Guia Interpretación 2da. Edición 2008

OCULUS
PENTACAM® /
PENTACAM HR®
INTERPRETATION GUIDELINE
2nd edition
Instruction Manual Pentacam / Pentacam HR (Version 01 – 2007-08-08) 1/1

Foreword
We thank you for the trust you have put in this OCULUS product. With the purchase of
this instrument, you have chosen a modern, sophisticated product, which was manufac-
tured and tested according to strict quality standards.
Our company has been doing business for over 100 years. Today, OCULUS is a medium-
sized company concentrating competely on helping ophthalmologists, optometrists and
opticians to carry out their responsible work by supplying an optimal range of
instruments for examinations and surgery on the eye.
The Pentacam is based on the Scheimpflug principle, which generates precise and sharp
images of the anterior eye segment. Oculus has produced an instrument that takes ex-
tremely accurate measurements and is easy to use.
If you have questions or desire further informations on this product, call, fax or email us.
We will be glad to help you.
OCULUS Optikgeräte
Managing director and The Management Team
OCULUS is certified according to DIN EN ISO 9001:2000 and 13485:2003, setting high
standards of quality where development, manufacture, quality assurance and service re-
garding the entire range of products are concerned.
i / iii Interpretation Guideline Pentacam® / Pentacam HR® (IG/70700/0608/en)

Table of Contents
Table of Contents
1 Introduction .................................................................................................................................1
2 Description of unit and general remarks.................................................................................1
3 Corneal Ectasia ............................................................................................................................2
3.1 Case 1, Ectasia after RK, Renato Ambrósio, Jr, MD ..................................................................................2

3.2 Case 2, Ectasia after LASIK?, Prof. Michael Belin ......................................................................................4
4 Glaucoma......................................................................................................................................7
4.1 Case 1, General screening, Tobias Neuhann, MD......................................................................................7

4.2 Case 2, YAG Laser Iridectomy, Eduardo Viteri, MD...................................................................................8
4.2.1 Comments ........................................................................................................................................................... 10
5 Screening for refractive surgery, Prof. Michael Belin .........................................................10
5.1 Screening Parameters, 4 maps refractive display Prof. Michael Belin .......................................... 10
5.1.1 Suggested Installation Settings.................................................................................................................. 10
5.1.2 Strategy on how to go through the exams ........................................................................................... 11
5.1.3 Proposed screening parameters ................................................................................................................. 11
5.2 Normal, astigmatic cornea, Prof. Michael Belin ..................................................................................... 13
5.3 Normal, astigmatic cornea, Prof. Michael Belin.................................................................................... 14
5.4 Normal, astigmatic cornea, Prof. Michael Belin ..................................................................................... 15
5.5 Astigmatism on the posterior cornea, Prof. Michael Belin ................................................................ 16
5.6 Spherical cornea, Prof. Michael Belin ......................................................................................................... 17
5.7 Thin, spherical cornea, Prof. Michael Belin............................................................................................... 18
5.8 Thin cornea, Prof. Michael Belin.................................................................................................................... 19
5.9 Borderline case, Prof. Michael Belin ............................................................................................................ 20
5.10 Displaced apex, Prof. Michael Belin............................................................................................................. 21
5.11 Pellucid Marginal Degeneration, Prof. Michael Belin........................................................................... 22
5.12 Asymmetric Keratoconus, Prof. Michael Belin ........................................................................................ 23
5.13 False negative on curvature map, Prof. Michael Belin......................................................................... 25
5.14 Keratoconus OD > OS, Prof. Michael Belin............................................................................................... 26
5.15 Classic Keratoconus map, Prof. Michael Belin ........................................................................................ 27
6 Corneal Thickness profile, Renato Ambrosio, MD ................................................................28
6.1 Screening for Ectacia Renato Ambrosia, Jr. MD, Marcela Q. Salomão, MD................................. 31
6.2 6.2 Case 1, Fuchs Dystrophy, R. Ambrosio, Jr. MD, M. Salomão, MD............................................. 35
6.3 Case 2, Ocular Hypertension, R. Ambrosio, JR. MD, M. Salomão, MD ........................................... 36
6.4 Case 3, Early Fuchs Dystrophy with Glaucoma, R. Ambrosio, Jr. MD, M. Salomão, MD ........ 38
6.5 Screening parameter’s, Renato Ambrosio, Jr. MD.................................................................................. 41
7 Belin/Ambrosio Enhanced Ectasia...........................................................................................42
7.1 Introduction........................................................................................................................................................... 42
7.2 Basics........................................................................................................................................................................ 42
7.3 Standard and enhanced fitted reference sphere (BFS)........................................................................ 42
7.4 Interpretation of the Belin/Ambrosio Enhanced Ectasia Display .................................................... 45
7.5 Pachymetry evaluation ..................................................................................................................................... 46
8 Ectasia susceptibility shown in the Belin/Ambrosio (B/A) Enhanced Ectasia Display......47
Interpretation Guideline Pentacam® / Pentacam HR® (G/70700/0608/en) ii / iv

Table of Contents
9 Locating the cone, Prof. Michael Belin..................................................................................50
10 INTACS® implantation ..............................................................................................................51
10.1 Case 1, Prof. Michael Belin .............................................................................................................................. 51

10.2 Case 2, INTACS® after PRK, Alain-Nicolas Gilg, MD.............................................................................. 53
11 Differences between Placido and elevation derived curvature maps ................................56
11.1 Keratoconus, OD & OS?, Prof. Michael Belin............................................................................................ 56

11.2 Form Fruste Keratoconus?, Prof. Michael Belin ...................................................................................... 59
12 Diagnosing ectasia and pseudo-ectasia: P. Vinciguerra M.D, M.I. Torres Munoz M.D ...62
12.1 Introduction........................................................................................................................................................... 62
12.2 The normal Cornea.............................................................................................................................................. 62
12.3 Ectasia: the key to diagnosis .......................................................................................................................... 64
12.4 Interlocking relationships between curvature-elevation-pachymetry maps ............................. 64
12.4.1 Preliminary considerations........................................................................................................................... 64
12.4.2 Maximum curvature, maximum anterior and posterior elevation and the point
with minimal pachymetry............................................................................................................................. 65
12.4.3 Analysis of the highest points of the anterior and posterior face............................................... 66
12.4.4 Eccentric position of the thinnest point................................................................................................. 68
12.4.5 Map patterns...................................................................................................................................................... 68
12.5 Conclusions and noteworthy points ........................................................................................................... 69
13 Holladay Report.........................................................................................................................70
13.1 Detecting forme fruste Keratoconus........................................................................................................... 70

14 IOL calculation for patients after refractive surgery ..........................................................72
14.1 EKR’s in the Holladay Report.......................................................................................................................... 72

14.2 Details of the Holladay Report....................................................................................................................... 73
14.3 High myopic refractive change after LASIK, Tobias Neuhann, MD................................................. 75
15 phakic IOL implantation...........................................................................................................76
15.1 Manual pre-op simulation and post-op control, Eduardo Viteri, MD ........................................... 76
15.1.1 Preoperative evaluation................................................................................................................................. 76
15.1.2 Postoperative evaluation............................................................................................................................... 77
15.2 3D - phakic IOL simulation, Burkhard Dick, MD, Sabine Buchner, Optometrist........................ 78
15.2.1 Myopic Artisan / Verisyse 6 / 8.5 mm ...................................................................................................... 78
15.2.2 Toric Artisan / Verisyse, 5 / 8.5mm............................................................................................................ 81
15.3 Patients selection criteria, Burkhard Dick, MD, Sabine Buchner, Optometrist........................... 84
16 From the daily practice ............................................................................................................85
16.1 Case 1, Cortical Cataract, Tobias Neuhann, MD...................................................................................... 85

16.2 Case 2, Corneal transplant, removing the sutures?, Tobias Neuhann, MD.................................. 86
16.3 Case 3, Keratoconus and Cataract, Tobias Neuhann, MD................................................................... 87
16.4 Case 4, Corneal Infiltrate, Renato Ambrósio, Jr, MD............................................................................. 90
16.5 Case 5, Incisional Edema, Renato Ambrósio, Jr, MD ............................................................................. 92
16.6 Case 6, Corneal Thinning after Herpetic Keratitis, Renato Ambrósio, Jr, MD............................. 93
16.7 Case 7, Epithelial Ingrowth after Keratomileusis in situ, Renato Ambrósio, Jr, MD................ 94
17 Scheimpflug and Slit lamp images .........................................................................................96
17.1 Corneal Dystrophy .............................................................................................................................................. 96
iii / iv Interpretation Guideline Pentacam® / Pentacam HR® (G/70700/0608/en)

Table of Contents
17.2 Congenital anterior pyramid cataract ........................................................................................................ 97

17.3 Posterior Capsular Cataract ............................................................................................................................ 98
17.4 Nuclear Cataract.................................................................................................................................................. 99
17.5 Posterior Synechia ............................................................................................................................................100
17.6 Pterygium .............................................................................................................................................................101
18 Orthokeratology ..................................................................................................................... 102
18.1 Case 1, General Screening, Alain-Nicolas Gilg, MD ............................................................................102

19 Recommended Settings and Color Maps ............................................................................ 104
19.1 Recommended Settings..................................................................................................................................105

19.2 Recommended Color Maps ...........................................................................................................................105
19.2.1 Screening for LASIK, PRK etc. ....................................................................................................................105
19.2.2 Screening for pIOL implantation..............................................................................................................105
19.2.3 Glaucoma Screening .....................................................................................................................................106
19.2.4 IOL Calculation for Treated and Untreated Corneas ........................................................................106
20 List Of illustrations ................................................................................................................ 104
21 References and Contact Addresses ...................................................................................... 107
Interpretation Guideline Pentacam® / Pentacam HR® (G/70700/0608/en) iv / iv

1 Introduction
1 Introduction
This guideline should help all Pentacam users to interpret the results and screens the Pentacam
provides.
We may not have covered everything which might be of interest. Therefore we ask each Pentacam user
for help to improve this guideline step by step. Please forward your special cases to us and we will be
happy to implant them.
Of course, this guideline cannot replace the years of experience and the medical studies, but it will be a
help in questionable cases as well as a help for beginners. The personal experience and impression from
each of you and the cross connection of the results from different instruments linked with the individual
patient’s history may sometimes lead to different results as shown in this guideline.
2 Description of unit and general

remarks
The OCULUS Pentacam/Pentacam HR is a rotating Scheimpflug camera. The rotational measuring pro-
cedure generates Scheimpflug images in three dimensions, with the dot matrix fine-meshed in the cen-
ter due to the rotation. It takes a maximum of 2 seconds to generate a complete image of the anterior
eye segment. Any eye movement is detected by a second camera and corrected for in the process. The
Pentacam calculates a 3-dimensional model of the anterior eye segment from as many as 25.000
(HR: 138.000) true elevation points.
The topography and pachymetry of the entire anterior and posterior surface of the cornea from limbus
to limbus are calculated and depicted. The analysis of the anterior eye segment includes a calculation of
the chamber angle, chamber volume and chamber height and a manual measuring function at any lo-
cation in the anterior chamber of the eye. In a moveable virtual eye, images of the anterior and posterior
surface of the cornea, the iris and the anterior and posterior surface of the lens are generated. The den-
sitometry of the lens is automatically quantified.
The Scheimpflug images taken during the examination are digitalized in the main unit and all image data
are transferred to the PC.
When the examination is finished, the PC calculates a 3D virtual model of the anterior eye segment, from
which all additional information is derived.
Attention
OCULUS Optikgeräte GmbH emphasizes that the user bears the full responsibility for the correctness of
data measured, calculated or displayed using the Pentacam. The manufacturer will not accept claims
based on erroneous data and wrong interpretation. This interpretation guideline has to be understood
as a help only to interpret the examination data the Pentacam provides.
The doctors and physicians have to consider all medical information which can be collected by using oth-
er diagnostic instruments e.g. slit lamp examination, ultrasound biomicroscopy, etc. to make the diag-
nosis. The results of the different diagnostic instruments have to be compared and closely scrutinized.
This interpretation guideline has to be understood as a completion to the Users Guide. The current ver-
sion of the Users Guide and the Interpretation Guideline are on every Pentacam Software CD-ROM and
should be read by all users prior to use.
1 / 111 Interpretation Guideline Pentacam / Pentacam HR (IG/70700 – 0608/en)

3 Corneal Ectasia
3 Corneal Ectasia
3.1 Case 1, Ectasia after RK, Renato Ambrósio, Jr, MD
A 28-year old male patient had RK in 1995 for myopic astigmatism with RK enhancement three years
later in OS.
Corneal topography was not performed prior to surgery according to patient information.
Uncorrected VA was 20/30 in OD and 20/200 in OS. Patient refers severe glare and starburst all day,
mainly at night.
Refraction is –0.25 –3.00 x 156, giving 20/20 in OD and –5.00 –2.25 x 39, giving 20/30 in OS.
Patient was fit with a RGPCL with significant improvement of the symptoms in both eyes.
The Pentacam Quad map demonstrates corneal Ectasia in both eyes, more advanced in OS (Figure 2).
In OD, (Figure 1) the patient has a central cornea with less distortion than OS, which enables relatively
good uncorrected vision.
However, the patient refers quality of vision was terrible in both eyes.
Figure 1, Pentacam, OD post LASIK, Ectasia
Interpretation Guideline Pentacam / Pentacam HR (IG/70700/0608/en) 2 /111

3 Corneal Ectasia
Figure 2, Pentacam, OS post LASIK, Ectasia
Figure 3, Pachymetry Progression, OD Figure 4, Pachymetry Progression, OS
The pachymetric progression is abrupt in both eyes as an important sign of Ectasia,

(Figure 3 and Figure 4).
Probably mild Ectasia could have been diagnosed prior to surgery if corneal topography and tomography
would have performed and well interpreted. This case would have been considered as a bad candidate
for RK.

