Jpn J Ophthalmol (2014) 58:483–489
DOI 10.1007/s10384-014-0344-2
CLINICAL INVESTIGATION
Corneal biomechanical properties in 3 corneal transplantation
techniques with a dynamic Scheimpflug analyzer
Naoyuki Maeda • Ryotaro Ueki • Mutsumi Fuchihata
Hisataka Fujimoto • Shizuka Koh • Kohji Nishida
Received: 24 February 2014 / Accepted: 17 July 2014 / Published online: 5 September 2014
Ó Japanese Ophthalmological Society 2014
Abstract
Purpose To compare the corneal biomechanical proper-
ties of eyes that have undergone penetrating keratoplasty
(PK), deep anterior lamellar keratoplasty (DALK), and
Descemet stripping automated endothelial keratoplasty
(DSAEK).
Methods This case–control study comprised 20 post-PK
eyes, 14 post-DALK eyes, 15 post-DSAEK eyes, and 50
normal control eyes. A dynamic Scheimpflug analyzer (the
Corvis ST) was used to evaluate the corneal biomechanical
properties including deformation amplitude (DA) and
radius at the highest concavity (Rhc).
Results In post-PK eyes, the mean DA was
1.20 ± 0.13 mm, which was significantly higher than those
of the control eyes (1.07 ± 0.09) and the post-DSAEK
eyes (1.08 ± 0.12). The DA (1.18 ± 0.18) in the post-
DALK eyes was significantly higher than in the control
eyes. The Rhc in the post-PK (6.34 ± 0.37 mm), -DALK
(6.04 ± 1.22), and -DSAEK (6.44 ± 0.58) eyes was sig-
nificantly smaller than in the control eyes (7.57 ± 0.78).
Electronic supplementary material The online version of this
article (doi:10.1007/s10384-014-0344-2) contains supplementary
material, which is available to authorized users.
N. Maeda (&)
M. Fuchihata
H. Fujimoto
S. Koh

K. Nishida
Department of Ophthalmology, Osaka University Graduate
School of Medicine, Room E7, 2-2 Yamadaoka, Suita,
Osaka 565-0871, Japan
e-mail: nmaeda@ophthal.med.osaka-u.ac.jp
R. Ueki
Department of Ophthalmology and Visual Sciences, Graduate
School of Biomedical Sciences, Nagasaki University, Nagasaki,
Japan
•
Conclusions The dynamic Scheimpflug analyzer provides
a method to obtain new biomechanical information on the
cornea such as the DA and Rhc, and these parameters dif-
fered among eyes that had undergone 3 different types of
corneal surgery. Abnormalities in these parameters after
the different corneal transplantation techniques may indi-
cate larger deviations in the stress–strain reaction of the
cornea and more uncertainty in the intraocular pressure
measurements than in normal eyes.
Keywords Corneal biomechanics
Corneal integrity

Keratoplasty
Scheimpflug image
Introduction
Penetrating keratoplasty (PK) has been the predominant
technique used for corneal transplantation for many years.
However, recent developments in selective lamellar kera-
toplasty including deep anterior lamellar keratoplasty
(DALK) [1–3], Descemet stripping automated endothelial
keratoplasty (DSAEK) [4–7], and Descemet membrane
endothelial keratoplasty (DMEK) [8, 9] have markedly
altered the indications for PK. DSAEK and DMEK have
been used for cases with corneal endothelial dysfunction
but an intact stroma and anterior shape. Such endothelial
keratoplasty can reduce postoperative corneal regular and
irregular astigmatism [10, 11]. DALK is used in patients
with a healthy endothelium and eliminates the risk of
endothelial rejection. These selective lamellar keratopla-
sties also have advantages over PK, i.e., reduced risks of
wound dehiscence and globe rupture due to trauma [12,
13].
To evaluate the integrity of the cornea following kera-
toplasty, the biomechanical properties of the cornea must
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be quantified. Because the ocular response analyzer (ORA;
Reichert Technologies, Buffalo, NY, USA) enables in situ
determination of the biomechanical properties of the cor-
nea [14], various studies have examined the effects on the
corneal biomechanics of diseases such as keratoconus and
of surgical procedures such as LASIK and corneal cross-
linking [15–17].
Several studies have also determined the corneal bio-
mechanics by measuring the degree of corneal hysteresis
and the corneal resistance factor following keratoplasty
[18–21]. Recovery of corneal hysteresis and the corneal
resistant factor in patients with keratoconus after PK has
been reported [18]. The results of earlier studies comparing
selective lamellar keratoplasty with PK were inconclusive:
1 study reported comparable corneal hysteresis after PK
and DALK [19], while 2 other studies showed more
favorable results on corneal hysteresis after DALK than
after PK [20, 21].
