Quality of Vision (Essential Optics)

SLACK Incorporated
Quality of Vision
Essent ial Opt ics
f or t he
Catar act and Ref r act ive Sur geon
J ack T. Hol l aday

MD MSEE FACS
JACK T. HOLLADAY, MD, MSEE, FACS
CLINICAL PROFESSOR OF OPHTHALMOLOGY
BAYLOR COLLEGE OF MEDICINE
HOUSTON, TEXAS
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Holladay, Jack T.
Quality of vision : essential optics for the cataract and refractive
surgeon / Jack T. Holladay.
p. ; cm.
Includes bibliographical references and index.
ISBN-13: 978-1-55642-801-2 (alk. paper)
ISBN-10: 1-55642-801-4 (alk. paper)
1. Eye--Surgery. 2. Physiological optics. I. Title.
[DNLM: 1. Ophthalmologic Surgical Procedures--methods.
2. Optics. WW 168 H733q 2007]
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Dedica tion
To my family
Sharon, Taylor, and Courtney
for their support, encouragement, and love.
Contents
Dedication ................................................................................................. v
Acknowledgments .....................................................................................ix
About the Author ...................................................................................... xi
Preface .................................................................................................... xv
Foreword by Richard L. Lindstrom, MD ............................................. xvii
Chapter 1 Understanding Optics..................................................1
Chapter 2 Astigmatism Analysis

Vector Analysis to Chart Residual Astigmatic Error
Can Improve the Accuracy of Refractive Surgery ............... 15
Chapter 3 Aspheric Treatments Reduce Spherical Aberration

After Cataract, Refractive Surgery
Implanting an Aspheric IOL or Incorporating a
Prolate Laser Treatment Into Corneal Refractive Surgery
Helps Reduce Spherical Aberration ..................................... 27
Chapter 4 Vertex Distance, Refraction and Intraocular Lens

Power Calculations
Measuring Vertex Distance and Performing Over-Refraction
With a Soft Contact Lens for Higher Prescriptions Can
Reduce Refractive Surprises After IOL Implantation.......... 39
Chapter 5 Intraocular Lens Calculations After Surgery

Surgeons Implanting Intraocular Lenses in Patients Who
Have Undergone Corneal Refractive Surgery Must Be
Precise in Their Measurements and Calculations ................ 47
Chapter 6 Surgical Correction of Presbyopia

Some Newer Refractive Surgeries Take Advantage of
Pupil Size Changes and Other Factors to Provide Good
Near and Distance Vision .................................................... 69
viii C o n te n ts
Chapter 7 Optical Improvements in Excimer Laser Surgery

Refinement of the Radial Compensation Function and
Other Optical Concepts Have Helped to Improve
LASIK Outcomes................................................................. 83
Chapter 8 Zernike and Fourier Polynomials

Describing Surfaces ............................................................. 93
Chapter 9 Ocular and Topographic Wavefront ........................ 105
Chapter 10 Understanding Neural Adaptation

