID I upll .0 rom zone centered at app im rely 180 degrees. (6 o'clock) cate.\'£ARCH J!l91 R. i ndkati ng. Q al ng tbe h rizonral meridcorrespond to th twO areu- happywithheI BCVAof20/40 butdid nerice halos and performed at . hypeuop. the cen tral cornea is 4.5 mrn dJ meter and tWO 31 . Tb EffRP i • pproximarely . axes astigmatism.5 0 variation (lighr blue m yellow). i:\ 0 a w 6.piJ: The flar and. ReftactitJ{! . (9 degr es).th two arcuate kemrotorniesar [he 5.0 rnrn zone aries Ia p wer 120 J CIlT}'lVIcr the 6.0 D and a St P size of 0.5 D. R£fin.0 D t 41. triploid.0 D flatter than normal with irregular ascigmao sru pres n t.

Optical design of intraocular lenses. The simulated varies 6 to 24 degrees from the refractive with 15 quantitative tional information istic changes objective parameters. Shah SI. is not an accurate predicwithin the tion of the actual flat and steep meridians surgery that are helpful in diagnosis..] Cataract Refract Surg 1996. Hersh PS. MARCH 1997 221 . and optical quality along Approach. and correlating toms.I ! IS CT USING THE HDS 12 degrees different from the Tot Astig. 27:S421-S428 5. Atchison DA. 3rd ed. CV Mosby. a Clinical (LTK). Waring GO Ill. This addi- the presence keratometry provides the clinician with characterdisease and keratorefractive monitoring procedures prowe these prowith a patient's information visual sympto explain the in corneal power axes but is very close to the refractive powers. 66:492-506 4. The relationship of visual acuity. Holladay]T. Geiger 0. I have tried to demonstrate the clinical usefulness of analyzing the cornea for true refractive power. .2 mm pupil ring used by the keratometer entire central 3. region is too flat for the central because the paracentral uniform (20/40). Hersh PS. Lynn M]. Corneal asphericiry following excimer laser photorefracrive keratectomy.0 mm zone. confirming of irregular astigmatism. 22:197-204 ~ I J CATARACT REFRACT SURG-VOL 23. et al.0 References l. and pupil size after radial keratotomy. The Asph (Q) indicates the central 3. refractive error. This asphebe expected following holmium laser cedures to optimize visual performance. The CU Index and PC Acuity indicate a noncentral 3. Michaels DO. 1985 2. Summary In the five clinical examples. Onaxis performance. MO. The difference in the axes is large because the 3. Holladay]T. Arch Ophrhalmol 1991. Visual Optics and Refraction. Corneal optical irregularity after excimer laser phororefractive keratectomy.0 mm pupil zones.0 mm zone of the cormore than a spherical ball. similar to a hyperopic LTK. Ophthalmic Surg Lasers 1996.0 and 6. Holladay]T. Optom Vis Sci 1989. power. 109: 70-76 3. I. St Louis.0 mm zone with fair optical quality The halos and ghosting of headlights at night between the are due to the significant optical distortion 3. To improve optical consequences must have this additional optical consequences our keratorefractive of our surgery. shape. Shah sr. gression. Recognizing will improve keratorefractive r The pupil is almost concentric nea is flattening ricity would thermokeratoplasty with the map.