A new dynamic Scheimpflug analyzer (the Corvis ST;
Oculus Optikgeräte, Wetzlar, Germany) has become
available for clinical use [22–26]. Because dynamic
deformation of the cornea by a constant pressure air pulse
is recorded through this ultra-high-speed Scheimpflug
camera, not only the intraocular pressure (IOP) and corneal
thickness but also several parameters associated with the
corneal biomechanics can be obtained.
The purpose of this study was to determine the biome-
chanical properties of the cornea after DSAEK, DALK, and
PK. The dynamic Scheimpflug analyzer was used to obtain
the biomechanical characteristics of the corneas after each
of these 3 keratoplasties, and the findings were compared
with those of normal eyes.
Patients and methods
Patients
The study comprised 20 eyes of 20 patients who had
undergone PK (mean age 62.3 ± 12.4 years; men/women
11/9), 14 eyes of 14 patients who had undergone DALK
(mean age 63.5 ± 15.6 years; men/women 6/8), and 15
eyes of 15 patients who had undergone DSAEK (mean age
71.3 ± 7.5 years; men/women 5/10) at Osaka University
Hospital. Patients included were those who had no clini-
cally relevant postoperative corneal edema and who had
reliable Corvis ST measurements. All of the patients were
followed for at least 3 months. Fifty normal eyes of 50
individuals with no ocular pathologies other than refractive
errors served as controls (mean age 62.7 ± 13.7 years;
men/women 16/34). The institutional review board of
Osaka University Hospital approved this study. The
research followed the tenets of the Declaration of Helsinki.
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N. Maeda et al.
Surgical technique
The PK procedure was performed in a conventional way;
the donor and host trephination sizes were 7.5 and 7.0 mm
or 8.0 and 7.5 mm in all cases, and the donor graft was
sutured with combined 10-0 nylon. The DALK procedure
was performed as described by Sugita and Kondo [2]. The
donor corneas were punched out with a diameter 0.25 mm
larger than the recipient bed of 7.5 or 8.0 mm, and the
donor cornea was sutured with combined 10-0 nylon
sutures. The DSAEK procedure included stripping the
Descemet membrane and endothelium from the recipient’s
central cornea and transplanting a 7.75- or 8.0-mm disc of
donor endothelium and posterior stroma that were dis-
sected with a microkeratome and inserted using the pull-
through technique.
During the follow-up period, after PK and DALK, only
loose sutures were removed, and after DALK, all of the
sutures in 8 eyes were removed.
Measurements
The Corvis ST can record 140 Scheimpflug images for
31 ms with a speed of 4,330 frames/s. It can then calculate
the IOP and corneal biomechanical parameters on the basis
of the dynamic deformation of the cornea while the air
pulse is being applied to it. The high-speed Scheimpflug
camera takes images of the horizontal section of the cornea
and anterior chamber up to 8.5 mm in diameter with a
resolution of 640 9 480 pixels.
Measurements were continued until 2 reproducible
results were obtained for each eye. The results of the
measurements of the better image for automated digitiza-
tion in the anterior and posterior corneal surfaces were
selected.
The parameters collected from the dynamic Scheimpflug
images were time (Thc; in ms) at the highest concavity,
peak distance (PDhc; in mm) at the highest concavity,
radius (Rhc; in mm) at the highest concavity, deformation
amplitude (DA; in mm) at the highest concavity, time (Ti;
in ms) at the inward applanation, length (Li; in mm) at the
inward applanation, velocity (Vi; in m/s) at the inward
applanation, time (To; in ms) at the outward applanation,
length (Lo; in mm) at the outward applanation, and velocity
(Vo; in m/s) at the outward applanation. The IOP (mmHg)
and central corneal thickness (CCT; in lm) were also
recorded.