Image-Enhancement Software in the Human Occipital
Cortex Is a Key Component in Vision Correction ............. 115
Acknowledgments
I greatly appreciate the hard work done by Tim Donald and Nicole Nader;
their contributions are invaluable to this book. I'm indebted to their service.
I'd also like to thank Elizabeth A. Davis, MD, FACS for her critical and help-
ful review and Richard L. Lindstrom, MD for his guidance and for writing
the foreword. Finally, I would like to thank all those who have attended my
lectures and asked the hard questions that made me think.
About the Author
Jack T. Holladay, MD, MSEE, FACS was born on October 13, 1946, while
his parents were stationed at Olathe Naval Base near Kansas City, Kansas. His
father went to work for Ford Motor Company and typical of many families
ascending the corporate ladder, the numerous relocations meant he attended
12 schools between kindergarten and high school. In 1961, the family moved
to Dallas, Texas, where Dr. Holladay began his sophomore year at South Oak
Cliff High School.
In 1964, Dr. Holladay graduated from South Oak Cliff High School, receiv-
ing an academic and music scholarship for tuition and room at Southern
Methodist University. He chose electrical engineering as his major and played
solo trumpet with the Mustang Band along with Harry James, Jr. He worked
in the student cafeteria for his meals, giving him the opportunity to meet many
students. These many friends were instrumental in his successful campaigns
for head cheerleader during his junior and senior years.
In 1969, he received his Bachelor of Science degree in Electrical Engineering
and was awarded a scholarship to graduate school. His work in the master’s
program was primarily in computer science, where he developed software
for the onboard aircraft computers to defeat Soviet radar systems. He also
designed night vision optical devices using early IBM programs, which repre-
sented his first exposure to the field of optics.
In 1971, Dr. Holladay received his Master of Science degree in Electrical
Engineering from Southern Methodist University and started course work
toward a doctorate. Attending classes at Southwestern Medical School was
part of the biomedical engineering program, and this fostered an interest in
the medical applications of his engineering background. As his interest grew,
he decided to attend medical school.
Dr. Holladay was accepted in the first on-campus class of 32 members
at The University of Texas Medical School in Houston in 1971. In 1974, he
received his Doctorate of Medicine, followed by a year of research developing
instrumentation for measuring the electrical charge of the eye. He then began
his residency in ophthalmology in 1975 at Hermann Hospital, the teaching
hospital for The University of Texas Medical School at Houston.
He completed his residency in ophthalmology in 1978 and was invited to
join The University of Texas Medical School faculty. In addition to his teaching
responsibilities and private practice, Dr. Holladay has invented the Brightness
Acuity Tester, an instrument that is used by ophthalmologists all over the
world to test the effects of glare on patients’ vision. He has also developed
the Holladay “IOL Consultant” and “Refractive Surgery Consultant” software
programs, which are currently used worldwide by ophthalmologists to help
xii Ab o u t th e Au th o r
restore patients’ vision following cataract removal and to obtain the best results
following refractive surgery (laser in situ keratomileusis [LASIK]).
Dr. Holladay specializes in refractive surgery, which includes LASIK-laser
vision correction, photorefractive keratectomy (PRK), and conductive kerato-
plasty (CK). He is very active in the American Academy of Ophthalmology,
serving as past Chairman of the Committee on Low Vision; Committee on
Optics, Refraction and Contact Lenses; Ethics Committee; and the Committee
for Ophthalmic Technology Development. Because of his service to the acad-
emy and his teaching contributions at the annual meeting, he received the
Honor Award in 1985 and the Senior Honor Award in 1995, which is awarded
to only 25 ophthalmologists a year. He has written over 96 scientific articles
and 30 book chapters, authored or edited 5 books, and made several hundred
scientific presentations. Dr. Holladay has been a visiting professor at many of
the major ophthalmology programs internationally.
In 1986, he received the Distinguished Service Award from the Commissioner
of the Food and Drug Administration for his service on the Ophthalmic Device
Panel. He has received the “Most Outstanding Lecturer in Ophthalmology”
award from his medical students numerous times. In 1991, he was named the
A. G. McNeese, Jr. Professor of Ophthalmology and was the second person to
be recognized as a Distinguished Alumnus of The University of Texas Medical
School at Houston. In 1992, he received the Binkhorst Medal Award from the
American Society of Cataract and Refractive Surgery, which is given to one
ophthalmologist each year. In 1995, he was honored with the Ridley Award
from the European Society of Cataract and Refractive Surgery, which is given
to only one ophthalmologist every 2 years. In 2001, he was the first recipient of
the John Pearse Memorial Award from the United Kingdom & Ireland Society
of Cataract & Refractive Surgeons (UKISCRS). He was acknowledged in
2002-2004 as one of the “Best Doctors in America” and has been recognized
as one of the “Top Doctors in Houston” by Inside Houston Magazine.
He is currently the Vice Chairman of the Executive Committee and
member of the Board for the International Society of Refractive Surgery of
the American Academy of Ophthalmology, Editorial Board Member of the
Journal of Cataract and Refractive Surgery, and a Board of Director for the
Council for Refractive Surgery Quality Assurance. He received the Barraquer
Medal in 2005 and the Lifetime Achievement Award from the ISRS/AAO in
2006.
Although Dr. Holladay’s professional activities are many, he still devotes a
significant amount of time to the community and his family. He has served as
a member of the Administrative Board, Council on Ministries, and Board of
Trustees for the Bellaire United Methodist Church. He was a member of the
Scientific Advisory Board for the Lion’s Eye Bank for 20 years. He is also very
Ab o u t th e Au th o r xiii
proud of coaching and managing in Little League Baseball and in the Houston
Youth Soccer Association from 1980 to 1992. In 1988, his son Taylor's baseball
team won the Major League Championship, and he managed and coached the
All-Star team, which placed second in the area play-offs that year. In 1989,
he helped coach his son's soccer team to the Houston City Championship
for 13-year-old boys. He was President of the Bellaire High School Baseball
Booster Club in 1994, when his son’s team won the coveted State 5A Baseball
Championship.
Taylor received a baseball scholarship to The University of Texas at Austin.
In 2000, he graduated with a Bachelor of Arts Degree from Houston Baptist
University with honors. In July 2001, he graduated from the London School of
Economics where he earned a Graduate degree in Business with honors. Taylor
was inducted into the Bellaire Baseball Hall of Fame in January 2000. In April
2002, Taylor married Kimberly Bullen and they reside in Houston. After work-
ing as a senior analyst at Frost Bank for 2 years, he attended and graduated
from the Rice University MBA program in May 2006. He is now employed for
Nesbitt Corporation as an associate in investment banking.
In 1990, his daughter Courtney’s softball team won the 12-year-old girls
Major League Championship. Dr. Holladay managed and coached the All-
Star team, which went on to win the District 16 Championship. In 1996, his
daughter graduated from Bellaire High School as a four-year letter athlete and
captain of the varsity soccer team that won the District 5A Championship for 4
years. She was also elected treasurer of the Bellaire High School Booster Club.
Courtney graduated from Texas A & M University in May 2000 with honors.
She received her Master’s degree in I/O Psychology in May 2002 and her PhD
in May 2004 from Rice University and is now working at M.D. Anderson
Hospital. In September 2006, Courtney married Mark Strong and they also
live in Houston.
Dr. Holladay strives for excellence in everything he does, but realizes that
his greatest sources of happiness are his wife (Sharon), son (Taylor), daughter
(Courtney), and their health, which are blessings for which he is most grate-
ful.
Prefa ce
The purpose of this book is to convey the essential optical principles
necessary for the cataract and refractive surgeon to maximize their surgical
outcomes. Optics is a difficult subject for most surgeons, but a better under-
standing of the optical principles involved in corneal and lenticular surgery
will translate directly into improved surgical techniques and utilization of
diagnostic and therapeutic equipment.
The explanations and illustrations have been refined from the valuable feed-
back received from 30 years of lectures to residents and practitioners that have
faithfully attended my courses and presentations at state, regional, domestic,
and international meetings. I have included those topics that are most relevant
to clinical practice. Topics such as vertex distance calculations and astigmatic
analysis are not new but are especially important today in refractive and cata-
ract surgery, where the goal is to be independent of spectacles or contact lenses
and to reduce—not induce—aberrations. Aspheric intraocular lenses, aspheric
excimer laser treatments, multifocal lenses, and cataract surgery after prior
refractive surgery are recent developments that require a greater understand-
ing of selecting the correct procedure, device, and proper refractive target for
a specific patient.
The optics of the eye, the sensory pathway, image processing, and neural
adaptation are all factors that when working in harmony allow us to perceive
our world in all the exquisite detail that makes us treasure vision as the most
important of our senses. Having our patients trust us with this treasure is a
responsibility that every refractive and cataract surgeon recognizes and can
also be the stimulus to persevere through the limited number of formulas and
physics inherent in this subject to gain a better understanding of the eye as an
optical system and how it relates to vision.
Foreword
Optics… the bane of most ophthalmologists during their training years, and
especially while sitting at their OKAPS, Written and Oral Board examina-
tions. Yet, in the clinical world of today, the comprehensive ophthalmologist
and cataract and refractive surgeon must have a strong understanding of optics.
To practice effectively, the ophthalmologist must understand wavefront analy-
sis; higher-order aberrations; corneal topography; aspheric, multifocal and
accommodative intraocular lenses; IOL power calculations; small diameter
aperture optics; photopic, mesopic and scotopic contrast sensitivity; light scat-
ter; glare; halo; and neural adaptation to name a few. The list is daunting and
growing every year.
Fortunately, Jack T. Holladay, MD, MSEE, FACS of the Holladay LASIK
Institute in Houston, Texas has come to the rescue with his book, Quality of
Vision: Essential Optics for the Cataract and Refractive Surgeon, published
by SLACK Incorporated. In 10 tightly written and well-illustrated chapters, Dr.
Holladay brings the reader up-to-date on the core optics knowledge required
to practice intelligently in today’s environment. Clinically relevant optics that
can be applied daily in the practice of ophthalmology is the purpose of this
amazingly easy-to-read book. For the reader desiring even greater depth of
understanding, appropriate references are provided at the end of each chapter.
This book is extremely timely and its content is a must-read for all oph-
thalmologists whose practice includes seeing patients who have or intend to
undergo cataract or refractive surgery, which is nearly all of us. Thank you,
Jack Holladay, for another outstanding job educating your colleagues.
Richard L. Lindstrom, MD
Adjunct Emeritus Professor of Ophthalmology
University of Minnesota
Founder and Attending Surgeon
Minnesota Eye Consultants, P.A.
Chief Medical Editor
Ocular Surgery News
1
Un d e rsta n d in g
O p tic s
To suppose that the eye with all its inimitable contrivances for adjusting
the focus to different distances, for admitting different amounts of light, and
for the correction of spherical and chromatic aberration, could have been
formed by natural selection, seems, I freely confess, absurd in the highest
degree.
—Charles Darwin, The Origin of Species, Chapter 6, “Organs of Extreme
Perfection and Complication”
Introduction
Optics is not a subspecialty of ophthalmology; it is a branch of physics.
However, optics is a subject that cuts across all subspecialties of ophthalmol-
ogy because the physical characteristics of light and the optical elements of
the visual system affect the way our patients perceive the world. This book
explores how the field of optics affects ophthalmology, especially the subspe-
cialties of cataract and refractive surgery, and how an understanding of optics
can help the clinician achieve better quality of vision in his or her patients.
To offer patients the best possible visual outcomes following cataract and
refractive surgery, ophthalmologists must first attain a clear understanding of
2 C h a p te r 1
optics and the role of optics in creating vision in the eye. Everyone working
with human vision should understand the optics of the eye, how optics relates
to vision, and how best to accurately measure the quality of that vision.
Qua lity of Vision