5 dinprers (D).0 mm and the large white circle: rnrn. erive p wer are made.• j f [Ii pupil is tear-shaped because of peaked pupil.' If the cornea were cornpletelyspherical.0 mm. This is why single lenses char require a dear image rue aspheric such as [he indirect ophthalmoscopic viewing lens. ecuof6. 10 the past. and a .CT USING TilE! ID. This characteristic: of <1 pherieal surface grsdually increasing toward th peri phery i known as rpbtfl'it'tll lIbemtti{m. 45.0 rnrn. within this LO mm region are almost perpendicular to I rnrn the error is approximatel).i rant objec since the rays. 50.84 D. like a steel ealibratien ball. 10 de ermine the actual refractive power IH any polnr 011 the cornea. I the radius were 7.6 D.0 rnm pupil perimeters are presenr on every map because th y help explain visual changes [hat may be a funC[lOn of pupil size. The "true" refractive power map ora pheriea] surfac should not b a single c lor over [he whole surface but hould shaw a gradual increase in powcr toward rhe periphery. power maps have no used true refractive power but have instead used "surface normal power.40 D. The numbers around the large white circle are the axes of the semirneridian r. 1 pherical Calibmtion Ball nn 11(1 an.7 rom at all points (ave ge human central corneal radius). igniRc. The 3. the refractive power vould be 43. Beyond 1.0 and 6. one must apply Snell's law of refmerion. this approximation is true for d. fI r very mall pupils «1.68 0. the radlu of curvature would be the same atevery point. bur [2. 47.0 mm along rh in the "rrne" mea. bur the refractive power increases reward me periphery f the cornea.83 D ( the center.0 nun from the cent r the p wer would be 4. l.0 mm incremears. at 4. all three white perimeter: will be tearshaped. The black l·eFereuce grid is in 1. ne sh 0 uJd alwaya ask for a lUap of a sph erical calibration ball 2JI} . The th 5.0 mm. 6. cornea.tnt AI.0 errors refr. 3. at 3. vel ge diarnrusl shap arrh white perimeters i identical ro the shape of lihe patient's actual detected pupil ar rhe time of rhe photograph.e.0 mm diameter)." urface normal power gives the power at ny point on me cornea assuming every ray 1 perpendicular to the crnea. Power Maps The "true" refractive power of the cornea ar any point must be relative to the fovea along rh visual axis.

50 to also aspheric and has a higher index of refraction in the center than at the periphery. It compares the shape of the patient's nea to the "normal" pheric cornea has an asphericity move toward the periphery. 37. commonly myopia. RefractiveMap-Auto Scale Distortion Map The distortion using traditional from blue (20/16) place. This occurs because the shadows seen in the retinoscopic reflex. MARCH . little remaining cal aberration spherical aberration. are due to irregular neutralized with and that cannot be completely upper left of the HDS.0 mm ftom the therefore change by center of the cornea and should three colors toward the red along any semimeridian. The correction is in the optical distortion in Snellen 211 map assumes the best spherocylindric REFRACT SURG-VOL 23.95 D at 5. This map is especially helpful in diagnosing corneal diseases in which the cornea changes its overall shape.00. HDS 1 is a 42.. The normal cornea in power by approximately above. At 5. The normal calibration ball. the radius of curvature is approximately (Asph [QJ) of -0.00 D. steepest.5 D. The exact value for green and the step size are shown in the key at the top of the map. the difference is plus and is toward the red. man corneal radius of curvature toward the periphery.0 D Green.26. If the cornea is flatter than the normal aspheric cornea. The step size can be 0. myopia rarely + 3. Significant spherireferred to as "night experi- will result in a myopic shift in the refrac10% of the population the induced tion as the pupil dilates. Green is 20/20.5 D by 5.12 D. The difference at every point is then plotted in diopters on the map. The remaining of the eye is corrected by the crystalline lens.CT USING THE HDS to determine the accuracy of the instrument of approximately and to ver- 0.0 mm from the center. or 2. such as with keratoconus." Approximately ences night myopia because of residual spherical aberrarion.0 mm from the center. and an Asph (Q) of -0. appearance Green indicates there is no difference between cornea and the normal cornea. to The distortion is mapped Snellen lines of visual acuity ranging red (20/200). The range is the same as that in a standard manual keratometer: increments. cornea is not spherical but asThe normal huflattens progressively The normal human pherical to reduce spherical aberration. spherical aberration will appear the same on the profile difference map. Because this scale is always the same. At any point.50 D and the range is from -3. ifY that the map demonstrates power toward the periphery a progressive increase in 6.25. whichever value best displays the data.0 mm from the center of the normal cornea. a quick glance reveals whether the central cornea is very steep (toward red) or very flat (toward blue).26. referred which means that it becomes flatter than a sphere as we This is sometimes to as a "prolate" surface since the central curvature is the I corne al power the theoretical refractive The actual refractive 7% flatter than at the center. actual corasaspheric cornea. central corneal power of the human eye.0 to 51.0 0 in 1.0 D and is the average. J CATARACT map shows the optical quality of the 5 corneal surface at every point." In these individuals. then grades 1997 The auto scale refractive power map is in the upper right of the HDS.50.' 34U' smg t h e panent s centra . and pellucid marginal degeneration. power at every point is calculated. one-half the powers mentioned the center to 46. This map displays the same data as the standard scale but chooses the range of powers and step size to use the 15 colors for the best visual display.51 D spherical Profile Difference Map The profile difference map is in the lower left of the HDS. resulting in about one-half the spherical aberration would therefore of a sphere. 1.50 D.83 0 at spherical aberration increase . such as scissoring. astigmatism inoscope a spherocylindric refraction. such as with keratoconus. The normal cornea will increase by approximately Patterns seen with the retradial astigmatism. the central color. 3. exceeds 0. which is The normal eye has very power of the cornea at every point is then compared with the ideal aspheric cornea. from 43. keratoglobus. The scale is always in step sizes of 0. the difference is negative and is toward the blue.0 D at 5. of the red reflex with the retinoscope when or the the patient's The profile difference map correlates well with the direct ophthalmoscope held at approximately RefractiveMap-Standard The standard Scale scale refractive power map is in the 66 cm (26 inches) from the eye along the visual axis. is always 44. an increase of 3. if the cornea is steeper than the normal aspheric cornea.