3 Corneal Ectasia
3.2 Case 2, Ectasia after LASIK?, Prof. Michael Belin
A 46 year old female had previous LASIK 2 years prior. She presented interested in an enhancement to
her dominant right eye. BSCVA was 20/20+ with – 1.25 D.
The referring surgeon was concerned about Post LASIK Ectasia based on Orbscan topography.
Orbscan topography shows significant posterior elevation (Figure 5).
Figure 5, ORB Scan post LASIK, Ectasia

3 Corneal Ectasia
Evaluation with the OCULUS Pentacam reveals no posterior elevation abnormality and no evidence of
post-operative Ectasia (Figure 6).
Patient underwent a routine LASIK enhancement without incident.
Figure 6, Pentacam 4 maps, post LASIK no Ectasia
Discussion
This case demonstrates one of the limitations with the current version of the B&L Orbscan®.
☞
The Orbscan® routinely fails to correctly identify the posterior corneal surface in post-operative patients
leading to underestimates of residual bed thickness and frequent incorrect diagnosis of post LASIK Ecta-
sia.
Here the Orbscan® incorrectly reads the corneal thickness 37µm thinner than the Pentacam and shows
an incorrect Ectasia (Figure 5).
The Pentacam shows a normal post-operative appearance (Figure 7).

3 Corneal Ectasia
Orbscan Pachymetry is
37 µm thinner
Figure 7, Orbscan® 4 Maps, Pentacam 4 Maps Refractive

4 Glaucoma
4 Glaucoma
4.1 Case 1, General screening, Tobias Neuhann, MD
A 48 year old white male patient wants to have a second opinion about his glaucoma treatment. His fa-
ther and grandfather have had glaucoma. He himself has had ten years of glaucoma medical treatment.
His ophthalmologist recommends now a second medication. We measured 24mmHG with Goldmann ap-
planation tonometer.
Figure 8, Pentacam 4 maps
After taking a Pentacam examination, looking to the 4 maps display (Figure 8), we put the 24mmHg in
the Dresdner scale and the corrected IOP was displayed with 11mmHg because of a corneal thickness of
about 728µm in the apex.

4 Glaucoma
The additional examination on HRT resulted in a healthy optic nerve and we recommend the patient to
stop his medication. His IOP today is during daytime between 19 and 22mmHg. We still see him 4 times
a year for IOP and HRT check (Figure 9, Figure 10).
Figure 9, HRT Image Figure 10, HRT Image
4.2 Case 2, YAG Laser Iridectomy, Eduardo Viteri, MD
This is a 64 year old female patient who was complaining of episodes of blurred vision and tearing.
The IOP was 18 mm Hg in both eyes. Anterior chamber was shallow on slit lamp examination and optic
nerve had a C/D ratio of 0.6 in both eyes. The lens was clear and gonioscopy exam revealed a narrow
angle in both eyes (grade I-II).
The anterior segment exam with the Pentacam (Figure 11) documented an irido-corneal angle of 22.5
degrees with an ACD (epithelial) of 2.43 mm.
The patient was reluctant to have YAG laser Iridectomy until she was able to compare her anterior seg-
ment biometry with that of other normal patients.
Figure 11, Pentacam Overview post op to YAG laser Iridectomy

4 Glaucoma
After YAG Laser Iridectomy was performed, several of her anterior segment measurements
changed (Figure 12).
This is quite evident in the differential display (Figure 13).
Figure 12, Pentacam Overview, 10 days after YAG Laser Iridectomy
Figure 13, Pentacam, 2 maps comparison
The irido-corneal angle is 4º wider, and, although the ACD only deepened 0.09 mm centrally, the main
difference is evident in the periphery, where you can see changes ranging from 0.19 mm to 0.30 mm.
This was enough to increase the AC volume from 64 to 92 mm3.

5 Screening for refractive surgery, Prof. Michael Belin
4.2.1 Comments
In narrow angle Glaucoma, the Pentacam is quite useful in measuring the irido-corneal angle, although
this may be difficult in 360º because of the eyelid interference.
We can obtain more consistent data when measuring peripheral ACD and AC volume.
The exam has been of great help also in educating the patient about this disease, and making evident the
effect of the treatment.
5 Screening for refractive surgery,

Prof. Michael Belin
5.1 Screening Parameters, 4 maps refractive display Prof.

Michael Belin
5.1.1 Suggested Installation Settings
The following are my guidelines for pre-operative refractive surgery screening for Keratoconus:
Use the 4 maps refractive display showing Anterior Elevation, Posterior Elevation, Pachymetry and
anterior Sagittal Curvature.
It is based to keep the display, scales and colors constant for refractive screening as this will allow
for a rapid visual inspection.
Pachymetry
Right click on the scale and set "ABS NORMAL", (300-900 µm)
Right click on the actual display for the drop down menu. Turn ON the following (Apex #1),
Thinnest ( #2), Pupil Edge ( #6), Nasal/Temp ( #7), Max Diam 9.0 ( #11) and Show Numeric ( #13).
Anterior Elevation & Posterior Elevation

Right click on scale and set to
"Belin Intuitive" +/- 75 microns for refractive practice
"Belin Intuitive" +/- 150 microns for medical practice
BFS Sphere, Float, MAN, BFS diameter set to 9.0 mm or 8.0 mm.
On the 9.0 mm display you should have none or minimal extrapolated data for the study
to be valid.
Right click on display and turn ON Apex (#1), Thinnest (#2), Pupil Edge (#6), Nasal/Temp (#7),
Max Diam9.0 (#11) and Numeric (#12).
Sagittal Curvature
Right click on scale and set to ABS NORMAL, AMERICAN and Diopter
Right click on the display and set to Min Radius (#3), Pupil Edge (#6), Nasal/Temp (#7),
Max Diam 9.0 (#11), Numeric (#12) and Min/Max (#13).

Note
The different borderline numbers for the elevation maps are depending on the BFS diameter you are us-
ing, 9 mm or 8 mm.
5.1.2 Strategy on how to go through the exams
The way I am usually going through the exams is:

Look at anterior elevation first
Look at posterior elevation
Look at the Pachymetry and thickness distribution
off center distribution of corneal thickness is highly suspicious
Look at the symmetry of both eyes
if one eye is abnormal, usually both eyes are abnormal
Look at curvature last
5.1.3 Proposed screening parameters
It is essential to check the settings for the fitting zone of the BFS in the settings of the Pentacam since
this influences the borderline numbers (Figure 14).
Figure 14, BFS fitting zone

If you are using the 9mm zone for fitting the BFS, the proposed screening parameters
I am using are:
In the anterior elevation map differences between the BFS and the corneal contour
less than +12µm are considered normal
between +12 µm and +15µm are suspicious
more than +15µm are typically indicative of keratoconus
Similar numbers about 5µm higher apply to posterior elevation maps
If you are using the 8mm zone for fitting the BFS, the proposed screening parameters
I am using are:
Anterior Elevation differences less than +8µm are considered in the normal range
Anterior Elevation differences > +8µm are typically indicative of keratoconus or other ectatic
disorders (in the central zone)
Posterior Elevation differences >11µm are considered in the normal range
Posterior Elevation differences >16µm are suspicious
Note
The above relate to elevation ISLAND patterns, not astigmatism.
These numbers pertain to elevation in the central and paracentral region in an island pattern.

5.2 Normal, astigmatic cornea, Prof. Michael Belin
This 4 picture composite map (Figure 15) shows a normal with the rule astigmatic cornea (both anterior
and posterior surfaces).
The sagittal curvature appears normal as would be expected from the normal symmetric anterior eleva-
tion and the pachymetry map reveals a normal thickness with a normal pachymetry distribution.
DIAGNOSIS - Normal Astigmatic Cornea
Figure 15, Pentacam, astigmatic cornea

This map (Figure 16) demonstrates a normal with-the-rule astigmatic cornea (2.6 D cylinder), Figure 15.
Both the anterior and posterior elevations demonstrate a similar pattern as does the anterior sagittal
curvature.
The curvature maps reveals a steep cornea (K1 = 47.6, K2 = 50.2) but the elevation maps do not reveal
any suspicious areas.
The pachymetry map is well centered with a thinnest reading of 546 microns.
This is a normal astigmatic corneal with steep curvature, but otherwise normal.
DIAGNOSIS - Normal Astigmatic Eye

This map (Figure 17) demonstrates a normal with-the-rule astigmatic cornea (4.1 D).
Both the anterior and posterior elevations demonstrate a similar pattern as does the anterior
sagittal curvature.
The anterior elevation map is symmetric the curvature shows a symmetric astigmatic pattern.
The pachymetry map is well centered with a thinnest reading of 522 microns.
DIAGNOSIS - Normal Astigmatic Eye

5.5 Astigmatism on the posterior cornea,

Prof. Michael Belin
This 4 picture composite map (Figure 18) shows only a small amount of anterior astigmatism (1.1 D)
but a larger amount of posterior astigmatism (more defined astigmatic pattern).
Because the posterior cornea, however, contributes a much smaller amount to the overall refractive state
of the eye, the posterior astigmatism reads only 0.4 D, in spite of a fairly well defined astigmatic pattern.
DIAGNOSIS - Normal Cornea with posterior astigmatism
Figure 18, Pentacam, posterior astigmatism

5.6 Spherical cornea, Prof. Michael Belin
This map (Figure 19) demonstrates a normal relatively spherical cornea (0.7 D cylinder).
The anterior elevation shows no defined pattern which is mirrored by the anterior sagittal curvature. The
corneal thickness is slightly high (583 microns in thinnest reading).
This is a normal spherical cornea.
DIAGNOSIS - Normal Spherical Cornea
Figure 19, Pentacam, spherical cornea

5.7 Thin, spherical cornea, Prof. Michael Belin
This 4 picture composite map (Figure 20) shows a relatively spherical anterior cornea (both anterior
elevation and anterior sagittal maps) and a more pronounced astigmatic pattern on the posterior corneal
surface.
Because of the optical properties of the posterior cornea (no cornea / air interface) differs from the an-
terior surface the refractive astigmatism of the posterior cornea is listed only as 0.3 D.
The pachymetry map shows a thin cornea (thinnest reading 496 microns) with a slight inferior displace-
ment of the thickness distribution.
DIAGNOSIS - Normal Spherical Cornea with Posterior Astigmatism and Thin Cornea
Figure 20, Pentacam, spherical thin cornea

5.8 Thin cornea, Prof. Michael Belin
This OD / OS comparison map (Figure 21) shows both the posterior elevation and the Pachymetry maps.
The posterior elevation is a normal astigmatic pattern (as is the anterior elevation (not shown).
The pachymetry maps show the thinnest regions OD at 492 microns and OS at 483 microns.
This is a normal eye topographically, but one that is on the thin side.
DIAGNOSIS - Normal but thin Cornea
Figure 21, Pentacam, thin cornea

5.9 Borderline case, Prof. Michael Belin
4 map composite display (Figure 22). The anterior elevation shows a low grade paracentral island (max-
imal elevation in island + 8 micron) and a diffuse oval island on the posterior surface (maximal elevation
in island + 16 microns).
The anterior values are within normal values, while the posterior numbers are just outside the normal
range.
The pachymetry map is normal with a thick cornea (thinnest region 608 microns) and normal pachym-
etry distribution.
The completely normal pachymetry map suggests that the borderline elevation changes are probably ac-
ceptable.
DIAGNOSIS - Borderline Cornea Map
Figure 22, Pentacam 4 maps, borderline case

5.10 Displaced apex, Prof. Michael Belin
4 map composite display of a normal astigmatic eye with a thick cornea (644 microns) (Figure 23).
The anterior elevation map shows a "displaced apex" (displaced inferiorly). This causes the curvature map
(anterior sagittal curvature) to show an asymmetric pattern.
Curvature is a referenced based measurement. An asymmetric curvature pattern can occur with a com-
pletely normal astigmatic cornea when the apex, line of sight and measurement axis do not line up.
This is a normal variant and in itself not indicative of pathology.
DIAGNOSIS - Normal Astigmatic Eye with a False Positive "asymmetric bowtie" on curvature
Figure 23, Pentacam, displaced apex

5.11 Pellucid Marginal Degeneration, Prof. Michael Belin
These are pictures of classic Pellucid Marginal Degeneration (PMD).

The pachymetry map (Figure 24) shows the band of thinning located 1 -2 mm from the inferior limbus.
This is an area that cannot be imaged on a Placido system which is limited to imaging the central 9.0
mm. The Scheimpflug images (Figure 25, Figure 26) show the relatively normal appearance when the
cornea is viewed through a horizontal cut and the pathonomic appearance when viewed through a
vertical cross-section with sever flattening over most of the cornea, an inferior band of thinning and a
sharp change in corneal contour over the area of thinning.
PMD is one of the most misdiagnosed conditions when the diagnosis is based on Placido imaging.
A Placido system cannot image out to the area of the pathology. Descriptive curvature terms such as
"lobster claw" pattern, etc. are fraught with problems and are associated with a very high false positive
rate.
DIAGNOSIS - Pellucid Marginal Degeneration
Figure 24, Pentacam 180°, S.image, PMD Figure 25, Pentacam 90°, S.image, PMD
Figure 26, Pentacam PMD pachymetry map

5.12 Asymmetric Keratoconus, Prof. Michael Belin
OD - 4 map composite display (Figure 27) of a normal astigmatic eye with a thin cornea (thinnest 483)
and an important abnormality in the pachymetry distribution with a significant displacement of the
thinnest zone inferior-temporal.
At times the only indicator of potential pathology may be the magnitude and distribution of the corneal
pachymetry.
OS - The left eye shows a major posterior Ectasia (+ 91 on inferior island), and marked inferior displace-
ment of the pachymetry map (thinnest reading 414 microns) (Figure 28).
The anterior elevation shows a somewhat irregular astigmatic pattern but without any obvious positive
island. The Tangential curvature incorrectly locates the cone much more inferiorly than the cone location
shown by both the posterior elevation data and pachymetry map.
DIAGNOSIS - Asymetric Keratoconus OS >> OD
Figure 27, Pentacam, asymetric cornea, OD normal topography

Figure 28, Pentacam asymetric cornea, OS Keratoconus

5.13 False negative on curvature map, Prof. Michael Belin
OS - 4 map composite display (Figure 29) of classic Keratoconus. The anterior elevation map show a
minor island that is still within the normal range.
The posterior elevation, however, shows a very significant area of inferior Ectasia (positive island up to
+ 35 microns) and the pachymetry map is significantly displaced and thinned to 499 microns.
If the surgeon would only relied on anterior curvature and central corneal thickness reading this patient
would have been classified as normal (normal anterior curvature and central corneal thickness of 520
microns).
This demonstrates the importance of having accurate posterior elevation data in addition to anterior sur-
face analysis.
DIAGNOSIS - Form Fruste or Sub-Clinical Keratoconus, False Negative on Curvature
Figure 29, Pentacam, false negative topography