Statistical analyses
Data were analyzed using JMP version 9 software (SAS,
Cary, NC, USA). One-way analysis of variance (ANOVA)
and the Tukey–Kramer test were used to compare the
Biomechanics after keratoplasty 485

Fig. 1 Representative displays of the dynamic Scheimpflug analyzer
in a normal eye (left) and in an eye following penetrating keratoplasty
(right). The Scheimpflug image at the highest concavity is shown in
addition to the IOP, pachymetry, and 10 biomechanical parameters
and graphs for deformation amplitude (DA), applanation length, and
corneal velocity. Note the DA in PK eyes (1.47 mm) is deeper than in
normal eyes (1.06 mm) and that the radius at the highest concavity
(Rhc) in the PK eyes (4.55 mm) is steeper than in normal eyes
(6.62 mm)

Table 1 Output of dynamic Scheimpflug analyzer in normal eyes and eyes that underwent one of three corneal transplantation techniques
Control DSAEK DALK PK P value

IOP 14.63 ± 1.49 15.03 ± 3.74 14.14 ± 3.16 14.28 ± 1.23 0.6678
CCT 552 ± 31*, ** 652 ± 61*, # 628 ± 63**, ##
552 ± 56#, ## \0.0001
DA 1.07 ± 0.09*, ** 1.08 ± 0.12# 1.18 ± 0.18* 1.20 ± 0.13**, #
0.0004
, , # #
Rhc 7.57 ± 0.78* ** 6.44 ± 0.58* 6.04 ± 1.22** 6.34 ± 0.37 \0.0001
Thc 17.19 ± 0.75 17.31 ± 0.67 16.93 ± 0.62 17.17 ± 0.42 0.4644
PDhc 3.62 ± 1.30 2.76 ± 1.08* 3.56 ± 1.37 4.37 ± 1.19* 0.0043
Ti 7.67 ± 0.24 7.72 ± 0.55 7.46 ± 0.47 7.60 ± 0.22 0.1456
Li 1.81 ± 0.24 1.81 ± 0.21 1.80 ± 0.24 1.80 ± 0.23 0.9968
Vi 0.16 ± 0.03 0.14 ± 0.03 0.15 ± 0.05 0.15 ± 0.03 0.3990
To 22.30 ± 0.39* 20.07 ± 0.69 21.85 ± 1.02* 22.11 ± 0.26 0.0471
Lo 1.86 ± 0.39 1.89 ± 0.11 1.93 ± 0.45 2.00 ± 0.48 0.6712
Vo -0.33 ± 0.07 -0.34 ± 0.12 -0.34 ± 0.12 -0.35 ± 0.11 0.8297
DSAEK Descemet stripping automated endothelial keratoplasty, DALK deep anterior lamellar keratoplasty, PK penetrating keratoplasty, IOP
intraocular pressure (mmHg), CCT central corneal thickness (lm), DA deformation amplitude at the highest concavity (mm), Rhc radius at the
highest concavity (mm), Thc time at the highest concavity (ms), PDhc peak distance at the highest concavity (mm), Ti time at the inward
applanation (ms), Li length at the inward applanation (mm), Vi velocity at the inward applanation (m/s), To time at the outward applanation (ms),
Lo length at the outward applanation (mm), Vo velocity at the outward applanation (m/s)
P value: 1-way ANOVA; *, **, #, ##
: Tukey–Kramer test, P \ 0.05

values of the different parameters obtained by the dynamic
Scheimpflug analyzer for the 4 groups of eyes. Probability
values below 0.05 were considered significant for all
analyses.
Results
Typical Scheimpflug images at the time of highest con-
cavity due to the air pulse in a normal eye and in an eye of
a patient who had undergone PK are shown in Fig. 1.
Supplemental digital videos of these eyes during the
measurements are shown in Video 1. The DA at the highest
concavity for the PK eye was 1.47 mm, which was larger
than the 1.06 mm in the normal eye. Moreover, the Rhc in
the PK eye was 4.55 mm, which was steeper than the
6.22 mm in the normal eye.
Statistical comparisons for the 4 groups of the parame-
ters obtained by the dynamic Scheimpflug analyzer are
shown in Table 1. One-way ANOVA showed significant

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Fig. 2 Scatterplot of deformation amplitude (DA) (left) and radius at
the highest concavity (Rhc) (right) as a function of age. Although
some of the DSAEK, PK, and DALK eyes are distributed inside the
differences among the 4 groups in CCT, DA, Rhc, peak
distance at the highest concavity, and time at the outward
applanation.
The CCT of the DSAEK or DALK eyes was signifi-
cantly thicker than that of the control or PK eyes.
The PK eyes had significantly larger DA than did the
control and DSAEK eyes, and the DALK eyes also had
significantly larger DA than did the control eyes. The
DSAEK, DALK, and PK eyes had shorter Rhc than did the
control eyes. The DSAEK eyes had a significantly shorter
peak distance at the highest concavity than did the PK eyes.
The DALK eyes had significantly faster time at the out-
ward applanation than did the control eyes.
The scatterplots in Fig. 2 show the relationships
between age and DA (left) and between age and Rhc (right).