0 mm pupil perimeter. This explains why studies trying to correlate the refractive change with the keratometric change following RK are poor. The greater the differences in the refractive power measurements in column 1 and the simulated keratometry in column 2. In short.0 mm Pupil There are four columns of corneal parameters at the bottom of the HDS. In a normal cornea.0 mm pupil perimeter. These two meridians are not necessarily 90 degrees apart. the keratometer Serial maps at different several days can document fluctuation in vision.0 mm power of the cornea within pupil zone.0 mm or less). This occurrence lenses. these two meridians are forced to be 90 degrees apart. Thisvalue roequivalent known as the sphethe 3. The Avg Sim K is the average of the Steep and Flat Sim K's. Optical quality of the corneal surface and. This map correlates visual performance cal irregularities membrane dystrophy. taking into account the Stiles-Crawford effect.0 mm pupil zone. oblique irregular astigmatism is present. Do not input the Steep RP and the Flat RP for IOL calculations spheroequivalent because this would not the simply give the average of the two meridians. not just the values along the 3. 3. The standard keratometer measures two points (50 /Lm areas). except when the pupil is dilated. documenting map usually shows many areas of optical the reason for poor vision.0 mm pupil zone. This value should be used for the power of the cornea in IOL calculations procedures. such as with IOL calculations four points to determine the flattest and steepest meridians of the cornea. those that have had penetrating refractive procedures. to determine the power of the cornea in that meridian. not the entire zone. These values are helpful when quantitative procedures. Column 2: Simulated Keratometry Measurements The simulated keratometry measurements are primarily for historical reference and comparison with the standard manual keratometer. in anterior the refractive power maps and the normal. The flat refractive power (Flat RP) is the weakest refractive power in any single meridian of the cornea. For programs profile difference map may be completely the distortion irregularity. parameters are necessary to describe the corand keratorefractive A description of each of these parameters nea. In irregular corneas. The flat simulated K-reading (Flat Sim K) is the flattest meridian of the cornea using only the points along the 3. Corneal Parameters for 3.0 mm perimeter. This is especially true of RK corneas with small optical zones (3. such as those with keratoconus keratoplasty or point. four sample points are usually enough to yield accurate values of the central corneal power. the greater the degree of irregular astigmatism and the greater the need to use the refractive power measurements (Eff RP) for any quantitative calculations. The instrument procedure is then rotated 90 degrees and the measures repeated.CT USING THE HDS equivalents and plots the appropriate color at every and opti- ular astigmatism. Delta K is the difference between the Steep Sim K and the Flat Sim K given in diopters at the axis of the Steep Sim K. Column 1: Refractive Power Measurements The steep refractive power (Steep RP) is the strongest refractive power in any single meridian by the axis of the meridian. consequently. The refractive power is given in diopters followed The system uses all points within the 3.CT SURG-VOL .0 mm pupil zone to find the meridian with the strongest refractive power. the four samples are usually not sufficient to provide an accurate estimate of the central corneal refractive power. For example. power of the entire cornea within the of the cornea outside the 3. The effective refractive power (Eff RP) is the surface within 3. times during the day or over in optical the the fluctuation distortions that require two K-readings. input the Eff RP twice. but The most common example today is in patients who have had radial keratotomy have now developed a cataract.0 mm pupil zone should have little effect on visual performance. The 23.2 mm apart. of the cornea. MARCH 1997 and their usefulness to the clinician is given. at the the cannot be fully corrected with spherocylindric RP is defined The difference between the Steep RP and the Flat as the total astigmatism given in plus cylinder and therefore refractive power of the corneal is commonly referenced Steep RP. of the cornea. If they are not. As with the standard keratometer. The steep simulated K-reading (Steep Sim K) is the steepest meridian of the cornea using only the points along the 3. or kerato(RK) and simply in the cornea. 212 as well as keratorefractive It is especially helpful in corneas with irregJ CATARACT REFRA. approximately 3. the four points measured by the standard keratometer are at a transition zone of the cornea that requires many more than four points to describe the changes in refractive power accurately.