The physiologic optics of the human eye affects the quality of vision. The
term quality of vision, as used in this book, is a multifactorial concept that
includes the entire visual system: optical, sensory and neural processing.
Measurements such as visual acuity and contrast sensitivity measure the entire
visual system, whereas wavefront aberrometry, topography and tomography
evaluate only the optical portion of the visual system. We will discuss the
appropriate use of each of these types of tests in the course of this book.
Good vision is no longer defined by 20/20 Snellen acuity. Quality of vision
is a comprehensive set of measures that includes visual performance at near
and far distances and in variable light and contrast conditions.
The necessity of moving beyond Snellen acuity in the evaluation of vision
has been recognized by officials at the Food and Drug Administration, who
now require contrast sensitivity and wavefront aberrometry measurements in
most clinical trials related to vision. These requirements will help clinicians
to better measure the performance of new devices and surgical procedures
quantitatively.
Before clinicians can accurately assess contrast sensitivity and other quality-
of-vision measures, however, they must first understand the complexities of the
human visual system and how optical aberrations and other factors can lead to
poor quality of vision.
The optics of the human eye, as Darwin acknowledged, is truly remarkable.
We have clear media to admit light to our visual system and conduct it toward
photosensitive cells; on the optical path to those photosensitive cells, we have
an adjustable diaphragm (the pupil) to limit the amount of light admitted and
an adjustable lens to focus the light.
But the optics of vision goes beyond these well-known elements. There are
complexities in the eye’s optical system that in some cases work to improve our
vision and in some ways may work to the detriment of vision.
The first part of this chapter reviews some of the physiological optical con-
cepts at work in the human eye and how the optical properties of the eye can
limit vision in some instances and improve it in others. The second part of the
chapter explores some of the ways we assess the performance of the visual
system.
Un d e rsta n d in g O p tic s 3
Figure 1-1. The optical axis of the human eye extends from the anterior
vertex (pole) of the cornea to the posterior pole of the eye, and it is
defined by the geometric centers of the two lenses of the eye, the cor-
nea and the crystalline lens. The visual axis of the eye extends from the
fovea through the nodal point of the eye and out through the cornea to
an object, a point at “infinite” distance, such as a star. Angle alpha is the
angle between the visual axis and the optical axis (angle A).
Pa rt 1: Introduction to the Optics of the Eye

ANGLE KAPPA VERSUS ANGLE ALPHA
The optical axis of the human eye extends from the vertex of the cornea
(anterior pole) to the posterior pole of the eye, and it is defined by the geo-
metric centers of the two lenses of the eye, the cornea and the crystalline lens.
The visual axis of the eye extends from the fovea through the nodal point of
the eye and out through the cornea to an object, a point at “infinite” distance,
such as a star (Figure 1-1).
More often than not, these two axes are not defined by the same line. They
are at a slight angle to each other. This optical and anatomical fact introduces
some complexity in the planning of refractive surgery corrections.
4 C h a p te r 1
Figure 1-2. The human eye on the average is tilted out 5.2° horizontally
and up 1.4° vertically from the optical axis (O C). This is the amount of
tilt described by angle alpha (<A), and it is a reliable measurement of
the optical orientation of the eye. Angle kappa (<K) is the term used to
describe the distance between the center of the pupil (PC) and the visu-
al axis (VA) of the eye. Horizontal angle kappa is typically 2.6°. Vertical
angle kappa is typically about one-fourth of this amount, 0.6°.
The angle between the visual axis and the optical axis is called angle alpha.
Angle alpha describes the degree of anatomical tilt of the eye relative to the
optical axis, the overall tilt of the globe as measured through the anterior nodal
point of the eye, which is about 7.2 to 7.6 mm posterior to the corneal vertex,
depending on the size of the anterior segment of the eye.
The human eye on the average is tilted out 5.2° horizontally and up 1.4°
vertically from the optical axis. This is the amount of tilt described by angle
alpha, and it is a reliable measurement of the optical orientation of the eye. It
varies slightly from patient to patient, but knowledge of its location is impor-
tant for centering corneal refractive surgical treatments (Figure 1-2).
Unfortunately, many refractive surgical decisions are based not upon angle
alpha, but rather on the clinical measurement angle kappa, a less reliable mea-
sure.
Angle kappa is the term used to describe the distance between the center
of the pupil and the visual axis of the eye. Horizontal angle kappa is typi-
cally described as being a 2.6° angle between the center of the pupil and the
visual axis. Vertical angle kappa is typically said to be about one-fourth of this
amount, 0.6°.
Angle kappa is determined by locating the center of the pupil and the light
reflex (vertex normal) and measuring the distance between these two points.
At the corneal plane, vertex normal is near the visual axis.
The problem with using angle kappa for these determinations is that the
location of the center of the pupil varies significantly from patient to patient.
The center of the pupil can be located on the visual axis, on the optical axis
or, most of the time, about halfway between the two. For that reason, using
measurements and treatments on the center of the pupil is not a good idea.
Most human pupils are decentered nasally, but the amount varies from
patient to patient, making it difficult to derive predictable surgical outcomes
from the use of angle kappa.
Measurements of refraction, topography and other tests are made on the
visual axis (vertex normal), not the center of the pupil. If refractive surgical
treatments were to be centered on the pupil, we would need an entirely differ-
ent set of values for our calculations to be correct.
Angle alpha has the least amount of inter-patient variability, and it is the
most reliable benchmark for refractive surgery. Surgeons should take this dif-
ference into account when determining the proper placement of corneal refrac-
tive surgery treatments.
LIMITATIONS OF TILT
The human eye functions at about 40% of the performance it theoretically
could achieve if its lenses were aligned optically (on-axis) rather than off-axis
as described above. Angle alpha—the angle between the visual axis and the
optical axis of the eye—is the principal reason for this limitation of the eye’s
quality of vision.
The eye is often described as being like a camera. If the eye were truly
designed like a camera, the aperture (the pupil) would be aligned on the optical
axis with the lenses (the cornea and crystalline lens) and the film (the fovea).
If the eye were a diffraction-limited camera with the same focal length and
aperture size as the human eye, our quality of vision would be 2.5 times better
than a human eye can achieve with the best optical correction.
Because the visual axis is tilted with respect to the optical axis, we experi-
ence optical aberrations, including astigmatism, coma and other higher-order
aberrations. If the lenses in a camera were tilted obliquely, the camera would
produce similar images, functioning at only 40% of its potential.
LIMITATIONS OF PUPIL SIZE