5.14 Keratoconus OD > OS, Prof. Michael Belin
The 2 map comparison of this patient with Keratoconus (Figure 30). Look to the post elevation and the
pachymetry map.
The right eye shows a significant posterior island (ectatic area) associated with marked corneal thinning
(430 microns) and significant pachymetry displacement of the thinnest area (inferior-temporal) to the
area of the posterior elevation changes.
The left eye shows a relatively normal posterior astigmatic pattern, but a distinctly abnormal pachy-
metry distribution with marked inferior-temporal displacement and a thinnest reading of 440 microns.
This example shows the importance of looking at the pachymetry distribution which may be the single
abnormal finding.
DIAGNOSIS - Keratoconus OD > OS
Figure 30, Pentacam, Keratoconus OD > OS

5.15 Classic Keratoconus map, Prof. Michael Belin
OD - 4 map composite display of classic Keratoconus (Figure 31).

Both anterior and posterior elevations show a prominent island of positive deviation (maximal for ante-
rior and posterior +33 / +89 microns) with an accompany displacement of the pachymetry map (thinnest
reading 485 microns).
The Tangential curvature map also shows inferior steepening, but again does not accurately locate the
cone.
DIAGNOSIS - Classic Keratoconus Map
Figure 31, Pentacam, classical Keratoconus

6 Corneal Thickness profile, Renato Ambrosio, MD
6 Corneal Thickness profile,

Renato Ambrosio, MD
The measurement of corneal thickness has become an important factor for several clinical situations, in-
cluding planning and evaluating the results of most types of corneal and anterior segment surgeries, the
evaluation of corneal endothelium dehydrating function, as well as an individual risk factor for glauco-
ma.
Ultrasonic central corneal thickness (US-CCT) are usually referred to the measurements at the corneal
geometric center or at the apex, which is not the corneal thinnest point.
Regional US pachymetry can been used, but the need for the pachymetric map for determining the lo-
calization and value of the cornea’s thinnest point is clear, if we consider that over 10% of normal cor-
neas have more than 10 micron difference in thickness from the central and thinnest points.
Corneal Tomography (CTm) provides a three-dimensional reconstruction of the cornea, enabling the
evaluation of the anterior and posterior corneal surfaces and thereby, the creation of a pachymetric map.
We believe Tomography should be a better term for such diagnostic approaches. It derives from the
Greek word "tomos" meaning "slice" and "graphia" meaning "describing".
The aim of this manuscript is to provide a comprehensive understanding on the current corneal thickness
profile studies introduced by the Pentacam software, along with other approaches that could be devel-
oped in the future.
Corneal thickness spatial profile (CTSP)

Corneal thickness values at the thinnest point (TP) is determined and the averages of thickness values of
the points within twenty-two imaginary circles centered on the TP with increased diameters at 0.4mm-
steps are calculated to create the CTSP. (Figure 32)
Figure 32, (CTSP)

Percentage of increase of thickness (PIT)

PIT is calculated for each position from the CTSP using a simple formula:
(CT @ x - TP) / TP,
where x representes the averages of thickness values of the points on imaginary circles centered on the
TP with increased diameters from 0.4 to 8.8mm.
Clinical Results
In a published study involving 46 eyes of 23 patients (13 females) diagnosed as mild to moderate Kera-
toconus and 364 normal eyes from 196 patients (97 females), statistically significant differences were
observed among the groups (P<0.01) for all positions of CTSP and PIT (Ambrósio R Jr, Alonso RS, Luz A,
Velarde LGC. Corneal-thickness spatial profile and corneal-volume distribution: Tomographic indices to
detect Keratoconus. J Cataract Refract Surg. 2006; 32: 1851- 1859).
Keratoconus had much lower (thinner) values, estimated to be on average, 27.3 micron thinner than nor-
mals. In Keratoconus eyes, mean TP was 428 micron, with a standard deviation of 72 (the 95% confi-
dence interval limits from 391 to 474, ranging from 245 to 563 micron), while in normal eyes, the mean
value was 537 micron and a standard deviation of 36.7 (95% confidence interval limits from 513 to 562,
ranging from 439 to 630 micron). For example, at the 4.8mm circle diameter, the mean average of thick-
ness values of the keratoconic corneas was 536.5 micron, with a standard deviation of 48.3 (95% con-
fidence interval limits from 516 to 566, ranging from 377 to 623 micron), while in normal eyes, the mean
value was 589 micron, with a standard deviation of 36.9 (95% confidence interval limits from 564 to
614.8, ranging from 467 to 693 micron).
The statistical significance of all positions of the PIT from normal eyes and Keratoconus was very signif-
icant (p<0.0001). Keratoconus corneas had much higher percentage increase at each diameter centered
on the TP.
In Keratoconus eyes, mean PIT for values for the 0.4mm diameter was 0.27%, with a standard deviation
of 0.29 (95% confidence interval limits from 0.19 to 0.26, ranging from 0.0 to 1.6 micron), while in nor-
mal eyes, the mean value was 0.07% and a standard deviation of 0.09 (95% confidence interval limits
from 0 to 0.18, ranging from 0.0 to 0.23 micron). For the 4.8mm circle diameter, the mean percentage
of increase of the keratoconic corneas was 28.2%, with a standard deviation of 21.4 (95% confidence
interval limits from 13.8 to 34.8, ranging from 6.1 to 129 micron), while in normal eyes, the mean value
was 9.9%, with a standard deviation of 1.9 (95% confidence interval limits from 8.7 to 11.1, ranging from
3.3 to 17.9).
This study demonstrated that new corneal tomography (CTm) findings – CTSP and PIT are highly different
in Keratoconus than normals. We also found that Keratoconus have thinner corneas with less volume
and faster and more abrupt increase in these parameters from the thinnest point (TP) towards the pe-
riphery than normal corneas. The Scheimpflug images from a normal thin cornea and a case with mod-
erate Keratoconus clearly illustrates the thickness profile in normal and ectatic (Figure 33).

Figure 33, Thickness profile in Ectatic and normal eye
It is very important to cite that Mandell and Polse pioneered this field in a study using a modified Haag-
Streit optical pachymeter, with an electronic recording system to document the variation in thickness
over the horizontal meridian measured at different angles (Mandell RB, Polse KA. Keratoconus: spatial
variation of corneal thickness as a diagnostic test. Arch Ophthalmol. 1969;82:182-188.). However, this
interesting approach to evaluate the cornea was not used clinically for decades.
Considering the results from our studies, new summaries and graphs exploring data from the CTSP and
PIT were developed by the Pentacam software to help clinicians evaluate objectively the thickness profile
and detect Ectasia. The examined eye CTSP and PIT lines are displayed with the 95%CI limits of a normal
population. Initially, these graphs were included in a “Keratoconus page” along with other topometric
indices derived from the 8mm anterior corneal curvature, which were similar than the ones used by Plac-
ido topography.

6.1 Screening for Ectasia Renato Ambrosia, Jr. MD,

Marcela Q. Salomão, MD
The new software combines M. Belin, MD’s elevation criteria for screening for Ectasia. This opens new
horizons to analyze the corneal thickness for diagnosis and classification of corneal Ectasia. In addition,
the CTSP and PIT are also relevant to evaluate abnormal thick corneas with endothelial disease.
The CTSP and PIT graphs provide very relevant clinical data to differentiate normal thin cornea, (Figure
34 and Figure 35) and ectatic cornea, (Figure 36 and Figure 37).
Figure 34, normal thin cornea, topography
Figure 35, normal thin cornea, Pachymetry

Figure 36, Ectatic cornea, topography
Figure 37, Ectatic cornea, Pachymetry
Currently, most diagnostic and classification criteria for Keratoconus are based on anterior corneal
curvature data, derived from corneal topography.
We point out that the thickness profile described should be used in conjunction with the classic ones
provided by corneal topography.

To test the hypothesis that the CTSP and PIT increase the sensitivity for the detection of very early forms
of Keratoconus, we have studied patients with Keratoconus in one eye and a contra-lateral normal
corneal surface curvature map (by Placido topography).
Interestingly, the contra-lateral eyes also exhibit signs of abnormality on the CTSP and PIT graphs
(Figure 38, Figure 39).
Figure 38, Asymmetric cornea, topography
Figure 39, Asymmetric cornea, Pachymetry

Considering the specificity of the artificial intelligence indexes for detecting Ectasia, the topometric ones
have a high index of false positives, which occur mainly in cases with moderate keratometric asymmetry
and inferior steepening (Figure 40, Figure 41).
Figure 40, False positive topography
Figure 41, Normal Pachymetry

6.2 6.2 Case 1, Fuchs Dystrophy, R. Ambrosio, Jr. MD,

M. Salomão, MD
In the opposite direction of Ectasia, in which central thinning causes a more pronounced or abrupt in-
crease in the thickness values from the center towards the periphery, corneal swelling makes the cornea
homogeneously thick decreasing the increase in the thickness values.
We have found that the “flattening” of the CTSP and PIT curves occur even in cases with very early in-
crease in corneal thickness caused by Fuchs Dystrophy and the cornea is still clear
(Figure 42, Figure 43).
Figure 42, Scheimpflug image, Fuchs Dystrophy
Figure 43, Fuchs Dystrophy, Pachymetry

6.3 Case 2, Ocular Hypertension, R. Ambrosio, JR. MD, M.

Salomão, MD
The case below shows a patient with Ocular hypertension. Please note the clear cornea shown in the
Scheimpflug images, (Figure 44) below as well as the thick cornea (Figure 45).
Figure 44, clear cornea in OD and OS with no peak in the densitogram for the endothelium
Figure 45, thick cornea and abnormal corneal thickness progression graph in OS and OD
In Figure 45 it is shown that the thickness progression graph is not parallel to the normative data in
the periphery, beyond the 4mm zone.
The Progression index is 0.9 for OD and 1.1 for OS. For screening for Ectasia we would consider 1.2 as
borderline. The profile curves should be analysed in combination with the progression indexes and Sche-
impflug images for a more accurate clinical decision.

The IOP measured with the Goldmann tonometer (2 pm) is 22 and 24 mmHg in OD and OS respectively.
Interestingly, the average of two ORA (Ocular Response Analyser) measurements for IOP-g, IOPcc and
Hysteresis were 20.4, 17.8 and 13.2 mmHg in OD and 25.1, 20.5 and 14.1 mmHg in OS.
Optic Nerve from both eyes were within normal limits (Figure 46) as computerized visual field tests.
Pascal DCT IOP measurements were 18.4 and 19.6 mmHg in OD and OS respectively. This is a case with
a normal thick cornea with stiffer biomechanical properties, leading to ocular hypertension. There is no
indication for topical medications to decrease the IOP.
Figure 46, HRT optic nerve OD/OS single report

6.4 Case 3, Early Fuchs Dystrophy with Glaucoma, R.

Ambrosio, Jr. MD, M. Salomão, MD
This is a 60 years old patient referred for a second opinion about normal tension glaucoma, cornea dis-
ease and early cataract.
The Scheimpflug images show higher scatter (less clarity) and a second peak on the level of Descemet’s
membrane and endothelium (Camel’s Sign) in both eyes. This indicates a less transparent cornea. Even
with the non-dilated pupil, lens is observed not to be clear in both eyes. The corneal thickness is slightly
thicker as usual but the shape of the corneal thickness progression graph is almost horizontal, which
indicates early Edema.
Figure 47, Scheimpflug images, unclear cornea in OD and OS

Figure 48, abnormal corneal thickness progression graph in OS and OD
The progression index are 0.5 in OD and 0.8 in OS which is lower than the normal values.
The IOP measured with the Goldmann tonometer (10 am) is 18mmHg in both eyes.
The average of two ORA (Ocular Response Analyser) measurements for IOP-g, IOPcc and Hysteresis were
19.6, 24.1 and 5.2 mmHg in OD and 16.7, 23.5 and 6.1 mmHg in OS.
Optic Nerve exam was difficult because of transparency of ocular media (early cataract) in both eyes, but
demonstrated cupping of 0.8 in both eyes.
HRT OD was not possible because of transparency of ocular media (early cataract) and had a bellow av-
erage quality in OS (Figure 50).
Pascal DCT IOP measurements were not possible due to patient cooperation and irregular reflex in both
eyes. Computerized visual field tests were inconclusive with diffuse loss in both eyes.
The examination with the specular microscope (BIO-OPTICS) demonstrated moderate guttae with loss of
normal endothelial mosaic. Cell counts were less than 1.000 cells per mm2 in both eyes. This is a case
with moderate Enothelial Fuchs’ Dystrophy and Glaucoma with early cataract. This patient has a formal
indication for topical glaucoma treatment.

Figure 49, Specular Microscopy, OD and OS
To complete the case report the examination with the HRT is displayed below. The optic nerve is dam-
aged, the rim configuration is abnormal and the Moorfields classification describes it as abnormal too.
This patient has glaucoma as well.
Figure 50, HRT single initial report, rim configuration out of normal limits, diagnosis glaucoma

6.5 Screening parameter’s, Renato Ambrosio, Jr. MD
From my experience the following parameters can be used for screening using the corneal thickness pro-
files.
It is very important to look at the blink or significant fixation loss during the scan the exam should be
repeated.
These parameters should be used as a guideline but the clinican should consider other clinical parameters
from the Pentacam and from clinical diagnosis,
APPI:
0.5 < APPI < 0.8 Fuchs Dystrophy or Edema
0.8 < APPI < 1.2 Normal or Ocular Hypertension
APPI > 1.2 Ectasia
The shapes of the curves of the thickness profile and percentage of increase give additional
information:
Flat curve: can be a normal cornea but watch for endothelial disease (Fuchs‘ dystrophy or guttata)
Steep curve: Ectasia or Ectasia Susceptibility
Curve that becomes flatter in the periphery only: Ocular Hypertension
Therefore, the course of the CTSP and PIT curve as well as the APPI provide additional information for
the clinical decision.