have a "negative" asphericity constant (Q < 0) and are "prolate" surfaces.0 mm from the center.2 mm diameter).2 mm out (temporal) from the center of the map. ues is therefore asngmansm. the same shape as the original pupil. such as corneas that have had RK. and laser in situ keratomileusis con(LASIK) for myopia. (0.2 mm diam- Regular astigmatism axis of astigmatism spherocylindric The program diameter that (Reg Astig) is the amount can be neutralized and a with correction.0 mm diameter and a large white perimeter with an area equal to that of a circle with a 6. The disparity in the two valof the degree of irregular a measure If no pupil is detected by the system.00 and if the patient's nitude of the asphericity would exceed -0. The normal value for Asph (Q) is -0. not eter) is shown. Although the Eff RP should always give a more reliable value for the corneal power than the Avg Slm K. The asphericity for a sphere would be 0. like the "normal" human cornea.26. the nominal medium is also the at the time of the and always be less than or equal to the Tot Astig.0 mm. then the magcompletely of the pupil to the center of the map (black The horizontal pupil decendistance in mil- mark) is then determined. This cylinder and axis are very helpful in refracting patients with irregular corneas. The Reg Astig often provides and sometimes particularly with time-consuming in patients in is ambiguous.0 mm diameter. The nominal diameter value in the human eye is almost zero." indicating previously. ample. a small (3. Aspheric surfaces that flatten toward the periphery. Column 3: Pupil Parameters and Regular Astigmatism The system detects the perimeter of the pupil at the time of the photograph. finds the best fit power and axis of the for a 3. tration (H Pupil Dec) is the horizontal pupil. and Table 1 shows typical values for various corneal abnormalities. and spherical curvatures. The exact shape of these larger perimeters same as the original pupil perimeter photograph. then calculates the centroid of the pupil. This value is commonly angle Kappa and is nominally referred to clinically as approximately 0. Aspheric surfaces that steepen toward the periphery. the pupil diameter is usually less of the distortion REFRACT SURG-VOL 23. the discrepancy indicates that one should expect a higher degree of variability in the results of an IOL calculation than with a normal cornea. The average pupil diameter Since the photograph than 3.2 mm (V from of spherical aberration from the cornea. A vety small white perimeter (0.50 almost eliminates any contribution cornea For exflattens more than the normal asphericity. J CATARACT stant (Q> 0) and are "oblate" surfaces.0 mm diameter) are shown and centered at decentration occurs. where "up" (superior) means the pupil is up with respect to the center of the map and "down" (inferior) means the pupil is down with respect to the center of the map.26. an asphericiry of -0. human about 7% in its radius of curvature compared to a sphere at a distance of5.0 mm pupil zone for the value. "No pupil" will be reported when this situation When centroid a pupil is detected.0 mm diameter). the relationship of the of 0. A pupil of 4. tions without dilation. Figure 1 shows prolate.0 mm a good crossedeliminates cylinder that best corrects the irregularity starting point for refraction the need for refinements whom the endpoint Tot Astig cylinder refraction techniques.4 The Asph (Q) is the only corneal parameter that uses an area other than the 3. most investigators use the Asph (Q) in the conic equation that the normal to describe the corneal cornea flattens by large circle (6. The corneal uniformity sure of the uniformity index (CU Index) is a meaof the corneal 213 of the pupil at the time of the photograph. Column 4: Miscellaneous Measurements As mentioned asphericiry. where "out" (temporal) limeters from the center of the map to the centroid of the means the pupil is out with respect to the center of the map and "in" (nasal) means the pupil is in with respect to the center of the map. The vertical pupil decentration Pupil Dec) is the vertical distance in millimeters the center of the map to the centroid of the pupil.CT USING THE HDS discrepancy between the Eff RP and the Avg Sim K is another measure of the degree of irregular astigmatism. have a "positive" asphericity out in the human eye. (Avg Pupil Dia) is the average is taken under bright light condi- oblate. MARCH 1997 . A medium white perimeter is shown with an area equal to that of a circle with a 3. pupil. at the centroid of the pupil. because the includes just regular astigmatism. irregular The Reg Astig will astigmatism.5 mm is used to calculate theAsph (Q). photorefractive keratectomy (PRK) .