Quality of vision is decreased in low-light settings such as nighttime. Any
time we make the aperture (the pupil) larger in an optical system, the aberra-
tions in the system increase.
6 C h a p te r 1
Figure 1-3. Snellen visual acuity versus pupil size as a function of defo-
cus. Note: If diffraction were the only consideration, the limiting visual
acuity would continue to improve the larger the pupil. O n the 0.0 D
defocus, the “peak“ vision is ~ 3.0 mm and then begins to decrease
with increasing pupil size due to optical aberrations. The Stiles-
Crawford effect reduces the impact of optical aberrations so they only
increase linearly with increasing pupil size as opposed to increasing by
the square of the pupil size. (Reprinted with permission from Holladay
JT, Lynn MJ, Waring GO, Gemmill M, Keehn GC, Fielding B. The
relationship of visual acuity, refractive error, and pupil size after radial
keratotomy. Arch O phthalm ol. 1991;109:70-76.)
At night, the pupil dilates to allow more light on the retina, and aberrations
in the periphery of the cornea and the crystalline lens are exposed. Visual
quality decreases, as manifested by starbursts, halos and glare that are caused
by diffraction and light scatter. Higher-order aberrations such as coma, trefoil
and spherical aberration are the mathematical measurements of these phenom-
ena.
As a result, the smaller the diameter of the pupil, the better the quality of
vision—that is, until a significant diffraction effect is reached, which occurs
at about a 2-mm pupil. Research has shown that 3.0 to 3.2 mm is the opti-
mal pupil size for achieving best uncorrected vision in a normal emmetropic
human eye, balancing the diffraction effect caused by a small pupil against the
aberrations let in by a large pupil (Figure 1-3).
When the pupil dilates above 4 or 5 mm, visual acuity begins to decline
due to aberrations, and diffraction is no longer a significant factor. This is in
contrast to expensive cameras with aspheric optics and many lenses in which
optical quality often improves with the widening of the aperture. Figure 1-3
illustrates the change in vision as a function of pupil size, refractive error and
aberrations.
Based on these limitations, in theory a camera may appear to be a more
technically advanced instrument than the human eye. However, the human eye
has evolved and adapted for millions of years to become a complex organ with
qualities that are still being understood.
STILES-CRAWFORD EFFECT
While it is true that optical aberrations increase as the pupil gets larger, the
eye has a remarkable quality that helps to reduce the effects of these aberra-
tions. The Stiles-Crawford effect, which weighs peripheral light rays as less
important for vision than central rays, reduces the effect of these aberrations
on the quality of vision.
The Stiles-Crawford effect, described in 1933, is caused by directional sen-
sitivity in retinal photoreceptor cells. Light passing through the center of the
pupil and striking the retina perpendicularly evokes a greater sense of bright-
ness than light passing through the periphery of the pupil and striking the
retina more obliquely.
Due to the Stiles-Crawford effect, the rays of light that strike the retina
obliquely have a reduced effect on vision compared to those that strike the
retina more perpendicularly. As a result, corneal and lenticular aberrations in
the periphery of the lens and cornea are weighted less and the affect on quality
of vision is minimized.
When the pupil dilates, light enters through the periphery of the cornea as
well as through the center. Through the Stiles-Crawford effect, photoreceptors
rely more heavily on the central light and less heavily on the aberrated periph-
eral rays. Consequently, the quality of an image in the human eye is far better
than could be achieved with a large pupil if the Stiles-Crawford effect did not
exist. In this way, the eye is superior to a camera.
HIGHER-ORDER ABERRATIONS VERSUS CHROMATIC ABERRATIONS

Another physiological property of the eye that improves the quality of vision
is the presence of higher-order aberrations that balance out chromatic aberra-
tions.
An article by James S. McLellan, PhD, and colleagues in 2002 found
that achromatic (colorless) higher-order aberrations offset the chromatic
8 C h a p te r 1
aberrations in the eye’s visual system. These higher-order aberrations balance

out the chromatic aberrations so that we do not see chromatic rainbows around
objects or light sources.
Chroma, or rainbows around lights, appear around objects when white light
is prismatically dispersed. The normal human eye has approximately 1.25 D of
clinical chromatic aberration, between red (+0.37) and blue (–0.87). However,
we do not normally experience chroma because higher-order aberrations in our
eyes cancel out the chromatic blur.
Higher-order aberrations can be measured with wavefront-sensing devices.
These imperfections in the ocular system are thought to cause problems with
quality of vision. It is important for clinicians and researchers to understand
that these measurements are monochromatic higher-order aberrations and
removing some of them may cause chromatic aberrations to become more
significant for patients.
BINOCULARITY
Our optical system, which has evolved over many thousands of years,
includes the visual cortex. As ophthalmologists, we tend to focus more on the
eye and the optic nerve. We do not always think about the brain’s interpretation
of images supplied by the eyes. Sometimes, things we think of as “limitations”
may actually provide a visual benefit.
Our human visual system may be the optimal evolutional solution for all
environments—near and far, night and day, light and dark. We do not know.
Before we decide to make permanent changes to our patients’ visual systems
through refractive surgery, we ought to consider the consequences of these
modifications.
For example, binocular vision and stereoacuity should always be considered
when we attempt to modify the optics of the human eye. We must not forget
that the two eyes work together synergistically to create binocular vision. We
should strive to improve outcomes based on binocular vision rather than cor-
recting each eye as an individual unit.
When we perform an intervention to optimize the visual system in a single
eye, it may not necessarily be a good thing for both eyes.
We know, for instance, that angle alpha, the 5.2° horizontal tilt of the eye,
induces coma, a distortion that causes a point of light to appear as a comet-
shaped image. We may intuitively think of this as a disadvantage for our opti-
cal system, and we have spent much time and effort recently in the quest to
eliminate higher-order aberration with refractive surgery.
But consider this: Because coma exists in both eyes, the distortion is dupli-
cated as a mirror image in each eye. Our brains have learned over time that
a coma image with its tail in opposite directions in the two eyes should be
a point. The brain can eliminate the tail and still achieve depth perception,
using Panum’s area to achieve binocular fusion. So it is possible that reducing
or eliminating coma may actually decrease stereoacuity at night, rather than
improve it.
Surgeons should always “think binocularly” when approaching the correc-
tion of human vision.
Pa rt 2: Assessing Vision
ASSESSING VISUAL ACUITY

Before we begin to alter a patient’s optical and visual systems to try to
improve quality of vision, we must first know how to assess quality of vision.
We have several tools available to us for assessing vision.
The first step in evaluating the visual system is to determine the patient’s
visual acuity, the resolution of the optical system. This has been done for 150
years using the familiar Snellen visual acuity chart and its many derivatives.
The theoretical limit of Snellen visual acuity based on the photoreceptor den-
sity in the retina is 20/5 and the read is 20/08.
But Snellen assessment is only part of the story. Functional vision includes
more than identifying the smallest recognizable letters one by one in a high-
contrast situation.
For near vision, reading rate is a much better measure of function than
acuity. Reading tests are more sensitive than the more static vision tests and
are more directly related to tasks that are required of our patients in everyday
life. Specifically, the near-vision performance of patients with multifocal and
accommodating IOLs should be evaluated using reading rate, not static near
acuity.
Reading rate testing should be automated and should last for about 3 to
4 minutes. Technician-dependent reading tests, which allow patients up to
5 minutes to read a single line of letters, are unpredictable and unreliable.
In some instances, patients may be “coached” by the technician or have an
extended period of time to fixate and focus, making the performance of some
devices more dependent on the technician than the patient being tested.
EVALUATING CONTRAST SENSITIVITY