Although most of the DSAEK eyes and some of the DALK
and PK eyes were located close to the distribution of the
normal eyes, all of the eyes that had DA greater than 1.29
were PK or DALK eyes. The DA in all of the normal and
the DSAEK eyes was 1.29 or less. Significant correlations
between age and DA were not found in any of the eyes:
normal eyes: P = 0.9996; DSAEK eyes: P = 0.1223;
DALK eyes: P = 0.6638; and PK eyes: P = 0.2106.
Similarly, in all of the control eyes, the Rhc was 6.2 mm
or larger. However, some of the DSAEK, DALK, and PK
eyes had a Rhc less than 6.2 mm. Significant correlations
between age and Rhc were not found in any of the eyes:
control eyes: P = 0.8587; DSAEK eyes: P = 0.6059;
DALK eyes: P = 0.9972; and PK eyes: P = 0.5341.
The scatterplots in Fig. 3 show the relationships
between IOP and DA and between IOP and Rhc. A sig-
nificant positive correlation between DA and IOP was
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N. Maeda et al.
normal zone, some of the PK and DALK eyes have higher DA and
lower Rhc values than those of the normal eyes of the same age
found in all eyes (control eyes: R2 = 0.5519, P \ 0.0001;
DSAEK eyes: R2 = 0.8437, P \ 0.0001; PK eyes:
R2 = 0.2923, P = 0.0138) except the DALK eyes
(P = 0.1644). A significant positive correlation between
IOP and Rhc was found in the control eyes (R2 = 0.1051,
P = 0.0217) and the DALK eyes (R2 = 0.3877,
P = 0.0174), but not in the DSAEK eyes (P = 0.4768) or
the PK eyes (P = 0.6801).
The scatterplots in Fig. 4 show the relationships
between CCT and DA (left) and between CCT and Rhc
(right). A significant negative correlation between CCT and
DA was found in the control eyes (R2 = 0.1080,
P = 0.0197), but not in the other eyes (DSAEK eyes:
0.9842; DALK eyes: 0.3306; and PK eyes: 0.9305). A
significant positive correlation between CCT and Rhc was
found in the control eyes (R2 = 0.2319, P = 0.0004), but
not in the other eyes (DSAEK eyes: P = 0.0720; DALK
eyes: P = 0.4008; and PK eyes: P = 0.4929).
Discussion
The in situ measurement of corneal biomechanics with the
Ocular Response Analyzer (ORA) uses 2 biomechanical
parameters: corneal hysteresis (CH) and corneal resistance
factor (CRF). These values are derived by measuring the
time of the 2 peak signals that correspond to the inward and
outward times of applanation of the cornea in response to a
variable air pulse. In contrast, the dynamic Scheimpflug
analyzer, the Corvis ST, records the dynamic deformation
of the horizontal Scheimpflug images in response to
Biomechanics after keratoplasty
Fig. 3 Scatterplot of deformation amplitude (DA) (left) or radius at
the highest concavity (Rhc) (right) as a function of IOP. A significant
positive correlation was found between DA and IOP (control eyes:
R2 = 0.5519, P \ 0.0001; DSAEK eyes: R2 = 0.8437, P \ 0.0001;
Fig. 4 Scatterplot of deformation amplitude (DA) (left) or radius at
highest concavity (Rhc) (right) as a function of central corneal
thickness. A significant correlation between central corneal thickness
pressure by a constant air pulse [22] In addition to the
inward and outward applanation times, the dynamic
deformation of the cornea in response to the air pulse is
recorded, as shown in the supplemental digital content
(Video 1). The biomechanical parameters such as the DA
at the highest concavity and the radius at the highest con-
cavity can be obtained from these images [25]. To the best
of our knowledge, this is the first study to use a dynamic
Scheimpflug analyzer to investigate the corneal biome-
chanics following corneal transplantation.
487
PK eyes: R2 = 0.2923, P = 0.0138). A significant positive correla-
tion between IOP and Rhc was found in the control eyes
(R2 = 0.1051, P = 0.0217) and the DALK eyes (R2 = 0.3877,
P = 0.0174)
(CCT) and DA (R2 = 0.1080, P = 0.0197) or between CCT and Rhc
(R2 = 0.2319, P = 0.0004) was found only in the control eyes
Under the constant strain of the air pulse, eyes with
higher ocular rigidity will show lower DA and larger Rhc.
In contrast, eyes with lower ocular rigidity will have higher
DA and smaller Rhc.