0 mm zone.25 0. The HDS is used to analyze the following clinical examples. Normal values usually exceed 80%. surface within the 3. If the PC Acuity were 20/60. 25 PRK corneas. and of 90% was within ± 3 lines of the actual BCVA. The CU Index is therefore useful in the differential diagnosis of corneal pathology where generalized or localized characteristic patterns are present. Asphericity (a) Corneal Condition Severe keratoconus Mild keratoconus Normal Spherical 8 cut RK 16 cut RK E"iptical Figure 1.00 -1. 214 J CATARACT REFRACT SURG-VOL 23. MARCH 1997 . and of95% was within ±31ines. They found that the actual BCVA of70% of the patients was within ± 1 line of the PC Acuity. removal of the cataract would not be expected to significantly improve the vision. and 50 corneal transplant corneas).00 (Holladay) Types of corneal asphericity. In contrast. For example. the cornea is clearly not reducing the vision significantly and cataract extraction is indicated and expected to improve the vision. Typical asphericity values for various corneal conditions.CT USING THE HDS Oblate Q Q=O Table 1.0 mm zone on the distortion map. such as the Stiles-Crawford effect. of 75% was within ±2 lines.0 mm pupil. The predicted corneal acuity (PC Acuity) provides a single value in units of Snellen acuity of the optical quality of the corneal surface within the 3. A CU Index of 0% indicates that the optical quality of the cornea is very nonuniform over the 3. The PC Acuity can be very helpful in differentiating corneal from lenticular disease.00 +2. a patient with diffuse microcystic edema from elevated intraocular pressure would be expected to have reduced vision from uniform poor optical quality of the cornea.00 +1. This does not indicate that the cornea has good optical quality. ranging from 20/10 to 20/200. A CU Index of 100% indicates that the optical quality of the cornea is almost perfectly uniform over the 3. however. of 90% was within ± 2 lines. The PC Acuity estimates the predicted acuiry if the cornea is the limiting factor in the visual system. simply that it is uniform. it is often difficult ro determine whether the cornea or the cataract is the major factor in the reduced vision.00 -0. Holladay found the PC Acuity of 48% of patients was within ± 1 line. Together. in a patient with a best corrected visual acuity (BCVA) of 20/60 who has anterior membrane dystrophy and a nuclear sclerotic cataract. visual estimation is only approximate. Hersh and coauthors? compared the actual BCVA of 167 PRK patients with the PC Acuity calculated from the topographic map taken at the same visit. These values should correlate visually with the appearance of the central 3. a person with localized areas of bullous keratopathy would be expected to have reduced vision from nonuniform poor optical quality of the cornea. Using the original data base of 100 patients (25 normal corneas. it could be uniformly bad or good.0 mm pupil. but since the program takes into account other parameters.0 mm pupil expressed as a percentage. For example. the CU Index and the PC Acuity help to characterize corneal abnormalities and monitor change over time. If the PC Acuity is 20/25. Spherical -2.