7 Belin/Ambrosio Enhanced Ectasia
7.1 Introduction
The aim of this display is to combine elevation based and pachymetric corneal evaluation in an all inclu-
sive display. This gives the clinician a global view of the structure of the cornea and allows the physician
to quickly and effectively screen patients for Ectatic disease.
The elevation maps and pachymetric data are placed side by side in a comprehensive display. By evalu-
ating these measurements from different perspectives, the ability to identify abnormalities is increased.
The elevation and pachymetric components of the display are designed to be complimentary.
The combination of the pachymetric graphs and indices and the enhanced elevation maps provided by
the Belin / Ambrósio Enhanced Ectasia Display have increased sensitivity and specificity in the screening
of patients for Ectasia.
7.2 Basics
Keratoconus, is by definition, a bilateral (often highly asymmetric) corneal disease characterized by pro-
gressive thinning and protrusion which leads to an increase in curvature, irregular astigmatism and pro-
gressive myopia. In about 5% of the cases, there is significant asymmetry in that the less involved eye
initially presents with a normal curvature map. Longitudinal studies have found that about 50% of such
cases progress to clinical Keratoconus. The new elevation based approach has increased sensitivity to
75% in eyes from patients previously diagnosed with unilateral Keratoconus (Salomão and Ambrósio,
unpublished data 2007). Superior specificity is demonstrated in studying eyes with inferior steepening
on corneal anterior curvature with no Keratoconus.
7.3 Standard and enhanced fitted reference sphere (BFS)
For refractive surgery screening and for most clinical situations using a standard best-fit-sphere (BFS)
gives the most useful qualitative map (i.e. easiest to read and understand). Fitting a best-fit-sphere to
the central 8 – 9 mm zone appears best for clinical interpretation. Since the normal eye is an aspherical
prolate surface the central 8 – 9 mm zone yields a reference surface that allows for subtle identification
of both Ectatic disorders and astigmatism. Larger zones would typically yield a flatter BFS and smaller
zones a steeper BFS.
While the Best-Fit-Sphere (BFS) is qualitatively useful, the clinician typically assumes that the reference
surface (the shape being subtracted) closely approximates a “normal” cornea. Some investigators, in the
past, have attempted to compare individual corneas to some “average normal shape.” The problem here
is that there is such variability in corneal shape that the “normal” or “average” shape does not represent
a clinically useful reference surface for individual corneal evaluation. What is typically not appreciated
is that the BFS will be influenced by any abnormal portion of the cornea. In the case of Keratoconus or
ectasia, the cone or apical protrusion will have the effect of steepening the BFS. This will actually mini-
mize the elevation difference between the apex of the cone and the BFS, (Figure 51).
Figure 51, standard best fitted sphere (BFS)

What the clinician would really like to see is how the corneal shape compares to the more normal portion
of the individual’s cornea, as this would better approximate the “normal” for this individual. This would
have the effect of better defining or exaggerating the Ectatic regions of the cornea. We designed a new
screening display (Belin / Ambrosio Enhanced Ectasia Display) that effectively does just that. Our goal
was to design a reference surface that more closely approximates the individual’s normal cornea and
then to compare the actual corneal shape to this new reference shape. We identified a 4 mm optical zone
centered on the thinnest portion of the cornea (exclusion zone). We defined the new “enhanced BFS” by
utilizing all the valid data from within the 9.0 mm central cornea with the exception of the exclusion
zone, see (Figure 52)
Figure 52, The image on the left shows a patient with Keratoconus. The image on the right reflects
how this abnormal area of elevation (red circle) is excluded from the BFS calculation.
Earlier investigations looked at centering the exclusion zone on the apex and also the zone of minimal
radius of tangential curvature, but the thinnest region turned out to be the most reliable.
We also looked at different optical zone sizes. Larger zones increased sensitivity at the expense of spec-
ificity, while smaller zones did the opposite. A 4 mm exclusion zone appeared to balance the need for
sensitivity without significant false positives.
The resulting new reference surface (“Enhanced BFS”) closely approximates the more normal peripheral
cornea while further exaggerating the conical protrusion, see (Figure 53).
Figure 53, enhanced best fitted sphere (BFS)
The advantage besides the more pronounced appearance of the cone is that a normal cornea still looks
same independent if the standard or the enhanced best fitted sphere is used. This makes the interpreta-
tion easy, please refer to (Figure 54) and (Figure 55).

Figure 54, normal cornea, on the left the standard BFS whereas on the right the
enhanced BFS is used.
Figure 55, abnormal cornea, on the left the standard BFS whereas on the right the
enhanced BFS is used
The average change for both anterior and posterior corneal surfaces for normal and known keratoconic
eyes were as follows:
Normal eyes showed an average change in anterior apex and maximum elevation of 1.86±1.9µm
and 1.63±1.4µm.
Keratoconus eyes showed anterior apex and maximum elevation changes of 20.4±23.1µm and
20.9±21.9µm. (P<.0001).
Posteriorly, normal eyes showed an average change in apex and maximum elevation of 2.86±1.9µm
and 2.27±1.1µm.
Keratoconus eyes showed posterior apex and maximum elevation changes of 39.9±38.1µm and
45.7±35.9µm. (P<.0001).

7.4 Interpretation of the Belin/Ambrosio Enhanced Ectasia

Display
Standard Elevation Maps:

On the left half of the Belin /Ambrosio ectasia display the elevation data is shown, please refer to
(Figure 56). The first two elevation maps (placed side by side) display the baseline relative elevation of
the cornea of off the best fit sphere. This map is displayed for the front surface (left map) and back sur-
face (right map) of the cornea. The radius of curvature of the best fit sphere (BFS) in millimeters and the
diameter of the zone used to compute the BFS is noted above each map.
Exclusion Elevation Maps:

Below the standard anterior and posterior elevation maps are the anterior and posterior exclusion maps.
These are enhanced elevation maps, which display the same elevation data as the baseline maps, but the
method used to calculate the best fit sphere (the reference surface) has been. In these maps (both ante-
rior and posterior) the best-fit sphere is calculated using all the raw elevation data located outside a
4mm circle centered on the thinnest point of the cornea. This area of excluded data is called the exclusion
zone and the map is an exclusion map. The location of the exclusion zone is indicated by a 4mm red circle
and cannot be modified. The newly calculated BFS is known as the “Enhanced Best Fit Sphere.” This “ex-
clusion map” may be significantly different from the baseline elevation map, or it may be very similar,
depending on the relative impact the 4 mm exclusion zone made to the original (standard) BFS compu-
tation.
Difference Elevation Maps:

The bottom 2 maps are difference maps showing the relative change in elevation from the standard
(baseline) elevation map to the exclusion map. The bottom maps contain only 3 colors, each one corre-
sponding to the amount of elevation change that occurs when moving between the baseline elevation
map and the exclusion map.
The green on the difference map represents a change in elevation (from the baseline to the exclu-
sion map) of less than 6 microns on the front surface and 8 microns on the back surface of the
cornea and are typically within the range seen in normal eyes.
The yellow areas represent a change between 6 and 12 microns for the front surface and 8 to 20
microns for the back surface. These eyes fall in the suspicious or suspect zone.
The red represents areas where the elevation difference between the 2 maps is 12 microns anteri-
orly or 20 microns posteriorly and are the magnitude typically seen in eyes with known Keratoco-
nus.
As you can see from (Figure 56), while the front surface does not show much change from the baseline
to the exclusion elevation map (the map is all green), the posterior surface has substantial change
(central area of red).

Figure 56, Belin/Ambrosio Enhanced Ectasia Display, elevation data on the left and
pachymetry data presented on the right
7.5 Pachymetry evaluation
The Pentacam provides a detailed corneal thickness distribution map with 3 µm accuracy and
repeatability.
Display Interpretation (pachymetry):

The pachymetric portion of the display includes the pachymetry map (Corneal Thickness), the two graphs
and the pachymetric indices. It identifies the corneal thickness at the apex (center of the exam), the thin-
nest point (TP) and the location and distance of the thinnest point relative to the apex.
The direction of the TP is displayed as temporal (T), nasal (N), superior (S) and inferior (I) or intermediate
(e.g. IT inferior-temporal). In only about 12% of normal corneas, the pachymetric difference between the
TP and the apex is > 10µm.
We also found a positive correlation (r2 = 0.61) comparing the distance difference and the pachymetric
difference between the apex and thinnest point (TP). In eyes with keratoconic the distance between the
apex and the thinnest point is significantly higher (1.52 ± 0.58mm) than normals (0.9 ± 0.23mm)
(p<0.05).
Along with the thinnest point evaluation, the pachymetric display evaluates the thickness profile of the
cornea.
The basics and interpretation of the Corneal Thickness Spatial Profile (CTSP) as well as the Percentage
Thickness Increase (PIT) is explained in chapter 6.

8 Ectasia susceptibility shown in the Belin/Ambrosio (B/A) Enhanced Ectasia Display
8 Ectasia susceptibility shown in the

Belin/Ambrosio (B/A)
Enhanced Ectasia Display
The case was sent over the Internet from a colleague and I advised not to proceed with LASIK and later
this wise colleague said "if there are too many doubts, there is no doubt!".
So that, based on the evidences found in the tomography, we agreed to avoid corneal refractive surgery
and to wait for evaluating stability before going for Custom Surface Ablation.
It is a 28 years old female, candidate for LASIK.
Man Refraction:
OD -3,00 -1,25 @ 105 20/20
OS -3,00 -1,00 @ 70 20/20
CCT is 515 and 501 OD/OS.
Interestingly, the case was also documented on a very good Placido’s topo with a good artificial intelli-
gence approach which was "green" in both eyes, please refer to (Figure 57) and (Figure 58).
Figure 57, Placido Topo OD, no Keratoconus

Figure 58, Placido Topo OS, no Keratoconus
If we consider Placido’s topography, CCT and the clinical parameters, the case would be qualified as a
good candidate for LASIK. However, the Pentacam exam finds some important characteristics on the cor-
nea that we consider to be a high risk case for ectasia. This case would be an example of ectasia suscep-
tibility.
In the Belin-Ambrósio Enhanced Ectasia Display, shown in (Figure 59) and (Figure 60), both eyes have
the distance of the thinnest point from the apex higher than 0.5mm. There is an "S" shape line in the
thickness profile graphs, more evident in the lower one (PTI) in both eyes. The enhanced elevation map
of the back surface is also abnormal in both eyes.
This case illustrates the importance of not just relying on central corneal thickness and anterior
curvature. In this case, both the thinnest corneal reading (OS) was below 500, the pachymetric progres-
sion graphs were borderline OD and abnormal OS and the enhanced elevation maps show changes (RED)
on the posterior surface OU while the anterior surface remains normal. Patients with changes limited
to the posterior surface and/or pachymetric progression may retain excellent visual acuity inspite of this
abnormalities. .
Discussing these findings with Dr. Cunha, I advised not to proceed with LASIK. Interestingly, she men-
tioned" if there are too many doubts, there is no doubt!".
Said that, based on the evidences found in the tomography exam, we agreed to avoid corneal refractive
surgery and to wait for evaluating stability before going for Custom Surface ablation.
This is sub-clinical Keratoconus

Figure 59, B/A Enhanced Ectasia Display OS
Figure 60, B/A Enhanced Ectasia Display OD

9 Locating the cone, Prof. Michael Belin
9 Locating the cone,

Prof. Michael Belin
Most clinicians have characterized Keratoconus based on the appearance on curvature maps.
This leads to inaccurate placement of the cone and a high incidence of pseudo “Pellucid Marginal De-
generation” which is a relatively rare occurrence.
Elevation and Pachymetry maps are more reliable in locating the apex of the cone. The example below
shows such a case.
While looking to the sagittal curvature map you would expect the cone between 6 and 7 o clock. The
elevation maps of the anterior and posterior corneal surface shows the real position (Figure 61) .
False Placement m
Real Position
Figure 61, Pentacam 4 maps, cone location

10 INTACS® implantation
10.1 Case 1, Prof. Michael Belin
27 year old female referred by his optometrist because of poor vision OD secondary to Keratoconus.
Her visual acuity BSCVA was 20/200 OD and with RGP over-refraction 20/30. Patient complained of poor
contact lens tolerance with less than 3 hours of daily wearing time. The patient was being considered for
INTACS.
Anterior Corneal Curvature analysis revealed the following (Figure 62).
Anterior Corneal Curvature analysis reveals significant inferior cone displacement, maximum steepness
of > 50D, with the steepest part of the cone well below the pupillary margin.
A presumptive diagnosis of Pellucid Marginal Degeneration (PMD) was made. Initial surgical planning
included dissimilar INTAC segments to treat PMD.
Figure 62, Pentacam Topography

Complete Pentacam Anterior Segment Analysis reveals the shortcomings of cone location and Kerato-
conus classification based solely on anterior curvature.
Both the anterior and posterior elevation map, as well as the pachymetry map locates the cone just at
the inferiorly pupillary border with a picture classic for traditional Keratoconus (Figure 63).
Figure 63, Pentacam 4 maps, Keratoconus
Surgical planning included identifying the steep axis for the incision and looking at the pachymetry over
the incision location to determine the incision depth (Figure 64).
Surgical planning included:
0.35 INTACS
Incision at axis 155
Incision depth 440 microns.
Figure 64, Pentacam Keratometer values

10.2 Case 2, INTACS® after PRK, Alain-Nicolas Gilg, MD
A female, 45 years-old, had PRK in both eyes 7 years before.

The visual acuity before the laser surgery was
OD sph. -7.50, cyl. -0.50 @170°,
OS sph. -6.75, cyl. -1.00 @10°.
She was referred for blurred vision, photophobia, and poor intermediate VA.
The Zernike analysis confirmed the functional disorders of the vision due to abnormal spherical and high
order aberrations, |Z|40 (spherical), |Z|53 (trefoil 5th order) |Z|62 (astigmatism 6th order)
(Figure 65).
Figure 65, Pentacam, Topography pre INTACS

The Keratoconus menu of the Pentacam identifies this cornea as an oblate postoperative cornea, note
the negative eccentricity and display an abnormal high aberration coefficient due to the high order
aberrations (Figure 66).
The Pachymetry map shows a smooth progression with a thick area for the implantation of the INTACS
in the 7mm zone.
She was a good candidate for INTACS implantation.
The visual acuity before the implantation of the corneal INTACS was:
OD 0.9; sph. -1.25, cyl. -0.50 @175°
OS 0.6; sph. -1.50, cyl. -0.50 @ 55°
Figure 66, Pentacam, Pachymetry progression

The visual acuity after implantation of the INTACS:

OS 1.0; sph. +0.50, cyl. -1.25 @30°.
The Scheimpflug image shows a successful fit of the implanted INTACS (Figure 67).
Figure 67, Pentacam Scheimpflug image, post op INTACS

11 Differences between Placido and elevation derived curvature maps
11 Differences between Placido and

elevation derived curvature maps
11.1 Keratoconus, OD & OS?, Prof. Michael Belin
The case shown below explains the difference between suspicious and significant elevation maps and
numbers.
The topographic map (Figure 68) shows the left and right eye but gives no unequivocal statement if it
is a Keratoconus or not.
Figure 68, Placido based Topography, OS & OD
The right eye seems to be fine. The left eye is a little steeper.
The Pentacam 4 maps screen answers clearly the question.