Our findings showed that the DA in the PK eyes was
significantly greater than in the control eyes and the
DSAEK eyes, and the DA in the DALK eyes was also
significantly higher than in the control eyes. No significant
difference in DA was found between the DSAEK and the
control eyes. That eyes after PK or DALK have lower
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rigidity than do normal eyes is reasonable because the
stromal wound healing at the host-graft junction and/or
pathologic peripheral host cornea is not strong enough to
keep the structural integrity of the cornea. Lower DA in
DSAEK eyes might suggest better corneal integrity than in
PK or DALK eyes.
On the other hand, the Rhc in all postkeratoplasty groups
was significantly smaller than in the control group. This
may suggest that the ocular integrity after these corneal
transplantations is not as good as that of normal eyes. The
discrepancy between DA and Rhc in DSAEK eyes should
be investigated further.
Significant difference in the peak distance at the highest
concavity between DSAEK and DALK eyes may indicate
differences among the procedures in centrifugal deforma-
tion to the same load. The time of outward applanation also
behaved differently in the DALK eyes. The shorter time of
outward applanation in DALK eyes may suggest that a
thicker cornea will return to normal shape more easily. The
relationships among the biomechanical parameters
obtained with the Corvis ST are unknown. At least, we can
say that these indices following keratoplasty show some
abnormalities. Further studies will be necessary to clarify
the significance of each parameter.
The rigidity of the eye is generally thought to be
affected by age, corneal thickness, IOP, and corneal bio-
mechanics. In this study, significant correlations were not
found between age and DA or between age and Rhc in any
of the groups. This may be due to the limited age range of
the patients studied. Significant correlations between IOP
and DA were found in normal, DSAEK, and PK eyes, and
significant differences were also found between IOP and
Rhc in normal and DALK eyes. These results suggest that
IOP should be matched when comparing the corneal bio-
mechanics among groups. A significant correlation
between the CCT and biomechanical parameters was found
only in the control group. Although higher ocular rigidity
can be expected in normal eyes with thicker corneas than in
eyes with thinner corneas, the integrity of the thicker cor-
nea after keratoplasty might not be similar to that of the
normal thicker cornea.
As shown in Figs. 2, 3, and 4, the variations in the
distribution of DA and Rhc for the postkeratoplasty groups
were more prominent than those for the control group.
Because the stress–strain relationship is the basis of IOP
measurements, careful attention should be paid during the
interpretation of measured IOPs in eyes with different
corneal biomechanical parameters. In addition, some
postkeratoplasty eyes might behave differently in corneal
refractive surgery from eyes with normal corneas owing to
these different corneal biomechanical properties.
Abnormal biomechanical parameters in postkeratoplasty
eyes may indicate the vulnerability of the host-graft wound.
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N. Maeda et al.
The relationship between the parameters obtained with
the ORA and those obtained with the Corvis ST should be
clarified in the future. Although both instruments use air
pulse pressure to induce strain, the air-pulse pressure is
variable with the ORA and constant with the Corvis ST.
The Corvis ST may have potential advantages for deter-
mining the stress–strain relationship of the eye. In addition,
the stress is evaluated by different principles, i.e., corneal
light reflex and Scheimpflug images. Therefore, it might be
difficult to develop interchangeable parameters for both
instruments.
This study has some limitations. The numbers of par-
ticipants was small, and there were many variables among
the participants and procedures. The mean age of the
DSAEK eye group was significantly higher than those of
the other groups. Such variations might lead to a scattering
of data. However, this preliminary study with a dynamic
Scheimpflug analyzer showed that differences in corneal
biomechanical properties exist between eyes with normal
corneas and eyes after corneal transplantation, or among
eyes that have undergone different types of corneal
transplantation.
Future studies will be necessary to clarify the effects of
keratoplasty on the integrity of the eye and to evaluate the
accuracy of IOP measurements in such eyes with different
corneal biomechanics. As shown in the video images, only
limited data are currently available for the dynamic Sche-
impflug analyzer. In other words, this technology may have
the potential to elucidate the detailed biomechanical
behavior of the eye in future investigations.
Acknowledgments Publication of this article was supported in part
by a Grant-in-Aid for Scientific Research (no. 24592669; to Naoyuki
Maeda) from the Japanese Ministry of Education, Culture, Sports,
Science and Technology. The authors would like to thank Duco
Hamasaki, PhD, for the English language review.
Conflicts of interest N. Maeda, Research Grant (Topcon), Instru-
ment (CorvisÒ ST: Oculus); R. Ueki, None; M. Fuchihata, None;
H. Fujimoto, None; S. Koh, None; K. Nishida, None.
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