15 X ·0 with Ilvisullloculryof20/60. Note a 7. The area n t!hecone is v ry distorted: die entire area appears red. resulting in POOT overall pdcal quality. The diseorted areas OD ilie superior cornea are a result f rhe powe. lndkadng the presence of irregular astigmatism 0 oblique axes.r being almo r ( . corneal scars. not mar . Distortion A-fap: The distortion map rna at firsr seem some'. in diCllting:l s ign i.Map--Sr471tiDrd 'cale: The (nap is very irregular.\CT REJlRAI. He has nev r worn om r len be c o.HDS2 Kerareconus ornea he pauenr is a 26-year-old rnan wid) progressive de re e LnBCVA in hls lefr 'ye with pectacles ver the past 8 years.5 mm corneal aephine would completely encompass the cone.0 mm is In focus. again. His curren t spectacle prescription is -8.. The peak of the cone can be more accurately locate I on the new scale between the 3.0 mill pupil zone ar 5 o'clock. distortions range From 2 '16 ro 201100.0 rnrn pupil zone (blue [0 red).0 mm upil zone. he" iea" a dark blue in [he oilier three quadrants indicates char ches regions are far to 8 t For nomina! central corneal refractive pow r of 50.f1call t derrimeeral eE'fecIon vision.00 l better udlize the l 5 01 rs. This finding is not unusual fau keraro onus.p: This map delineates the cone most m::cu:rnrel und I1S previously mentioned appear very imilar to the red reflex seen with retinoscopy near neutralizati n. The exact peak f rhe cone can easily 90 degrees. rs jot 3.. rhe program has chosen the green color (0 be 8.. MARCH 1~~7 .0 and 6. with an extremely greep acea that exceeds 5 J .0 mm Pupt]: N rice mar che steep and Jl-lr meridians are 101 degrees apart.0 D. Remember that the program will tI)' to find rlk besrspherccylindrlcal orrection for the 3. h t surprising becausethere arc rnnny areas of distortion in addition [0 uhe area of [he cone. and [her meal P<tho logy J CAl'A1t. Corneal Paramet.00 D to clle lower rizht quadrant (lnferoternp rally).25 + . 1 1 (I'fRP). Profilt' Diffirm r MfI. Ro/fJctil)~ .Q D o Lit OfFOCLLS when rhe centra! . R41'IJC't7Vt Map-Amo SCfJli!: On rhe auro scale map. Th fa i a signi 1cantvariatioJ1 ill re ractive power-within (be 3.r this localized steep SIal bawd affecr the vision.':TSURG-VOL2). Th more sensitive scale con inns the significant varinrion in refracrive p wer within th . Thi area would bc9. indicating tl. \ h il me step ize remains at 1.(j 0 1 wer tho n die central area. Widrin eh i 'Zone.U rom pupil 'Zone.

the erial h-amt:. depending c rues. he CU ludex revealsa nouu nlfonn cornea and the P Amiry correlates wdl with the parienr's actual acuity indicate II. Oil tion or dll~ umet" is not at [he axis 1'11C r the steepest ehe exact characreri tics n r we (Steep RP) but 8 degrees :l\.-readjng were much eep r rhan normal. and G.0 rom zone thai can account for the p or visi entral 11.0" in.0 rnrn prlcal 'Lone R.CI USIN'G THE HIlS 't'h I creares a. irregular s nd the best pher lcylintil'ic COl1ICC- n nUllif rmly distorred licares there i. isual acuity was om: ted e 20/20 wirh a correccion of -2. 01 0 in this z ne.@ 4. The Reg Ast. This di. 9.0.s patient.750 @95°with 1I preoperaeive refra ri on of . The ftP is 6. 5Q we know there is very lird lenticular asdgmarlsm. rren much too rapidly in the periphery.\raJ :l( 40 degrees.)Jld then performing a spherical r fJ crion is much 'impler than de. it was nored that the preoperative K. 3. m pr. ed cylinders and i less ftustntring t uhe patient. nearest available cylinder of" + . difFerem axis. so d:1e defaulr 02. 1l).r. 1 day a ter an eight incision.ear-old w man.00 X 98. ye. large degree of rhe patient' myopia is pr bably due to excess corneal power and nor 00 increased axial length of the eye.ffi'ren 3srigm •.i rneter circles are-shewn.O rnrn d. since the endp inc are never clear. due to !lhe limitari n f our samples along tilt: . The simulated keratorn try is up tI'I LO dLffercm rom the refrac:d e p Wet measurements... within rhe .50 +4. There was '110 pHp11 dececred in rhi paden r.. The Reg Astig is ve. sent . relative to the cenrral meridian Placi. ling ith cr .y los to tilt! actual refraction.25 D. 1r was derermined retrospec- .. he Asph ( indicates that rh e mea fl. but in other patients the dlfference can [ e much grearer.50 sphere. Alchuugh corneal topogra2]u phy W"dS nor done preoperativel .K in the lef.25 D @~" X 9. n1tSe parameter severe..0 mm pupil p tiro '[cr. 3.mdin i usyrn m try f rh e mea. Radla1Kcratoromy HD Cornea The patieun is <126.ig is less than [he TOl Asdg and is IU 3 or .0 0 tC'pCI' han normal. In thi. the error in tandard keraromecry is relatively small.