The right eye (Figure 69). has a regular corneal thickness but the elevation maps of the anterior and
posterior surface indicates this cornea as a suspicious cornea. Both sides show inferior position of the
cone with suspicious elevations.
Figure 69, Pentacam 4 maps, OD suspicious elevation

The left eye (Figure 70) indicates an inferior steepening, but smooth anterior elevation map. The reason
for the thinning in the pachymetry map is the posterior elevation map, where there are significant
elevations of more than 30 µm. Note the position of the thinning in the pachymetry map and the
highest spot on the elevation map are exactly at the same position.
significant elevation
Figure 70, Pentacam 4 maps OS significant elevation
This is an excellent example to document that topography or anterior elevation only does not
indicate Keratoconus.

11.2 Form Fruste Keratoconus?, Prof. Michael Belin
A 47 year old female was presented for a second opinion. She was previously told she was not a candi-
date for refractive surgery and that she had “Form Fruste” Keratoconus.
Her exam revealed a BSCVA 20/20+ OU, Slit Lamp and external examination WNL, Placido Topography
(Figure 71).
Figure 71, Placido based Topography, OS & OD
Pentacam anterior segment analysis reveals normal pachymetry (normal distribution & central thickness
> 650 microns).
The anterior & posterior elevation reveals a slightly decentered apex leading to a “False Positive” inferior
steepening on a curvature map.
Custom LASIK was performed without incident (Figure 72, Figure 73).
Discussion
This case illustrates the limitation on curvature analysis in trying to analyze a shape abnormality.
☞
Curvature is a reference based measurement and in this case, inaccurately reflects shape information.
Elevation is independent of axis or orientation and does not have the false positive rate commonly seen
with curvature maps.

Figure 72, Pentacam 4 maps OS false positive topography

Figure 73, Pentacam 4 maps OD false positive topography

12 Diagnosing ectasia and pseudo-ectasia: P. Vinciguerra M.D, M.I. Torres Munoz M.D
12 Diagnosing ectasia and pseudo-

ectasia: P. Vinciguerra M.D, M.I.
Torres Munoz M.D
12.1 Introduction
Ectatic pathologies are among the most frequently diagnosed among candidates for refractive surgery
and sometimes it is very challenging to differentiate between Ectasia and pseudo-Ectasia. With this
manual we shall attempt to establish a guideline for correctly diagnosing ectasia, even in borderline cas-
es, when using Pentacam instruments.
Set out below is an analysis of the features of a normal cornea and how the parameters differ in patho-
logical or suspect cases.
12.2 The normal Cornea
A physiological cornea is considered normal when its thinnest point is located centrally. It is thicker in
the nasal and superior areas and flattens in the nasal region. The gradient curve of a normal cornea is
predictable in that it is thinner in the center with the pachymetry progressively increasing toward the
limbus.
Figure 74, analyzing the features of a normal cornea
We can use this example (Figure 74) to analyze the features of a normal cornea from a Pentacam:
We see that the tangent curvature map reveals a maximum curvature within the norm (<48-49 D).
The pachymetric map shows normal thickness (>520-540µ) with a concentric morphology and the
thinnest point in the center.

The elevation maps show normal anterior and posterior elevation < 12-15 µ for the anterior surface
and < 20 µ* for the posterior surface (*Pentacam Values ) and the highest points of the
anterior and posterior surface do not coincide. However, the most important factor is that
the position of the highest curvature point and that of the thinnest point do not
coincide.
The Pentacam has a valid diagnostic tool, the graph showing changes in thickness.
This diagnostic representation shows changes in the thickness from the center to the periphery of a nor-
mal cornea (indicated with a red line). The same graph shows what the change in thickness should be in
a normal cornea (indicated with a central broken line) and +/- 2 the SD (indicated with broken lines above
and below).
In a normal cornea the pachymetry gradient should be parallel to one of the lines and included among
these lines that represent the abnormality.
Let us consider an example:

In the clinical case (Figure 75), the x axis represents the increase in thickness from the center (left) of
the corneal periphery (right). The Y axis represents the pachymetry values in µm.
Note how the pachymetry gradient of the cornea under examination (red line) is pathological because it
is not parallel to the line of reference, indicating a loss of tissue toward the periphery with respect to a
normal pachymetry gradient for the thickness of this cornea (broken line).
Figure 75, pachymetry gradient of the cornea under examination

12.3 Ectasia: the key to diagnosis
We must first ask ourselves: what parameters lead us off track when diagnosing ectasia?
Undoubtedly, diagnosing this pathology based on only one parameter like the curvature in a axial map
(for example curvature >48D) or the thickness in a pachymetry map (for example <500µ) may lead to a
wrong diagnosis because it is likely that an isolated parameter will lead us to a certain diagnosis of ecta-
sia.
Some corneas may have parameters that differ slightly from normal values and still be perfectly physi-
ological and pathology-free. For this reason, to make a correct diagnosis we must refer to different prin-
ciples and interlocking relationship all of the parameters that are needed to measure
the cornea:
curvature,
thickness,
anterior and posterior elevation
distribution pattern of each of these elements.
This might seem complex as a first approach, but in fact interfacing these parameters to successfully di-
agnose a pathology is simple is you follow a set method.
12.4 Interlocking relationships between curvature-elevation-

pachymetry maps
As already mentioned, a single topographic map is unreliable in diagnosing a pathology because no mat-
ter how normal a clinical case may seem sometimes surprises can lead to misdiagnosis, especially in bor-
derline cases.
We shall now analyze in detail the fundamental parameters that we must learn to interface, i.e., the key
corneal parameters whose position we must study:
A – Maximum curvature, maximum anterior and posterior elevation and the point with minimal
pachymetry
B – Coincidence of the highest points of the anterior and posterior face
C – Eccentric position of the thinnest point
D – Map patterns
12.4.1 Preliminary considerations
Before delving into the issue, a series of fundamental principles must first be clarified.
When we analyze elevation maps our reference surface must be aspherotoric.
The reason for this is simply that a normal cornea is always aspheric and if we compare it to a spheric
surface it will always be higher in the center, even in normal corneas.
However, if we study an astigmatic cornea and compare it to an aspheric reference surface the
resolution will be insufficient because the color range is not enough wide and an “ectatic nipple” could
be masked in the initial phase.

12.4.2 Maximum curvature, maximum anterior and posterior elevation

and the point with minimal pachymetry
A brief introduction is in order so that you may more easily understand certain concepts, which how-
ever I am sure you all already know well.
In elevation maps high curvature points are indicated with warm colors like orange and red.
In altimetry maps the highest points are also indicated with warm colors. The color red in pachymetry
maps identifies the thinnest point. In Holladay relative pachymetry maps the corneal points with a less
than normal thickness are also shown in warm colors (red).
Having clarified this concept, a cornea can be considered highly suspect for an ectatic pathology if the
following parameters are present:
The highest curvature point (usually shown in red and which we shall call “RED”) and the thinnest
point (RED) coincide: highly suspect cornea, alert!
The highest curvature point (RED) coincides with the highest anterior and posterior points (also
shown with warm colors and which we shall also refer to as “RED”): highly suspect cornea, alert!
The highest curvature point (RED), the thinnest point (RED) and the highest anterior and posterior
points of the corneal surface (RED) all coincide: based on these elements ectasia can be diagnosed!
We have referred to this interfacing of parameters as the “RED-ON-RED effect” and it is an
indication of ectasia.

Let us consider the example in (Figure 76).

In patient with Keratoconus , we notice that the highest curvature point (50.9D), on both the axial map
and the refractive map, coincides with the thinnest point (481µm) and with the highest anterior and pos-
terior points in altimetry.
RED ON RED
Figure 76, Coincidence of max. curvature, ant- and posterior elevation and thinnest point
12.4.3 Analysis of the highest points of the anterior and posterior face
In studying the anterior and posterior elevation maps we can consider the following as ectasia
risk factors:
Coincidence between the highest anterior and posterior points
Eccentric position of the highest point, both anterior and posterior
Anterior elevation values > 10 µm
Posterior elevation values >15 µm

Let us consider this interesting clinical case (Figure 77) of a patient with post-lasik Ectasia.
The pathology could be misdiagnosed as a case of decentralizing if we only analyze the tangent and
refractive maps. Evaluating all the interfacing parameters is the key to a correct diagnosis.
We notice that the highest anterior and posterior points have pathological values that coincide and
overlap with the thinnest point and the highest curvature point (Red-on-Red effect).
If this would be the case of a decentralization, the highest curvature point would neither coincide with
the highest point of the posterior elevation map nor with the thinnest point in pachymetry.
RED ON RED
Figure 77, POST LASIK ECTASIA

Let us look at another very didactic example (Figure 78) of a diagnosis different from that of the pre-
vious patient. In this Pentacam map the refractive ablation does not show ectasia.
We can note that the thinnest point (RED) does not coincide with the highest curvature point, but does
overlap with the flattest point (BLUE), as we would expect in the case of myopic ablation.
At the same time, the flattest point and the thinnest point coincide with the lowest elevation point in
the anterior elevation map (represented with cool colors, BLUE).
In the elevation maps of the anterior and posterior surfaces the highest points do not coincide.
We have called this pattern the “RED-on-BLUE effect” and in most cases it rules out ectasia diagnosis.
RED ON BLUE
Figure 78, POST REFRACTIVE ABLATION
12.4.4 Eccentric position of the thinnest point
Another interesting factor worthy of analysis is the position of the thinnest point.
Usually, the thinnest point is centered in normal corneas and decentered in ectasic corneas (KC, Pellu-
cid). In patients that have undergone refractive surgery the thinnest point is in the center, for example
post-lasik (obviously provided that the treatment has been centered correctly). A particular case is that
of patients with post-lasik ectasia. At the onset of the ectasia pathology the thinnest point is centrally
positioned, but as the pathology progresses the thinnest point tends to migrate toward an eccentric
position in the direction of the region of ectasia.
12.4.5 Map patterns
Finally, another very important factor to be analyzed is the morphology of distribution of the different
parameters: curvature, thickness and elevation. We can consider the following patterns as indicating
a risk of ectasia:

Curvature: eccentric and asymmetric distribution with a cornea curve (>48D) surrounded by a rel-
atively flat area.
Pachymetry: asymmetric or eccentric island d with lower than normal values.
Elevation: eccentric island with higher than normal values.
We see in this example (Figure 79) of a patient with Keratoconus that the Pentacam maps show the
before mentioned morphology.
Figure 79, Keratoconus PATTERN
12.5 Conclusions and noteworthy points
We consider the Pentacam as the most reliable instrument for diagnosing ectasia to be the analysis and
interfacing of the parameters obtained from each single map.
We can define an ectasic cornea or one with a high risk of ectasia as one showing the “Red-on-Red”
effect and in which:
the areas of highest curvature (RED) overlap with the thinnest point (RED) or
the areas of highest curvature (RED) overlap with the highest anterior and posterior points (RED)
in the same way, there is a good likelihood that we can exclude ectasia when the Pentacam exam
reveals that the cornea analyzed shows a “Red-on-Blue” effect, i.e.,:
the suspect areas of highest curvature (RED) overlap with the flattest elevation points in the eleva-
tion map (BLUE)
the suspect areas of highest curvature (RED) do not overlap with the thinnest point

13 Holladay Report
13 Holladay Report
13.1 Detecting forme fruste Keratoconus
This Holladay Report was developed together with Jack T. Holladay, MD.
The goal was:
the improvement of the calculation of IOL’s for patients who have underwent corneal surgery in
the past
to design a display which contains the most necessary information for screening patients.
The Holladay Report is shown in (Figure 80).

In the upper left hand corner is the patient’s demographic information. The upper center box are the
Equivalent K-readings (EKR) that may be used for IOL calculations. The upper right hand corner is what
the program calculates the K’s would have been before refractive surgery. In this case, since there has
been no surgery, the values are almost identical to the EKR values.
Figure 80, Holladay Report, virgin eye
On the middle row of Maps are the Sagittal Front, Pachymetry and Front Elevation Maps.
The Sagittal Front or Axial Power Map is the most common map used in topography and represents
the axial power of the cornea at all points.
The Pachymetry Map shows the thickness at all points in the cornea and is especially helpful for the
central corneal thickness.

13 Holladay Report
The Front/Back Elevation Map shows the height of the anterior/posterior cornea relative to the Best
Fit Toric Ellipsoid. Although a sphere may be used for the fit, a Toric Ellipsoid is nearer the shape of the
normal cornea.
Because the cornea is normally Ellipsoid, if a sphere is used the center is always above the sphere and
the periphery is always below. This makes it difficult to give normal values because it depends on the
shape of the cornea. Also, if astigmatism is present, a ‘Band’ will appear across the center because the
steeper meridian will be below the reference sphere and the flatter meridian above. When a Toric Ellipsoid
is used the Band disappears because the reference surface is Toric and because the Ellipsoid is used the
central vaulting above the reference surface has less variation.
The Tangential Map is the most sensitive for determining the geometry of the cornea. Unlike the
Sagittal Map, the Tangential Map Curvatures are relative to the surface, not the axial center of the sur-
face. A simple analogy would be to consider the earth a sphere with a radius of 8,000 miles with a hemi-
sphere on the surface that was 6 miles high (Mount Everest). On the Sagittal Map, the radius would
measure 8,000 and 8,006, since the center of the earth is the reference, almost no difference is detected.
On the Tangential Map, the Earth would be 8,000 miles, but the hemisphere radius would be 6 miles, so
a very large difference is detected. The Tangential Map is always the most sensitive measure of the geo-
metric surface. Because of this property the Tangential Map shows the exact location of the ‘nipple’ of
the cone. Notice the steepest part is at 330 degrees approximately 2 mm from the center (white dia-
mond).
The Relative Pachymetry Map gives the thickness of the cornea at that point relative to the normal
thickness at that point as a percentage. A normal Map would be 0% at all points. Even though the cornea
gets thicker as we move to the periphery, if the patients thickness increases normally, the Map still ap-
pears green (0.0%).
Strategy:
In (Figure 80), we see that the Relative Thinnest Point is -5.0% thinner than it should be at that point.
Note that this point is at the same location as the nipple on the Tangential Map. Finally, the Back Eleva-
tion Map using the Best Fit Toric Ellipsoid, has a yellow spot that is +16 microns above the Reference
Toric Ellipsoid, also at the same ‘hot spot’ as the Tangential and Relative Pachymetry Map. Note that this
point on the Normal Pachymetry Map does not show up because the cornea is still thinnest centrally, so
the Relative Thickness is obscured. It is of interest to note that epithelium of the corneal anterior surface
thins over the nipple, reducing the sensitivity of the diagnosis from the front surface alone. In this case
the anterior surface is only 10 microns above the Reference Surface (not 16 microns as on the Back El-
evation). Normal epithelial cells are 6 to 8 microns thick and there are usually 6 to 8 layers of epithelial
cells. The epithelium is ~ 1 epithelial cell thinner over the ‘nipple’.
Summary
The result is that when the ‘hot spot’ on the Tangential Map, Relative Pachymetry Map and Back Eleva-
☞
tion Map using the Toric Ellipsoid are all at the same point, the diagnosis of Forme Fruste Keratoconus
is confirmed.
In our experience:
Relative Pachymetry Measurements that exceed -3.0% are significant
elevations above 15 microns above the Toric Ellipsoid on the Back Elevation Map are significant.