Visual acuity (resolution) is only one piece of the puzzle. It measures our
ability to see small objects at high contrast, but it does not tell us how well a
10 C h a p te r 1
Figure 1-4. Red curve: normal contrast sensitivity function (CSF) curve.
Blue curve: CSF reduced to 63.8% of normal from decentered excimer
ablation zone. Yellow curve at 79.5% of normal is the CSF after retreat-
ment to center the ablation zone.
patient can see objects in lower contrast settings, such as a large gray truck in
the fog.
Beyond measuring a patient’s ability to see a letter on a 100% contrast,
black-and-white Snellen acuity chart, clinicians must be able to assess shades
of gray—“real world” aspects of vision, as measured by contrast sensitivity.
For our patients to feel comfortable when driving at night and to retain their
independence, it is important for them to have good contrast sensitivity. For
driving, walking and getting from place to place, good contrast sensitivity is
a necessity. Not being able to see things at low contrast can be debilitating,
causing patients to miss steps, increasing the risk of falls and severely affecting
nighttime driving ability. Contrast sensitivity testing gauges the visual system’s
ability to detect various size objects at low contrast.
Peak contrast sensitivity occurs around the size of a 20/200 to 20/100 let-
ter (3 to 6 cycles/degree), but this varies depending on the environment. The
average patient’s peak threshold for low contrast is at 0.5% at age 20, 1% at
age 40 and 1.5% by age 60 (Figure 1-4). This decrease in contrast sensitivity
is primarily due to an increase in spherical aberration and light scatter in the
crystalline lens with age.
Contrast sensitivity also varies depending on lighting conditions. A patient

who is able to see a high-contrast street sign in broad daylight may not be able
to detect a gray truck on a highway in the fog.
Tests that use charts with vertical sinusoidal gratings but require little con-
trol of room lighting are incapable of measuring contrast sensitivity accurately
and will produce variable results depending on ambient lighting conditions.
Contrast sensitivity testing must be performed in a standardized environment
to acquire useful information for clinical practice and research.
WAVEFRONT DIAGNOSTICS
Objective methods of testing the human optical system had not made great
strides until wavefront diagnostics was developed. Wavefront aberrometry
measurement provides invaluable diagnostic information about the optical
system that was never before obtainable.
Wavefront measurement of optical aberrations is a concept borrowed from
astronomy. Wavefront technology was famously used in designing a lens to fix
an aberrated mirror in the Hubble Space Telescope.
In wavefront assessment, an array of laser beams is projected into the eye,
reflected back off of the retina and captured as it exits the eye. The wavefront
leaving the eye, having traveled through all the ocular media twice, is ana-
lyzed for aberrations. A perfect optical system would return a perfectly flat
wavefront. Because the eye is not perfect, the wavefront returns with distor-
tions. These distortions are detected and analyzed by computer algorithms that
produce graphic images that help clinicians to diagnose the aberrations in the
patient’s optical system.
The computer graphic outputs, depending on the diagnostic system used,
can include wavefront maps (which look like corneal topographic maps but
have important differences that we will discuss later), point spread function
(PSF) diagrams and bar charts showing the amounts in microns of Zernike
lower- and higher-order aberrations (Figure 1-5).
Wavefront measurement has improved the surgeon’s ability to assess the
visual outcomes after LASIK and other refractive surgical procedures, but its
capabilities are much greater. Wavefront-generated information is tremendously
valuable diagnostically. It measures the optical performance of the entire eye,
including the cornea and the crystalline lens. Combining ocular aberrometry
with corneal topography allows the clinician to determine the location where
aberrations lie (i.e., in the cornea or the crystalline lens).
When we look at a wavefront printout, we are looking at the contour of a
wavefront of light, measured at the corneal plane of the eye, with the entrance
pupil projected on the cornea. Another way to look at the quality of the optics is
the spot diagram or PSF, which is more intuitive and describes the quality of the
12 C h a p te r 1
Figure 1-5. Wavefront map showing 0.404 µm of root mean square

(RMS) error over a 6-mm optical zone. The average RMS error in the
human eye is 0.38 µm.
image on the foveola or at the retinal plane. In a perfect optical system, the PSF
should look like a point or a distant star.
The PSF can be mathematically converted to a modulation transfer func-
tion (MTF), allowing the clinician to determine the overall performance of a
patient’s eye as a function of spatial frequency (Figure 1-6). By comparing the
area under the MTF curve with the area under the CSF curve, the clinician can
pinpoint the location of a visual deficit as either an optical or a sensory defect.
If the reduction in the CSF is proportional to the reduction in the MTF, the
problem is optical. If the MTF is normal and the patient has a reduced CSF,
the problem is sensory (central serous maculopathy, optic neuritis, ischemic
optic neuropathy, etc.).
Using the tools described in this first chapter, ophthalmologists can under-
stand patients’ visual performance and capabilities and their “real world”
quality of vision. With these concepts, clinicians can begin to more accurately
assess their patients’ quality of vision, specifically understanding how aberra-
tions influence visual performance and how new technologies such as aspheric
IOLs affect visual performance.
Figure 1-6. Modulation transfer function (MTF). The y-axis is a measure

of the performance of the system with 1.0 being perfect. The x-axis is
the spatial frequency, where 20 /20 is 30 cyc/degree (cpd) and 20/200
is 3 cpd. The green curve is “normal“ and for any patient the area under
the MTF can be expressed as a percentage of normal, similar to the
CSF area. The MTF is only a measure of the optical system of the eye,
whereas the CSF is a measure of the entire visual system.
References
Burian HM. Strabism us. Early treatm ent im proves the child ’s app earance and
helps develop norm al binocular vision. Am J Nurs. 1960;60:653-656.
Cam pb ell FW. The accom m odation resp onse of the hum an eye. Br J Physiol Opt.
1959;16:188 -203.
Holladay JT, Lynn MJ, Waring GO, Gem m ill M, Keehn GC, Fielding B. The rela-
tionship of visual acuity, refractive error, and pup il size after radial keratoto -
m y. Arch Ophthalm ol. 1991;109:70 -76.
McLellan JS, Marcos S, Prieto PM, et al. Im p erfect optics m ay b e the eye's defense
against chrom atic blurs. Nature. 2002;417(6885):174 -176.
Stiles WH, Craw ford BH. The lum inous efficiency of rays entering the eye pupil at
different p oint s. Proc R Soc Lond B Biol Sci. 1933;112:428 -450.
2
Astig m a tism An a lysis

Vector Analysis to Chart Residual
Astigmatic Error Can Improve
the Accuracy of Refractive Surgery
Astigmatism analysis can help refractive surgeons refine the results of their
surgery and better understand the changes they are inducing in their patients’
eyes. Analysis of postoperative changes in the magnitude and orientation of
astigmatic error can help pinpoint the error induced in a single patient or look
for patterns of error in multiple patients.
If we do not analyze our surgical outcomes regularly, we cannot know how
to adjust our techniques to reach the intended postoperative refraction in our
patients. This chapter discusses some of the tools we can use to analyze the
astigmatic outcomes of refractive surgery.
16 C h a p te r 2
Assessing Astigma tic Cha nge

The refractive outcome of surgery can differ from the intended outcome
due to variables that include surgical technique, nomogram accuracy and laser
configuration. To determine why a patient achieved a postoperative result dif-
ferent from what we intended, the surgeon must determine the amount of error
that was surgically induced.
Let us start by defining some terms that will help determine induced error.
The spheroequivalent (SEQ) is one method of calculating a single value to
describe both sphere and cylinder in an eye. The SEQ is calculated by find-
ing the sphere that is halfway between the dioptric mean of the powers in the
principal meridians. For example, a refraction of –5.00 +10.00 90° has an
SEQ of 0.00 D. Mathematically, the SEQ is the sphere plus half of the cylinder.
However, a refraction of –0.50 + 1.00 90° also has an SEQ of 0.00 D. But
certainly two patients with these two refractive errors would not see equally
well without correction.
In 1991, we defined the term defocus equivalent (DEQ). The DEQ is equal
to the sum of the magnitude of the SEQ and half of the magnitude of the cyl-
inder. It is always positive.
Equation 1. DEQ = SEQ + 0.5 Cyl
In the numerical examples above, the DEQ for the first eye is 5.00 D and
for the second 0.50 D. The DEQ for the first example is 10 times worse than
the second and is also proportional to the size of the blur circle on the retina
for both spherocylinders.
The DEQ is especially valuable when correlating residual refractive errors
with uncorrected visual acuity. Figure 2-1 is an equivalency plot of the intend-
ed versus actual values of the DEQ following LASIK surgery. Values above the
equivalency line are overcorrections and below are undercorrections. These
plots are valuable when determining nomogram adjustments for specific lasers
and surgical techniques.
The surgically induced refractive change (SIRC) is determined by measur-
ing the difference between the refractive surgery patient’s preoperative refrac-
tive error and postoperative refractive error, or, in the case of cataract surgery,
the preoperative and postoperative keratometry. The formula for determining
SIRC involves simple subtraction when the refractive error is only spherical or
when astigmatism is at the same axis preoperatively and postoperatively. When
the axis of astigmatism has changed from preop to postop, the calculation
becomes more complex, requiring vector analysis using doubled angles.
Astig m a tism An a lysis 17
Figure 2-1. Equivalency