The simulated keratometry measurements were from 4 to 8 degrees off in the axes but very close to the refractive power values. She had noticed some glare or "ghosting" around headlights at night but said that it did not cause much of a problem.0 D of symmetrical with-the-rule astigmatism. However.CT USING THE HDS tively that the patient may have had a forme fruste keratoconus that was undetected and resulted in an abnormal response to RK and. due to elongation at 4 o'clock. the vertical meridian is much steeper than normal. This patient's cornea is less than perfect. The eight radial yellow distortions that are seen correspond to the eight RK incisions.0 mm zone is of good optical quality with very little distortion. Notice the values are not 100% and 20/10 like the perfect steel ball in HDS 1.50 D. compared with the preoperative K's. Reftactive Map-Standard Scale: The central zone is uniformly light blue. Reftactive Map-Auto Scale: The auto scale increases the green to 46. by four colors.0 mm diameter are progressively steeper than normal.0 mm zone. Refractive Map-Standard Scale: This map reveals over 4. which corresponds to the change in the spheroequivalent of the refraction. The irregular contour of the green area indicates that the cornea is not a normal shape. Distortion Map: The central 3. 0 mm Pupil· The Eff RP is much steeper than the average corneal power following RK (37. the standard keratometry can be quite variable and differ by several diopters. but the cornea is still able to achieve 20/20 acuity. indicating that the astigmatism is all corneal.25 +0. The Reg Astig is very close to the magnitude and axis of the postoperative refractive cylinder.50 D and reduces the step size to 0. however.5 mm. with almost no astigmatism present.0 mm pupil zones correspond to the edge of the ablated optical zone that is 4. Corneal Parametersfor 3. She is correctable to 20/16 with a -0. consequently. These distortions are dramatically enhanced because it is only 1 day after the surgery. On this scale we see that there is a "sea" of light blue that is J CATARACT HDS4 horizontally oval and not concentric with the pupil. the EFF RP is approximately 4. The center is always chosen as the reference because this area is most important to vision.75 X 100. Profile Di/firence Map: The central green area is also oval. be the limiting factor in the visual acuity. the cornea steepens more rapidly than the normal cornea. The central green area is not concentric with the pupiL The cornea progressively increases in power peripherally. The CU Index and the PC Acuity indicate that the central 3.5 mm optical zone in her right eye 6 months earlier. Refractive Map-Auto Scale: The auto scale has chosen green as 42. In these cases.0 mm pupil zone is mostly blue with a few areas of green.0 and 6. Exdmer PRK Cornea The patient is a 24-year-old woman who had an excimer laser PRK with a 4. This optical zone is not concentric with respect to the pupil. 23.0 mm or smaller pupil should be very good. since the incisions have not been fully epithelialized and the tear fum is highly variable. The Asph (Q) indicates that within the 3. This is to be expected in keratorefractive procedures for myopia. a large degree of induced astigmatism.0 D flatter than normal.0 mm pupil zone is very good with a few areas of green.0 D). Remember that it is only 1 day after the surgery and there is probably some corneal edema still present. MARCH 1997 REFRACT SURG-VOL 217 .50 D and a step size of 0. but slightly displaced to the right (nasally).0 D less. indicating the peripheral cornea is much steeper than average for the central power. indicating the central cornea is 3. There could be a great deal of variation if serial photographs were taken.0 to 40. indicating that the patient's vision with a 3. since the optical zone becomes flatter with respect to the periphery. Profile Di/firence Map: The curvatures in all directions outside most of the central 2. Distortion Map: The central 3. It may. demonstrating that this cornea is steeper in the periphery than normal for this central power.50 D revealing a mild asymmetry in the bow tie. The arcs of yellow between the 3.

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