14 IOL calculation for patients after refractive surgery
14 IOL calculation for patients after

refractive surgery
14.1 EKR’s in the Holladay Report
More and more patients who have received a LASIK, PRK or RK treatment in the past are developing now
cataract. But often we have no information about the pre-op K-readings and therefore the
double-K-Method does not work to calculate the IOL.
This problem is well known and several methods have been tried to obtain proper K-readings for the cal-
culation of the IOL.
Placido based topographers calculate the refractive power of the cornea with the approximation that the
radii ratio between back/front of the cornea is 82% and constant. This leads to an overall average corneal
refractive index of n=1.3375.
This is correct for untreated eyes but after any surface alteration the radii ratio changes. For myopic
treatment, it decreases and for hyperopic treatments, it increases.
Therefore, we have to consider the anterior and posterior curvature to calculate the true corneal power.
The specific refractive indices for cornea and for aqueous have to be used to convert curvature into re-
fractive power.
Another fact is that Placido based topographer always have a blind spot in the center and this area is
interpolated assuming a central steepening. This is correct for untreated eyes but after myopic treat-
ments it is vice versa. This results in wrong curvature and wrong refractive central corneal power.
It is essential to measure the center for accurate corneal measurement, especially for the K-readings. The
Pentacam´s rotating scan measures the central cornea very precisely.
The Equivalent Keratometer Readings, EKR’s consider all the effects. Additionally, they are calculated
with reference to the pupil center.
In a study that J. T. Holladay, MD and Warren Hill, MD performed for post LASIK, PRK and RK patients,
the best post-op visual acuity was found while using the EKR’s in the 4.5mm zone.
Figure 81, EKR’s in 4.5mm zone
The EKR’s in the 4.5mm zone can be used for post refractive and for normal patients. They can be
directly typed-into the IOL Master.

14.2 Details of the Holladay Report
The printout of the detailed Holladay Report displays more information.

The table chart in the upper left displays the EKR’s in different zones around the pupil center. This is use-
ful for patients with very large or small pupils.
The diagram in the lower left displays the refractive power distribution of the EKRs in the selected zone,
here the 4.5mm. The example shows a clear peak.
This corresponds well with the upper right diagram which shows the progression of:
the mean zonal sagittal curvature vs. zone diameter in red
the mean ring sagittal curvature vs. ring diameter in green.
The red and the green graph are parallel up to the 4.5mm zone around the pupil center.
The big advantage is the pre-op estimation of the outcome after IOL implantation. Because of the small
range in power (which results in the clear high peak), a good post-op outcome can be expected. This al-
lows an adjustment in the patient´s expectations.
Figure 82, Holladay EKR Detail Report, post LASIK

The opposite example is shown in the image below. The refractive power distribution diagram displays a
wide range of refractive power and no clear peak. It shows several peaks.
The diagram in the upper right hand side shows that the red and green graphs are not parallel as well.
This confirms the EKR distribution.
In this case, we will never reach “100 %” of visual acuity. This is caused by the highly distorted cornea
and allows an adjustment of patient´s expectations.
This makes it understandable why the IOL calculation for post RK patients is often so difficult.
Figure 83, Holladay Detail EKR Report, post RK patient
For more information concerning the Holladay Report and the Holladay IOL formula, please visit the
homepage of Jack T. Holladay MD www.docholladay.com.

14.3 High myopic refractive change after LASIK, Tobias

Neuhann, MD
There is no ideal formula available for a reliable IOL calculation for very high refractive changes. I can
recommend a simple way for those cases to meet both patient and surgeon’s expectation:
Use the central measured power of the Pentacam (true net power) and fill this number into K1 and K2
into your preferred IOL formula. Also, use several other formulas to get a better idea where one will fin-
ish.
This is the best solution I can recommend.
The BSCVA pre-op of the patient shown below was 20/200 with a myopic maculopathy. The central pow-
er in the True Net Power Map, (Figure 84) of the cornea was 22.3 D after PRK for –14 D myopia! This
power result is very low. More than 20 D lower than a normal cornea. We only had this information for
the cataract surgery and we ended –1.5 D off the intended refraction which was emmetropia with a BSC-
VA of 20/40 because of the myopic maculopathy. The patient is now very happy and wants absolutely
no IOL exchange.
Figure 84, Pentacam True Net Power map, post LASIK

15 phakic IOL implantation
15.1 Manual pre-op simulation and post-op control,

Eduardo Viteri, MD
15.1.1 Preoperative evaluation
A high myopic, 20 year old patient enters the office; refraction data:
OD: -12.00 (-1.50 x180),
OS: -12.50 (-1.50 x 10).
She complained of poor contact lens tolerance with less than 4 hours of daily wearing time.
We discussed several treatments and the possibility of implanting a pIOL.
The Pentacam allows us to measure very easily and accurately the anterior chamber, in order to deter-
mine if there is enough space to implant an iris fixation Artisan Phakic IOL.
One can measure, not only the distance from the endothelium to the anterior surface of the crystalline
lens, but also the available space at the point where the claws will grasp the iris (Figure 85).
Most important are minimum distances which are in most of the cases not perpendicular to the iris, but
diagonal.
Figure 85, Scheimpflug image with pre-op measurements
The Pentacam examination for the pre-op planning of the surgery shows there is enough space for the
Artisan pIOL implant.

15.1.2 Postoperative evaluation
The Scheimpflug image shown below displays the same case after the successful Artisan pIOL implanta-
tion.
It is evident there is space from the anterior pIOL surface to the endothelium centrally and at the periph-
ery (Figure 86).
The posterior of the pIOL presents also enough distance to the iris and to the crystalline lens. Her post-
op refraction:
OD: +0.25 (-1.00 x 180),
OS: +0.50 (-1.00 x 180).
We had a good pre-op planning and a happy post-op patient.
Figure 86, Scheimpflug image after Artisan IOL implantation

15.2 3D - phakic IOL simulation, Burkhard Dick, MD, Sabine

Buchner, Optometrist
15.2.1 Myopic Artisan / Verisyse 6 / 8.5 mm
A 40 years old female:

OD: sph -15; cyl -1.25 @82°,
and
OS: sph -14.75; cyl -1.75 @83°,
BSCVA in both eyes was 0.63
asked for refractive correction.
She complained of poor contact lens tolerance because of dry eyes with less than 3 hours daily wearing
time. Because of the high ametropia in both eyes we thought of phakic IOL implantation to obtain her
ability to accommodate because of her age of 40 years.
The pupil sizes were:

scotopic: OD 6.24mm, OS 6.27mm
mesopic low: OD 4.74mm, OS 4.78mm
mesopic high: OD 3.62mm, OS 3.56mm.
Because of the high ametropia, LASIK and PRK were not an option. Therefore we checked the possibility
of a phakic IOL implantation. The 3D simulation of the fit of a phakic IOL provides the answer quickly.
Because of the big pupil size, only the Artisan/Verisys with the 6mm optic would be suitable. The mini-
mum clearance in the anterior chamber between the pIOL optic edge and the endothelium was 1.22m.
Figure 87, phakic IOL fit simulation, current age

Because of these distances between the pIOL and the endothelium, it would be currently safe.
The mimimum clearance between the pIOL and the endothelium is 1.22mm calculated in 3D.
The iris convexity which is shown on the lower right hand side.
What happens when the patient is getting older?

The crystalline lens grows app. 19µm per year. This would necessarily cause a shift of the pIOL towards
the endothelium.
The result is less distance between the pIOL and the endothelium. To avoid possible endothelium cells
loss, one must be aware of this.
The Pentacam offers the unique aging prediction software which simulates the position of the pIOL after
10, 15 or 20 years.
The lower image shows the distances ten years after pIOL implantation.
Figure 88, pIOL fit simulation, 10 years after implantation
The horizontal Scheimpflug image shows a minimum clearance between optic edge and endothelium of
1080µm, but the true minimum clearance between the pIOL optic edge and the endothelium is 1.00
mm which is already borderline.

The image below shows the simulated pIOL position 20 years after implantation.
Figure 89, pIOL fit simulation, 20 years after implantation
The horizontal Scheimpflug image shows a minimum clearance between optic edge and Endothelim of
920µm, but the true minimum clearance between the pIOL optic edge and the endothelium is
0.86 mm, which is too small.
Discussion:
From the first impression, this patient is suitable for pIOL implantation considering the anterior chamber
☞
conditions.
Without the Pentacam, we would have done the implant.
Because of the pIOL position after 10 or 20 years, we decided not to perform the surgery.
This case demonstrates the big advantage of the Pentacam in the daily clinical practice.
Without touching the patients eye, we were able to make a competent diagnosis and decision followed
by an elaborated conversation with the patient.

15.2.2 Toric Artisan/Verisyse, 5/8.5mm
A 22 years old female:

OD: sph. -18.5dpt / cyl. 4.0dpt / @ 127°
OS: sph. -10.5dpt / cyl. 1.5dpt / @ 45°
Asked for refractive surgery.
On the left cornea, a small corneal cicatrice was detected centrally during slit lamp examination.
The pupil size is:
scotopic: OD 7.51mm, OS 7.34mm
mesopic low: OD 5.40mm, OS 5.24mm
mesopic high: OD 4.34mm, OS 4.27mm.
IOP is 16mmHg in both eyes. We count OD 2318 cells/mm2 and OS 2418cells/mm2.

We used the Pentacam 3D pIOL simulation program to simulate the fit of the pIOL and to check its po-
sition years after surgery using the aging prediction module.
Figure 90, pIOL fit simulation, current age
After typing in the subjective refraction, the pIOL lens power is calculated automatically. The toric
Artisan/Verisyse was selected and the simulation display shows the pIOL fit in axis of the astigmatism.
The maximum iris convexity is 12.9° and the minimum clearance between pIOL optic edge and endothe-
lium is 1.63mm. Therefore from the current point of view everything is within the limits.

The patient is a 22-year old female. We want to check the pIOL position after ten and twenty years,
and to be on the safe side, for 40 years as well.
Figure 91, pIOL fit simulation ten years after implantation
Figure 92, pIOL fit simulation twenty years after implantation
The aging prediction module displays a minimum clearance of 1.48mm ten years after and 1.32 mm
twenty years after implantation.
Please pay attention to the minimum distance shown in the Scheimpflug images. The Scheimpflug im-
ages are showing the pIOL position in 41°, near to the axis of the astigmatism. Ten years after implanta-
tion the distance is slightly higher and twenty years after implantation displays it surpasses the true
minimum clearance as well.
This is very important since the clearances between the pIOL and the endothelium is an exclusion criteria.
Just looking to one or two different images may not give the true minimum clearances. This is the big
advantage of the real 3D simulation which shows immediately the minimum clearance between the pIOL
optic and the endothelium.

We checked the pIOL position 40 years after surgery as well.

The simulated minimum clearance is now 1mm.
Figure 93, pIOL fit simulation 40 years after implantation
Discussion
The amount of endothelium cells is in the normal range. Patient is young with stable refraction for one
☞
year. The minimum clearance of 1.63mm between pIOL and endothelium is large enough. The aging pre-
diction shows 1.32 mm clearance after twenty years which is sufficient.

15.3 Patients selection criteria, Burkhard Dick, MD, Sabine

Buchner, Optometrist
The pre-op evaluation and careful patient selection is essential for a successful implantation.
There are several criteria that have to be considered.
In our clinic, we are looking to the following:
Minimum clearance between pIOL and endothelium should be higher than1mm
Minimum of 2000 endothelium cells per mm2
A dislocation of the pupil higher than 1mm is not advisable. The Scheimpflug Image in (Figure 94)
shows a dislocation of app 1070µm.
Clear cornea and crystalline lens
Iris convexity, if the iris is very irregular, it is not advisable. The Pentacam pIOL simulation highlights
an iris convexity that is higher than 15 degrees, shown in (Figure 95).
Figure 94, pupil dislocation visible and measurable in the Scheimpflug image
Figure 95, pIOL simulation, large iris convexity
The following warning appears:

"Automatic pIOL alignment may be influenced negatively by large iris convexity."

16 From the daily practice
16.1 Case 1, Cortical Cataract, Tobias Neuhann, MD
A 23 year old -12.5 D myopic white female have had a fundus examination in a local eye department.
Best spectacle corrected visual acuity (BSCVA) was 20/30.
Best corrected visual acuity with contact lenses (BCLCVA) was not documented.
She was told having cataract surgery would be the only option to enhance visual acuity.
Now she appeared in our clinic for a second opinion.
Scheimpflug image (Figure 96) could perfectly document the peripheral cortical density (yellow ar-
row). The cause for the reduced spectacle best corrected vision was corneal warpage caused by the con-
tact lenses which slightly changed in two weeks (Figure 97).
Figure 96, Pentacam Scheimpflug image, Cortical cataract
Figure 97, Pentacam, Show 2 Exams

16.2 Case 2, Corneal transplant, removing the sutures?,

Tobias Neuhann, MD
A 22 year old white male had a corneal transplant due to Keratoconus 12 months earlier. The first
suture was already removed.
The examination with the Pentacam shows a small corneal astigmatism, (Figure 98) but a peripheral
hot spot (white arrow).
The BSCVA was 20/25 after removing the first sutures. I have no idea what happens after removing the
second sutures.
WHAT WOULD YOU RECOMMEND
Question is now:
REMOVE THE SECOND SUTURES YES or NO
Figure 98, Pentacam topography, corneal transplant
We recommended no suture removal because of the „hotspot“ temporal of the center and the low
astigmatism.
The patient only wears his glasses for driving at night.