plot: Y-axis is the actu-
al SEQ of the surgically
induced refractive change
(SIRC) and the X-axis is the
desired SEQ of the SIRC.
Values above the equiv-
alency line are overcor-
rections and those points
below are undercorrec-
tions.
It is important for clinicians to understand the theories behind the calculation

of SIRC so that they can use these calculations in their own practices. While
computer programs have been developed to analyze astigmatism change, some
software programs are not accurate and do not use well-known, established
mathematical formulas. Available computer programs that use approximation
methods to calculate the SIRC can lead to significant errors in analysis and
cause erroneous conclusions.
It is therefore important for clinicians who perform refractive or cataract
surgery to understand the calculation of SIRC so that they can use them to
enhance their surgical accuracy. A few concrete examples with known results
can help validate the technique.
Ca lcula ting From Refra ction

SIRC produces the same effect on an eye as spectacle correction. Whether
refractive error is corrected with a laser, a phakic intraocular lens (IOL)
or some other method, the effect on vision is the same as that of a pair of
glasses—it is added to the existing error of the eye. If the SIRC is equal and
opposite to the existing error, the result is emmetropia.
18 C h a p te r 2
If our surgery fails to completely correct an eye’s preoperative refraction to

the intended target, we say there is a residual refractive error in the eye. The
first step in assessing residual refractive error after surgery is to calculate the
patient’s SIRC.
To determine the SIRC, we take the refraction of the eye after surgery,
including sphere, cylinder and axis of cylinder, and subtract from it the preop-
erative refraction. The outcome is the SIRC. The calculation of the SIRC can
be simply expressed by this equation:
SIRC = postoperative refraction – preoperative refraction
When calculating the SIRC, the surgeon should use the error of the eye,
rather than the spectacle prescription, to avoid sign errors. For example, if a
patient’s spectacle prescription is –1 D, that means the error of the eye (the
optical power of the eye) is actually +1 D too strong. The eye is 1 D stronger
than emmetropia, with a total ocular refractive power (total power of cor-
nea plus crystalline lens) of 61 D versus the standard 60 D in a normal eye.
Therefore, adding a spectacle prescription of –1 D to a patient with a +1 D
error should result in 0 D of refractive error. The error of the eye is always
equal and opposite in sign to the refractive correction.
In theory, the same outcome should be achieved in a LASIK patient who
wears a –1 D spectacle (with +1 D error of the eye) who receives –1 D of
SIRC.
Vertexing the Refra ctive Error

When calculating the SIRC after a laser refractive surgical procedure, we
must add an extra step—taking into account the vertex distance from the spec-
tacle plane to the corneal plane.
When we measure refraction, we measure at the spectacle plane using the
phoropter, which is at a nominal distance of 13.75 mm from the front of the
cornea. The refractive error at the corneal plane is different from that at the
spectacle plane because the cornea is farther away (for a minus spectacle
power) from the spectacle focal point than a lens at the corneal vertex. The
inverse is true for plus lenses.
A spectacle lens with –1 D of power has a focal length of 100 cm. When that
correction is moved back ~ 1 cm from the spectacle plane to the corneal plane,
the new focal length is now 1 cm longer, or 101 cm. In air, the power of a lens
is always its focal length in centimeters divided into 100, so the actual power
at the cornea would be 0.99 D (not 1.00 D).
This difference is insignificant for refractions less than ±4 D at normal

spectacle vertex distances, but it becomes significant at values above ±4 D.
When we change the focal length at the spectacle plane to the focal length
at the corneal plane, we call this calculation vertexing the spherocylindrical
error to the corneal plane. The new focal length at the corneal plane can be
determined by adding the focal length of the old lens at the spectacle plane (in
the above example, 100 cm) to the vertex distance (in the example, 1 cm) to get
the new focal length at the corneal plane (in the example, a total of 101 cm).
This equation can be expressed as follows:
focal length of new lens = focal length of old lens + vertex distance
When we perform this calculation, the vertex distance is considered to be

negative when going from spectacle plane to corneal plane, just as the focal
length for a minus lens is negative.
Similarly, when we implant a phakic IOL in the anterior or posterior cham-
ber, the focal length must be vertexed from the spectacle plane to the IOL
plane. The location of the phakic IOL plane varies depending on the axial loca-
tion of the phakic IOL (anterior chamber, iris supported or posterior chamber).
The calculation follows the same concepts outlined above for vertexing to the
corneal plane but is slightly more complicated because it must be vertexed
through the cornea. (Vertexing and vertex distance will be further discussed
in Chapter 4.)
Ca lcula ting With Kera tometry

We have been discussing calculation of SIRC using preop and postop refrac-
tion. It can also be calculated using preop and postop keratometry readings (K-
readings), taken either with a keratometer or a corneal topographer. Surgeons
can use keratometry as a second method to calculate SIRC in order to validate
their findings with refraction. In cataract surgery or refractive lensectomy,
the keratometric method is more meaningful because we are removing power
from the eye and the total effect is a combination of the corneal changes and
crystalline lens removal.
When we compare SIRC outcomes using refraction to SIRC outcomes using
keratometry readings, it is absolutely necessary to vertex the refractive calcula-
tion to the corneal plane. Because keratometry and topography measurements
are taken at the corneal plane, they do not need to be vertexed like refractive
measurements taken at the spectacle plane.
20 C h a p te r 2
To calculate the SIRC using corneal topography or keratometry, we subtract

the preop K-reading from the postop K-reading.
Keratometry measures the power of the anterior central corneal surface,
which is 45 D when the central radius is 7.5 mm using the keratometric index
of refraction of 1.3375. Using the SIRC formula, a patient with a preoperative
K value of 45 D and a postoperative K value of 44 D has a SIRC value of –1
D because, as we said above, SIRC = postoperative refraction – preoperative
refraction.
In this case, 44 D – 45 D = –1 D. Thus, the SIRC of –1 D we ascertained by
keratometry matches the SIRC of –1 D we calculated by refraction above.
In a perfect world, the SIRC from K-readings would always match the SIRC
from refraction after we have vertexed to the corneal plane. But these values
are rarely exactly the same due to measurement errors. Keratometry measure-
ments are seldom accurate in the irregularly shaped corneas of patients who
have undergone corneal refractive surgery. Because of this, the surgeon should
rely more heavily on refractive measurements than corneal measurements in
patients who have had such interventions.
Assessing Residua l Sphere

If a patient’s postoperative refraction is not plano, the patient may be left
with spherocylindrical error.
Take a myopic patient with a preoperative refraction of –1 D. If, instead of
achieving a postoperative refraction of 0 D, he is left with –0.25 D of sphere
after surgery, the SIRC can be ascertained by plugging the patient’s postop-
erative and preoperative refractive errors into the universal formula, SIRC =
postoperative refraction – preoperative refraction.
The myopic patient had a –1 D refraction (an error of +1 D) before surgery,
and surgery corrected only –0.75 D, leaving a SIRC of –0.25 D of undercor-
rection.
Assessing Cha nge in Cylinder Axis