16.3 Case 3, Keratoconus and Cataract,

Tobias Neuhann, MD
A 54 year old male asks for glasses. BSCVA is on both eyes 20/80.
The Pentacam gives the solution in two seconds. The right eye has a cataract and undetected
Keratoconus (Figure 99, Figure 100, Figure 101). The left eye has no cataract but undetected Kera-
toconus (Figure 102, Figure 103, Figure 104).
Figure 99, 4 maps refractive OD
Figure 100, Pachymetry Progression, OD Figure 101, Scheimpflug Image, OD

Figure 102, 4 Maps Refractive, OS
Figure 103, Pachymetry progression, OS Figure 104, Scheimpflug Image, OS

Our recommendation is:

1 cataract surgery on the right eye,
2a deep lamellar keratoplasty left eye,
2b toric IOL implantation left eye after suture removal.
There is still one question open for the right eye!
Which K reading shall we use for the IOL calculation?
Figure 105, Topography, central part
The Pentacam gives us the true and real measured central power of the cornea!
We used 42.9 for both K1 and K2 (Figure 105).
Postoperative refraction is +0.5 D of the intended refraction!
Note:
The Pentacam measures the true power of the central cornea while topographers have to extrapolate the
central power of the cornea because of the blind spot in its center where the camera is located!

16.4 Case 4, Corneal Infiltrate, Renato Ambrósio, Jr, MD
A 33-year old female referred for evaluation of a corneal infiltrate.

The patient mentioned having used tap water for cleaning the soft contact lens overnight two days ago
and started symptoms after 6 hours using the lens in OS. She woke up with moderate secretion.
She complains about photophobia and blurred vision in OS with glasses.
Pentacam was performed in both eyes and the infiltrate could be documented with clinical correlation
with slit lamp biomicroscopy (Figure 106, Figure 107).
Figure 106, Pentacam Scheimpflug image, corneal infiltrate
Figure 107, Slit lamp photo, corneal infiltrate

She herself prescribed topical drop of combination of neomycin, polymixin B and dexametasone, using
4 times since last night and referred mild improvement.
Patient was advised to discontinue contact lens use in both eyes and asked to stop the medication. We
decided to empirically start 4th generation Fluoroquinolones every hour around the clock, having initi-
ated with attack dose of one drop every ten minutes during the first hour.
One day later she referred improvement in the symptoms and vision.
Figure 108, Pentacam scheimpflug image, corneal infiltrate 3 days after
Figure 109, Slit lamp Photo, corneal infiltrate, 3 days after
Pentacam was repeated in day 3. The infiltrate has deceased as seen in the Scheimpflug images and slit
lamp biomicroscopy (Figure 108, Figure 109). She noted improvement in BSCVA in OS.

16.5 Case 5, Incisional Edema, Renato Ambrósio, Jr, MD
A 76 year old female patient referred with incisional edema 12 months after phaco that improved with
discontinuation of topical carbonic anydrase inhibitor use.
Endothelial morphology demonstrates large cells with pleomorfism and polymegatism.
Central cell count was 1.079 cells/mm2.
Figure 110, Slit lamp photo, incisional edema Figure 111, S.image, incisional edema
Slit lamp exam (Figure 110) can be correlated with the Pentacam exam (Figure 111).
The central cornea was clear with no edema.
The peripheral cornea at the incision location was edematous with small bullae formation on the
surface. The pachymetric map correlates with this finding.
Interestingly the Scheimpflug image demonstrates the “U shape” sign or “Camel sign” on the
densitometry over the edematous area.
This is the high reflectivity of the posterior layer of the cornea at the incision level.

16.6 Case 6, Corneal Thinning after Herpetic Keratitis,

Renato Ambrósio, Jr, MD
A 68 years old female patient enters the office with a long history of several episodes of HSV (Herpes-
simplex-Virus) stromal keratitis. The careful slit lamp examination (Figure 112) reveals a sub-epithelial
scarring of the central cornea consistent with “ghost scarring” of HSV.
Figure 112, Slit lamp photo Figure 113, Overview, corneal thinning
Pentacam exam is useful to document corneal thickness. The thinnest spot is displayed in the Pachym-
etry map and can be seen in the Scheimpflug images which serve for follow up examination
(Figure 113). Patient was kept on prophylactic Acyclovir 800 mg per day, omega 3 essential fatty acid
supplementation (Flaxseed oil, 1g BID) and topical artificial tears.

16.7 Case 7, Epithelial Ingrowth after Keratomileusis

in situ, Renato Ambrósio, Jr, MD
A 41 years old male patient with history of in situ Keratomileusis in 1991 and one re-treatment for re-
moval of epithelial ingrowth asked for a second opinion.
The Slit lamp examination (Figure 114) reveals epithelial ingrowth under a moderately deep cap in OD,
reaching the center of the pupil area.
Figure 114, Slit lamp photo and Tomography
With the Pentacam the ingrowth can be easily seen in the tomography (Figure 114).

The pachymetry map in the four map screen (Figure 115) shows this effect, too, even while having an
opaque cornea.
The Pentacam was useful for evaluating corneal elevation, curvature, thickness and opacity.
Figure 115, Pentacam 4 Maps Refractive

17 Scheimpflug and Slit lamp images
17.1 Corneal Dystrophy
Figure 116, Pentacam Scheimpflug Image, Corneal Dystrophy, posterior surface
Figure 117, Slit lamp photo, Corneal Dystrophy, posterior surface

17.2 Congenital anterior pyramid cataract
Figure 118, Pentacam Scheimpflug image, anterior pyramid cataract
Figure 119, Slit lamp photo, anterior pyramid cataract

17.3 Posterior Capsular Cataract
Figure 120, Pentacam Scheimpflug image, posterior capsular cataract
Figure 121, Slit lamp photo, posterior capsular cataract

17.4 Nuclear Cataract
Figure 122, Pentacam Scheimpflug Image, nuclear cataract
Figure 123, Slit Lamp Photo, nuclear cataract

17.5 Posterior Synechia
Figure 124, Pentacam Scheimpflug image, posterior Synechia
Figure 125, Slit lamp photo, posterior Synechia

17.6 Pterygium
Figure 126, Pentacam Scheimpflug image in 190°, Pterygium
Figure 127, Topography, Pterygium Figure 128, Photo, Pterygium

18 Orthokeratology
18 Orthokeratology
18.1 Case 1, General Screening, Alain-Nicolas Gilg, MD
A male, 34 years old, referred for changing his soft contact lenses because of a progressive intolerance
during the day.
The subjective refraction results in visual acuity

OD sph. -2.5,
OS sph. -1.0.
The Pentacam “Show 2 examinations screen” displays an optimal eccentricity on the 30° of both eyes,
OD 0.50, OS 0.49 which permits us to propose the orthokeratology treatment to this patient
(Figure 129).
After fitting the lenses, prior to midday examinations revealed a good visual acuity on day 1, VA: 0.8, day
8 and 28 VA: 1.0.
Figure 129, Pentacam, OS & OD, pre Orthokeralotogy

18 Orthokeratology
The patient was examined 4 times within 2 months to view the corneal progression.
The 4 maps comparison screen confirmed the efficacy of the treatment (Figure 130).
Figure 130, Pentacam, follow up Orthokeratology

19 Recommended Settings and Color Maps
On day 28, the patient complained of fluctuations during the day of his visual acuity.
The Patient was examined in the morning after wearing the lens over night and in the late afternoon.
The Pentacam confirmed using the “Compare 2 Exams” screen that the effect of the ortho-K lens was
reversible during the day which leads to the diagnosis to fit a more effective ortho-K lens to this patient
(Figure 131).
Figure 131, Pentacam, follow up
19 Recommended Settings and

Color Maps
During many talks with doctors who are starting to work with the Pentacam, we often got the question
concerning the settings and step width of the color scale, which maps and values should we look before
doing LASIK, PRK, RK or before doing an implantation of an phakic IOL or for detecting Keratoconus etc.
In the following chapter, we give additional recommendations while knowing we will not cover every-
thing but hopefully most of the cases. We know each doctor is used to work with his individual maps
and settings for many years.
Therefore, please understand the following chapter as recommendations only, but perhaps some new
and interesting points are mentioned.

19.1 Recommended Settings
For the correct use and interpretation of the following chapters it is necessary to use the same settings
because the given values often need defined basic settings.
In the scan menu 25 images per scan and auto release;

For the elevation maps, a sphere, fitted in float (BFS), diameter manual 8mm or 9mm;
Keratometer presentation Rflat/Rsteep, refractive power (dpt);
Corneal Form Factor Asphericity Q
Q < 0 untreated cornea, normal case,
Q > 1 treated cornea LASIK/PRK/RK etc.
Color scale American Style,
step width normal (10µm) for pachymetry maps;
step width normal (1dpt) for topography maps;
step width rel. (2.5µm) minimum for elevation maps.
Especially for the American market, use the 9mm loupe function.
19.2 Recommended Color Maps
19.2.1 Screening for LASIK, PRK etc.
We recommend using the following maps and analyzing displays:
Belin/Ambrosio Enhanced Ectasia

or:
Holladay Report
Scheimpflug Image ( clear lens)
Zernike Analysis
especially for re-treatments to see if there are high order aberrations (highlighted in red).
Important values
K1, K2, Asti and Axis, Q-value, QS, Pachymetry in the thinnest spot and in the pupil centers, border
values in the elevation maps (following the recommendations in chapter 5.1).
19.2.2 Screening for pIOL implantation
We recommend using use the following maps and analyzing displays:
pIOL simulation (available for the Pentacam HR only)

4 maps Chamber
to check the anterior chamber depth, especially in the periphery; sometimes it is helpful to look at
the large color map of the anterior chamber depth. The topography maps in sagittal radii as well as
the True Net Power map are displayed, too, to check whether the cornea was treated or if the pos-
terior corneal surface shows abnormalities which may cause changes in refractive power.

Scheimpflug images
to get information about the dimensions of the anterior chamber and of the iris curve. The chamber
angle is shown also to see whether there is an open or closed angle.
Important values
K1, K2, Asti and Axis, Q-value, QS, ACD (anterior chamber depth) Pachymetry in the thinnest spot
and in the pupil center.
19.2.3 Glaucoma Screening
We recommend using the following maps and analyzing displays:
Overview screen
Look to the chamber angle (<25° is not normal) in the Scheimpflug images and to the corneal thick-
ness. Correct the tonometrically measured IOP with the implanted correction tables. The chamber
depth and chamber volume is obviously small; usually < 100mm3 for close angle
glaucoma risk patients.
Important values
ACD, chamber volume, chamber angle, QS, Pachymetry, IOP-correction.
19.2.4 IOL Calculation for Treated and Untreated Corneas
The Holladay Report which has the advantage of a comprehensive overview about the cornea.
The topographic maps are displayed as well as the pachymetry map and the anterior and posterior
elevation maps.
The ACD, the simulated K-values (SimKs) are presented as well as the Equivalent-K-Readings (EKRs).
The current ratio back/front power is depicted, too. This makes it easy to check whether the cornea
has undergone any refractive surgery or not.
Based on the individual experiences each one can decide which values will give the best outcome
for the patient, using the EKR’s, SimK’s or the Rm.
The BESSt formula, which requires Rm anterior; Rm posterior; CCT and ACD.

20 List Of illustrations
Figure 1, Pentacam, OD post LASIK, Ectasia ...................................................................................................................................2
Figure 2, Pentacam, OS post LASIK, Ectasia ................................................................................................................................... 3
Figure 3, Pachymetry Progression, OD............................................................................................................................................. 3
Figure 4, Pachymetry Progression ..................................................................................................................................................... 3
Figure 5, ORB Scan post LASIK, Ectasia ...........................................................................................................................................4
Figure 6, Pentacam 4 maps, post LASIK no Ectasia .................................................................................................................... 5
Figure 7, Orbscan® 4 Maps, Pentacam 4 Maps Refractive ......................................................................................................6
Figure 8, Pentacam 4 maps .................................................................................................................................................................. 7
Figure 9, HRT Image................................................................................................................................................................................. 8
Figure 10, HRT Image ..............................................................................................................................................................................8
Figure 11, Pentacam Overview post op to YAG laser Iridectomy ......................................................................................... 8
Figure 12, Pentacam Overview, 10 days after YAG Laser Iridectomy .................................................................................9
Figure 13, Pentacam, 2 maps comparison ..................................................................................................................................... 9
Figure 14, screening parameters ..................................................................................................................................................... 11
Figure 15, Pentacam, astigmatic cornea ...................................................................................................................................... 13
Figure 18, Pentacam, posterior astigmatism.............................................................................................................................. 16
Figure 19, Pentacam, spherical cornea ......................................................................................................................................... 17
Figure 20, Pentacam, spherical thin cornea ............................................................................................................................... 18
Figure 21, Pentacam, thin cornea ................................................................................................................................................... 19
Figure 22, Pentacam 4 maps, borderline case ........................................................................................................................... 20
Figure 23, Pentacam, displaced apex ............................................................................................................................................ 21
Figure 24, Pentacam 180°, S.image, PMD ................................................................................................................................... 22
Figure 25, Pentacam 90°, S.image, PMD ...................................................................................................................................... 22
Figure 26, Pentacam PMD pachymetry map .............................................................................................................................. 22
Figure 27, Pentacam, asymetric cornea, OD normal topography ...................................................................................... 23
Figure 28, Pentacam asymetric cornea, OS Keratoconus ...................................................................................................... 24
Figure 29, Pentacam, false negative topography ..................................................................................................................... 25
Figure 30, Pentacam, Keratoconus OD > OS .............................................................................................................................. 26
Figure 31, Pentacam, classical Keratoconus ............................................................................................................................... 27
Figure 32, (CTSP) .................................................................................................................................................................................... 28
Figure 33, Thickness profile in Ectatic and normal eye .......................................................................................................... 30
Figure 34, normal thin cornea, topography ............................................................................................................................... 31
Figure 35, normal thin cornea, Pachymetry ............................................................................................................................... 31
Figure 36, Ectatic cornea, topography .......................................................................................................................................... 32
Figure 37, Ectatic cornea, Pachymetry ......................................................................................................................................... 32
Figure 38, Asymmetric cornea, topography ............................................................................................................................... 33
Figure 39, Asymmetric cornea, Pachymetry ............................................................................................................................... 33
Figure 40, False positive topography ............................................................................................................................................. 34
Figure 41, Normal Pachymetry ........................................................................................................................................................ 34
Figure 42, Scheimpflug image, Fuchs Dystrophy ..................................................................................................................... 35
Figure 43, Fuchs Dystrophy, Pachymetry .................................................................................................................................... 35
Figure 44, clear cornea in OD and OS with no peak in the densitogram for the endothelium............................. 36
Figure 45, thick cornea and abnormal corneal thickness progression graph in OS and OD .................................. 36
Figure 46, HRT optic nerve OD/OS single report ....................................................................................................................... 37
Figure 47, Scheimpflug images, unclear cornea in OD and OS .......................................................................................... 38
Figure 48, abnormal corneal thickness progression graph in OS and OD ...................................................................... 39
Figure 49, Specular Microscopy, OD and OS .............................................................................................................................. 40
Figure 50, HRT single initial report, rim configuration out of normal limits, diagnosis glaucoma ..................... 40
Figure 51, standard best fitted sphere (BFS) .............................................................................................................................. 42
Figure 52, Keratoconus, abnormal area of elevation (red circle) ....................................................................................... 43
Figure 53, enhanced best fitted sphere (BFS) ............................................................................................................................ 43
Figure 54, normal cornea ................................................................................................................................................................... 44
Figure 55, abnormal cornea............................................................................................................................................................... 44
Figure 56, Belin/Ambrosio Enhanced Ectasia Display ............................................................................................................. 46
Figure 57, Placido Topo OD ................................................................................................................................................................ 47
107 / 111 Interpretation Guideline Pentacam / Pentacam HR (IG/70700/0608/en)

Figure 58, Placido Topo OS ................................................................................................................................................................48

Figure 59, B/A Enhanced Ectasia Display ..................................................................................................................................... 49
Figure 60, B/A Enhanced Ectasia Display OD ..............................................................................................................................49
Figure 61, Pentacam 4 maps, cone location ...............................................................................................................................50
Figure 62, Pentacam Topography ....................................................................................................................................................51
Figure 63, Pentacam 4 maps, Keratoconus .................................................................................................................................52
Figure 64, Pentacam Keratometer values ....................................................................................................................................52
Figure 65, Pentacam, Topography pre INTACS ..........................................................................................................................53
Figure 66, Pentacam, Pachymetry progression .........................................................................................................................54
Figure 67, Pentacam Scheimpflug image, post op INTACS ..................................................................................................55
Figure 68, Placido based Topography, OS & OD ........................................................................................................................ 56
Figure 69, Pentacam 4 maps, OD suspicious elevation ...........................................................................................................57
Figure 70, Pentacam 4 maps OS significant elevation ...........................................................................................................58
Figure 71, Placido based Topography, OS & OD ........................................................................................................................59
Figure 72, Pentacam 4 maps OS false positive topography .................................................................................................60
Figure 73, Pentacam 4 maps OD false positive topography ................................................................................................61
Figure 74, analyzing the features of a normal cornea ...........................................................................................................62
Figure 75, pachymetry gradient of the cornea under examination ..................................................................................63
Figure 76, max. curvature, max. anterior, posterior elevation, point with minimal pachymetry .........................66
Figure 77, POST LASIK ECTASIA ........................................................................................................................................................ 67
Figure 78, POST REFRACTIVE ABLATION .......................................................................................................................................68
Figure 79, Keratoconus PATTERN .................................................................................................................................................... 69
Figure 80, Holladay Report, virgin eye ..........................................................................................................................................70
Figure 81, EKR’s in 4.5mm zone .......................................................................................................................................................72
Figure 82, Holladay EKR Detail Report, post LASIK .................................................................................................................. 73
Figure 83, Holladay Detail EKR Report, post RK patient ........................................................................................................ 74
Figure 84, Pentacam True Net Power map, post LASIK ..........................................................................................................75
Figure 85, Scheimpflug image with pre-op measurements .................................................................................................76
Figure 86, Scheimpflug image after Artisan IOL implantation ...........................................................................................77
Figure 87, phakic IOL fit simulation, current age .....................................................................................................................78
Figure 88, pIOL fit simulation, 10 years after implantation .................................................................................................79
Figure 89, pIOL fit simulation, 20 years after implantation .................................................................................................80
Figure 90, pIOL fit simulation, current age .................................................................................................................................81
Figure 91, pIOL fit simulation ten years after implantation ................................................................................................82
Figure 92, pIOL fit simulation twenty years after implantation .........................................................................................82
Figure 93, pIOL fit simulation 40 years after implantation ..................................................................................................83
Figure 94, pupil dislocation visible and measurable in the Scheimpflug image.......................................................... 84
Figure 95, pIOL simulation, large iris convexity .........................................................................................................................84
Figure 96, Pentacam Scheimpflug image, Cortical cataract ................................................................................................85
Figure 97, Pentacam, Show 2 Exams .............................................................................................................................................85
Figure 98, Pentacam topography, corneal transplant ............................................................................................................86
Figure 99, 4 maps refractive OD ......................................................................................................................................................87
Figure 100, Pachymetry Progression, OD .....................................................................................................................................87
Figure 101, Scheimpflug Image, OD ...............................................................................................................................................87
Figure 102, 4 Maps Refractive, OS ..................................................................................................................................................88
Figure 103, Pachymetry progression, OS .....................................................................................................................................88
Figure 104, Scheimpflug Image ....................................................................................................................................................... 88
Figure 105, Topography, central part ............................................................................................................................................89
Figure 106, Pentacam Scheimpflug image, corneal infiltrate .............................................................................................90
Figure 107, Slit lamp photo, corneal infiltrate........................................................................................................................... 90
Figure 108, Pentacam scheimpflug image, corneal infiltrate 3 days after ....................................................................91
Figure 109, Slit lamp Photo, corneal infiltrate, 3 days after ................................................................................................91
Figure 110, Slit lamp photo, incisional edema........................................................................................................................... 92
Figure 111, S.image, incisional edema ..........................................................................................................................................92
Figure 112, Slit lamp photo ...............................................................................................................................................................93
Figure 113, Overview, corneal thinning ........................................................................................................................................93
Figure 114, Slit lamp photo and Tomography............................................................................................................................ 94
Figure 115, Pentacam 4 Maps Refractive ....................................................................................................................................95
Figure 116, Pentacam Scheimpflug Image, Corneal Dystrophy, posterior surface .................................................... 96

Figure 117, Slit lamp photo, Corneal Dystrophy, posterior surface.................................................................................. 96

Figure 118, Pentacam Scheimpflug image, anterior pyramid cataract ........................................................................... 97
Figure 119, Slit lamp photo, anterior pyramid cataract ........................................................................................................ 97
Figure 120, Pentacam Scheimpflug image, posterior capsular cataract ........................................................................ 98
Figure 121, Slit lamp photo, posterior capsular cataract ...................................................................................................... 98
Figure 122, Pentacam Scheimpflug Image, nuclear cataract .............................................................................................. 99
Figure 123, Slit Lamp Photo, nuclear cataract .......................................................................................................................... 99
Figure 124, Pentacam Scheimpflug image, posterior Synechia ...................................................................................... 100
Figure 125, Slit lamp photo, posterior Synechia ....................................................................................................................100
Figure 126, Pentacam Scheimpflug image in 190°, Pterygium ....................................................................................... 101
Figure 127, Topography, Pterygium ............................................................................................................................................ 101
Figure 128, Photo, Pterygium ........................................................................................................................................................ 101
Figure 129, Pentacam, OS & OD, pre Orthokeralotogy........................................................................................................ 102
Figure 130, Pentacam, follow up Orthokeratology ................................................................................................................103
Figure 131, Pentacam, follow up....................................................................................................................................................104
109 / 111 Interpretation Guideline Pentacam / Pentacam HR (IG/70700/0608/en)

21 References and Contact Addresses

Tobias H Neuhann MD
Clinical director
AaM Augenklinik am Marienplatz
Marienplatz 18/19
Munich 80331
Germany
sekretariat@a-a-m.de
www.augenklinik-marienplatz.de
Tel: +49-89 230 8890
Fax: +49-89 230 88910
Michael W. Belin, MD
Department of Ophthalmology
Albany Medical Center
1220 New Scotland Road
Suite 101
Slingerlands, New York 12159 (USA)
www.MWBelin.com
MWBelin@aol.com
Jack T. Holladay, MD, MSEE, FACS

Holladay Consulting, Inc.
P. O. Box 717
Bellaire, Tx, USA 77402 - 0717
Email: holladay@docholladay.com
Fax: 713 669 9153
Gilg A.N., MD
Lyon-Europe Vision Center
14 Rue Rabelais
F - 69003 Lyon
FRANCE
docteurangilg@club-internet.fr
Eduardo Viteri, MD.

Humana Vision, Centro Oftalmologico
Panama 616 y Roca
4759 Guayaquil
Ecuador
eviteri@ecuadorlaser.com
Interpretation Guideline Pentacam / Pentacam HR (IG/70700/0608/en) 110 / 111

Renato Ambrósio Jr, MD, PhD

Director of Cornea and Refractive Surgery Instituto de Olhos Renato Ambrósio & Refracta - RIO
Rua Conde de Bonfim 211/712
20520-050 Tijuca, Rio de Janeiro,
Brazil; zip code 20520-050
http://www.iolhosrenatoambrosio.com.br/
renatoambrosiojr@terra.com.br
Oculus Optikgeräte GmbH

Münchholzhäuser Str. 29
35582 Wetzlar
Tel:+49-(0)641-2005-0
Fax:+49-(0)641-2005-295
j.iwanczuk@oculus.de
www.oculus.de
111 /111 Interpretation Guideline Pentacam / Pentacam HR (IG/70700/0608/en)

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OCULUS

Instruction Manual Pentacam / Pentacam HR (Version 01 – 2007-08-08) 1/1

i / iii Interpretation Guideline Pentacam® / Pentacam HR® (IG/70700/0608/en)

2 Description of unit and general remarks.................................................................................1

3 Corneal Ectasia ............................................................................................................................2

3.1 Case 1, Ectasia after RK, Renato Ambrósio, Jr, MD ..................................................................................2

4.1 Case 1, General screening, Tobias Neuhann, MD......................................................................................7

Interpretation Guideline Pentacam® / Pentacam HR® (G/70700/0608/en) ii / iv

9 Locating the cone, Prof. Michael Belin..................................................................................50

10 INTACS® implantation ..............................................................................................................51

10.1 Case 1, Prof. Michael Belin .............................................................................................................................. 51

11.1 Keratoconus, OD & OS?, Prof. Michael Belin............................................................................................ 56

13.1 Detecting forme fruste Keratoconus........................................................................................................... 70

14.1 EKR’s in the Holladay Report.......................................................................................................................... 72

16.1 Case 1, Cortical Cataract, Tobias Neuhann, MD...................................................................................... 85

17.1 Corneal Dystrophy .............................................................................................................................................. 96

iii / iv Interpretation Guideline Pentacam® / Pentacam HR® (G/70700/0608/en)

17.2 Congenital anterior pyramid cataract ........................................................................................................ 97

18.1 Case 1, General Screening, Alain-Nicolas Gilg, MD ............................................................................102

19.1 Recommended Settings..................................................................................................................................105

21 References and Contact Addresses ...................................................................................... 107

Interpretation Guideline Pentacam® / Pentacam HR® (G/70700/0608/en) iv / iv

2 Description of unit and general

1 / 111 Interpretation Guideline Pentacam / Pentacam HR (IG/70700 – 0608/en)

3.1 Case 1, Ectasia after RK, Renato Ambrósio, Jr, MD

Figure 1, Pentacam, OD post LASIK, Ectasia

Interpretation Guideline Pentacam / Pentacam HR (IG/70700/0608/en) 2 /111

Figure 2, Pentacam, OS post LASIK, Ectasia

Figure 3, Pachymetry Progression, OD Figure 4, Pachymetry Progression, OS

The pachymetric progression is abrupt in both eyes as an important sign of Ectasia,

3 / 111 Interpretation Guideline Pentacam / Pentacam HR (IG/70700 – 0608/en)

3.2 Case 2, Ectasia after LASIK?, Prof. Michael Belin

Figure 5, ORB Scan post LASIK, Ectasia

Interpretation Guideline Pentacam / Pentacam HR (IG/70700/0608/en) 4 /111

Figure 6, Pentacam 4 maps, post LASIK no Ectasia

5 / 111 Interpretation Guideline Pentacam / Pentacam HR (IG/70700 – 0608/en)

Figure 7, Orbscan® 4 Maps, Pentacam 4 Maps Refractive

Interpretation Guideline Pentacam / Pentacam HR (IG/70700/0608/en) 6 /111

4.1 Case 1, General screening, Tobias Neuhann, MD

Figure 8, Pentacam 4 maps

7 / 111 Interpretation Guideline Pentacam / Pentacam HR (IG/70700 – 0608/en)

Figure 9, HRT Image Figure 10, HRT Image

4.2 Case 2, YAG Laser Iridectomy, Eduardo Viteri, MD

Figure 11, Pentacam Overview post op to YAG laser Iridectomy

Interpretation Guideline Pentacam / Pentacam HR (IG/70700/0608/en) 8 /111

Figure 12, Pentacam Overview, 10 days after YAG Laser Iridectomy

Figure 13, Pentacam, 2 maps comparison

9 / 111 Interpretation Guideline Pentacam / Pentacam HR (IG/70700 – 0608/en)

5 Screening for refractive surgery,

5.1 Screening Parameters, 4 maps refractive display Prof.

5.1.1 Suggested Installation Settings

Anterior Elevation & Posterior Elevation

Interpretation Guideline Pentacam / Pentacam HR (IG/70700/0608/en) 10 /111

5.1.2 Strategy on how to go through the exams

The way I am usually going through the exams is:

5.1.3 Proposed screening parameters

Figure 14, BFS fitting zone

11 / 111 Interpretation Guideline Pentacam / Pentacam HR (IG/70700 – 0608/en)

Interpretation Guideline Pentacam / Pentacam HR (IG/70700/0608/en) 12 /111

5.2 Normal, astigmatic cornea, Prof. Michael Belin

DIAGNOSIS - Normal Astigmatic Cornea

Figure 15, Pentacam, astigmatic cornea

13 / 111 Interpretation Guideline Pentacam / Pentacam HR (IG/70700 – 0608/en)

5.3 Normal, astigmatic cornea, Prof. Michael Belin