Calculations become more complex when there is a change in axis of astig-
matism from preop to postop. If an astigmatic patient has cylinder at one axis
preoperatively and cylinder at a different axis postoperatively, calculating the
SIRC requires the subtraction of vectors with doubled angles rather than simple
mathematical subtraction.
Take a patient with 1 D of astigmatic error at 180° who achieves an unin-
tended postoperative outcome of 0.5 D of residual cylinder at 145°. We can-
not take that 0.5 D error at 145° and subtract it directly from the 1 D at 180°.
Arithmetic analysis will not work because the axes are not the same; they are
oriented differently. We must employ vector analysis.
In an article in the Journal of Cataract and Refractive Surgery in 1992,
Holladay, Crary, and Koch outlined the 10 steps for determining obliquely
crossed cylinder, a sequence of formulas for performing vector analysis, which
is needed to determine the SIRC of a patient with different axes. If we follow
the 10 steps to determine obliquely crossed cylinder, the SIRC will be at a new
axis, different from both the preoperative and postoperative axes. The 10 steps
can easily be programmed into a computer.
Mathematical Solution to Obliquely Crossed Cylinders

Determine the resultant Spherocylinder 3 from obliquely crossed cylinders
Spherocylinder 1 and Spherocylinder 2.
Given: Spherocylinder 1 = SC1

where S1 = sphere of SC1
C1 = cylinder of SC1
A1 = axis of cylinder C1
Spherocylinder 2 = SC2
Find: Spherocylinder 3 = SC3

Step 1. Transpose SC1 and SC2 so their cylinders have the sam e sign.
Step 2. SC1 must be chosen so the value of A1 is smaller than A2.
Step 3. Find angle , the difference between A2 and A1.

= A2 – A1
Note: must be positive.
Step 4. Find angle 2 from the formula:
C2 sin 2
c1 + c2 cos 2
(continued)
22 C h a p te r 2
Mathematical Solution to
Obliquely Crossed Cylinders (continued)
The denominator can sometimes be zero, which “blows up” on most computers
that cannot divide by zero. The whole term actually approaches infinity when
the denominator approaches zero, which results in 2 equaling 90°. A simple
programming solution is to add a very small value to the denominator such as
0.0000000001.
Step 5. Find angle from the follow ing formula:
= (2
+ 180°)
2
Step 6. Determine the sphere contributed by the two cross cylinders (SC) from
SC = C1 sin 2 + C2 sin 2 ( – )
Step 7. Determ ine the total spherical result (S3) from the follow ing formula:
S3 = S1 + S2 + SC
Step 8. Determine the total cylindrical result (C3) from the follow ing formula:
C3 = C1 + C2 – 2 SC
Step 9. Determine the resultant axis (A3) in standard notation from the follow ing
formula:
A3 = A1 +
If A3 is greater than 180°, subtract 180° for standard axis notation; if A3 is nega-
tive, add 180°.
Step 10: Any spherocylinder (SC3) can be w ritten in one of three forms: the plus
or minus spherocylinder form and the cross cylinder form. The alternate spherocy-
lindrical form (SC4) and cross cylinder form (XC5) are calculated in the follow ing
manner using the transposition rules.
A. Alternate spherocylindrical form (SC4) of SC3:

S4 = S3 + C3 = sphere of SC4
C4 = – C3 = cylinder of SC4
A4 = A3 ± 90° = axis of SC4
(continued)
Mathematical Solution to
Obliquely Crossed Cylinders (continued)
B. Cross cylinder form (XC5) of SC3:
C5A = S3 = cross cylinder A of XC5
A5A = A3 ± 90° = axis of cross cylinder A of XC5
C5B = S3 + C3 = cross cylinder B of XC5
A5B = A3 = axis of cross cylinder B of XC5
Although each of these three forms represents the exact same spherocylinder, we
will see that each form has specific benefits in visualizing the effect of the surgi-
cal procedure being evaluated.
Plotting Astigma tic Errors

If a surgeon notices a pattern of residual astigmatism in his or her patients,
where refractive surgical outcomes differ regularly from intended outcomes,
there could be a problem with the surgeon’s technique, nomogram, laser align-
ment or laser calibration.
Surgeons can look for cylindrical error trends in their surgical results by
plotting the SIRC of multiple patients on a double-angle polar plot.
To plot astigmatic error on these charts, the angles of astigmatism must be
doubled, so that 0° and 180° are equivalent. The radial axes on a double-angle
polar plot are oriented at 45° (at 12 o’clock), 90° (at 9 o’clock), 135° (at 6
o’clock) and both 0° and 180° (at 3 o’clock). This is necessary because we use
meridians in refractions and K’s, rather than semimeridians. Zero and 180° are
the same in K’s and refraction, whereas they are on opposite sides of the circle
when we use semimeridians. By doubling the angles of refraction and keratom-
etry, 180° becomes 360° and is equivalent to 0°. After doing this doubled angle
transformation, all the standard trigonometry calculations work.
When we plot our residual surgical errors on a double-angle plot, patterns
that otherwise might look random may become clustered. Figure 2-2 illustrates
a standard polar plot without doubling the angles, and Figure 2-3 has the angles
doubled. We are able to get a sense of the trend in error of astigmatism across
many patients with the double-angle plot that cannot be seen with the single
angles.
At the center of the cluster is the centroid, the average of each of our individ-
ual errors. By determining the centroid of a cluster, the surgeon can determine
the average astigmatic error in the SIRC for all of his or her refractive cases.
The ellipse (oval) around the centroid is the standard deviation. In Figure 2-4,
24 C h a p te r 2
Figure 2-2. Standard single angle plot. Data appear random with no
"cluster." Zero and 180˚ should be the same, and yet they are on
opposite sides of the graph.
Figure 2-3. Double-angle plot. Same data as in Figure 2-2, but now
it is clear the centroid can be seen by the small circle (–0.40 at
1.6°) and there is a "trend" in the data.
Figure 2-4. Centroid and stan-

dard deviation. The centroid
of the data is the small blue
square (–0.40 at 1.6°), and
the blue ellipse is the bound-
ary of one standard devia-
tion. It can be seen that with
this laser there is more vari-
ability in the principal merid-
ians (90° and 180°) than
in the oblique meridians by
almost a factor of 2.
we can see that the variability is much greater in the oblique meridians (45°
and 135°) than at the principal meridians (0° and 90°). This information is
highly valuable. Once we determine the centroid and standard deviation of
our procedures from actual to intended outcomes, we can readjust our surgical
settings and hopefully reduce the amount of residual astigmatism in our future
patients.
References
Holladay JT. Refractive p ower calculations for intraocular lenses in the phakic eye.
Am J Ophthalm ol. 1993;116:63-66.
Holladay JT, Cravy TV, Koch DD. Calculating the surgically induced refractive
change following ocular surgery. J Cataract Refract Surg. 1992;18:429-443.
Holladay JT, Dudeja DR, Koch DD. Evaluating and rep orting astigm atism for indi-
vidual and aggregate data. J Cataract Refract Surg. 1998;24:57-65.
Holladay JT, Moran JR, Kezirian GM. Analysis of aggregate surgically induced
refractive chang e, prediction error, and intraocular astigm atism . J Cataract
Refract Surg. 2001;27:61-79.
Eydelm an MB, Drum B, Holladay JT, et al. Standardized analyses of astigm atic cor-
rections by laser system s for corneal reshaping. J Refract Surg. 2006;22(1):81-
95.
3
Asp h e ric Tre a tm e nts
Re d u c e Sp h e ric a l
Ab e rra tio n
Afte r C a ta ra c t,
Re fra c tive Su rg e ry
Implanting an Aspheric
IOL or Incorporating
a Prolate Laser Treatment Into
Corneal Refractive Surgery
Helps Reduce Spherical Aberration
Aspheric treatments, in the form of aspheric modified prolate IOLs and
prolate laser ablations, can reduce the total amount of SA in the eye (the total
ocular SA). This can in turn improve contrast sensitivity and reduce the occur-
rence of glare and halos in patients’ vision after surgery.
Surgeons have become familiar with SA in recent years as the “Mexican
hat” in the diagrams of the Zernike aberrations. It is a fourth-order Zernike
28 C h a p te r 3
Figure 3-1. Spherical surface produces SA. When parallel rays are refract-
ed by a spherical surface, the peripheral rays are refracted too strongly
compared to the paraxial rays. The difference in diopters between the
paraxial and marginal rays is referred to as the spherical aberration of
the optical system.
aberration [Z(4,0)]. SA and coma are the higher-order aberrations that contrib-
ute the most heavily to visual disturbances and dissatisfaction in our patients
after refractive surgery.
SA is caused by refractive surfaces in the eye that cause rays of light in the
periphery to bend too strongly compared to paraxial or central rays (Figure
3-1).
IOLs with spherical surfaces, laser ablations that are calibrated on flat sur-
faces (and consequently undercorrect the corneal periphery) and changes in
the crystalline lens over time all contribute to increasingly positive SA in the
human eye, which diminishes visual performance.
Introducing a refractive surface that is prolate—that is, steeper in the center
and flatter in the periphery—can reduce SA in the eye and bring light rays to
a perfect point of focus on the retina. This aspheric refractive surface, whether
on a modified-prolate anterior surface IOL or as the result of a modified
laser ablation, has the same end effect: improving our patients’ postoperative
vision.
Asp h e ric Tre a tm e n ts Re d u c e Sp h e ric a l Ab e rra tio n 29
Figure 3-2. In the young eye (19 years old), the average corneal SA over
a 6-mm zone is +0.270 µm, and the crystalline lens is –0.270 µm, so
that the entire young eye has little or no SA with all rays coming into a
point of focus.
For the Middle-Aged Eye

Correcting SA returns the eye closer to the physiologic optics of the young
human eye.
By making the cornea more prolate than it was preoperatively in our refrac-
tive surgical procedures, we can minimize the SA of the entire eye in the
middle-aged patient. Reducing SA by making the cornea more prolate is an
important step in improving surgical outcomes for patients over 40 years of
age (Figure 3-2).
Likewise, minimizing SA through proper IOL selection is important for our
cataract surgery patients. With modern IOL surgery, we are now able to con-
sistently achieve our target refraction to within ±0.25 D due to improved IOL
power calculation formulas and more precise axiometers and keratometers.
We can also eliminate astigmatism through intraoperative techniques such
as limbal relaxing incisions or secondary corneal refractive surgery. We have
now moved to the point of correcting the next higher aberration in the human
eye—SA.
30 C h a p te r 3
Figure 3-3. An indirect ophthalmoscopic viewing lens with a parabolic

shape (Q = –1.00) can bring all rays into a single point of focus.
Asphericity Quotient
The key to reducing SA in the eye during refractive surgery is to preserve
or increase the natural prolate shape of the cornea.
The cornea is a three-dimensional prolate ellipsoid, like a bullet or a tulip.
It is steeper in the center and flatter in the periphery, and because of this it
reduces the total SA of the entire eye (Figure 3-3).
Introducing an oblate ellipsoid, steeper in the periphery and flatter in the
center, increases the amount of SA in the eye and reduces visual perfor-
mance.
The curvature of an ellipsoid—whether prolate or oblate—can be expressed
as an asphericity quotient, called the Q value. The Q value for a sphere is 0, the
Q value for a prolate ellipsoid is negative and the Q value for an oblate ellipsoid
is positive (Figure 3-4).
The average Q value for a normal prolate human cornea is about –0.26. If
the cornea was a perfect ellipsoid, with no SA, the Q value would be approxi-
mately –0.53. So, while the cornea has some positive SA, it is only about half
as much as a sphere (Q value = 0) because it is halfway between a sphere and
a perfect ellipsoid (at Q = –0.53) (Table 3-1).
Figure 3-4. Spherical, prolate and oblate ellipsoid surfaces are described
mathematically by using the asphericity quotient (Q value). Negative
values are prolate, positive values are oblate and a value of 0.0 is a
sphere. (Reprinted from J Cataract Refract Surg, 23(2), Holladay JT,
Corneal topography using the Holladay diagnostic summary, 209-221,
© 1997, with permission from ASCRS & ESCRS.)
1
-
Physiologic Q Values for the Human Cornea
3
e
l
Q = –2.00 Severe keratoconus, +5 D PRK
b
a
T
Q = –1.00 Mild keratoconus, + 2 D PRK
Q = –0.53 No corneal SA
Q = –0.26 Normal
Q = 0.00 Spherical
Q = +1.00 8 cut RK, –5 D PRK
Q = +2.00 16 cut RK, –12 D PRK

32 C h a p te r 3
Presbyopic Shift
Relating the Q value of a cornea to the Zernike calculations that are used in
wavefront-guided refractive surgery, the mean Q value of the human cornea is
–0.26. The average power is 43.86 D and the mean SA is +0.27 µm of positive
SA over a 6-mm optical zone. In a young person, 19 years old or younger, the
+0.27 µm of SA in the cornea is “cancelled out” by –0.27 µm of negative SA
in the crystalline lens.
Thus, the SA of the entire eye is almost zero in the youthful eye. The best
optical performance of the eye is at age 19. SA in the eye increases as we age
due to changes in the crystalline lens.
Studies by Adrian Glasser, PhD, an associate professor of optometry at the
University of Houston, and Pablo Artal, PhD, at the Laboratorio de Óptica
Universidad de Murcia, in Spain, have shown that the crystalline lens increases
in SA in a positive direction over time. The SA of the cornea remains constant
(when corneal disease is not present), but the total SA in the optical system of
the eye (cornea plus lens) moves in a positive direction.
At age 19, the crystalline lens has an SA of approximately –0.27 µm; by
age 40, the SA is ~ 0; and at age 60 ~ +0.13 µm. Since the SA of the normal
cornea does not change, the ocular SA average is ~ 0.00 µm at age 19, +0.27
µm at age 40 and +0.40 µm at age 60.
Aspheric Intra ocula r Lenses

Sverker Norrby, PhD, and Patricia A. Piers, MSc, IOL scientists at
Pharmacia, introduced the idea of designing an IOL with an aspheric modi-
fied-prolate anterior surface. With –0.27 µm of SA, the IOL they created was
designed to mimic the negative SA of a young crystalline lens. That lens,
originally developed by Pharmacia, is now the Tecnis IOL (Advanced Medical
Optics, Santa Ana, Calif.).
The idea of the aspheric modified-prolate lens is that it corrects the SA
in the optical systems of most elderly patients, eliminating disabling visual
effects such as glare and halo (Figures 3-5 and 3-6). It brings patients back
to the visual performance of a 19-year-old eye, rather than a 60-year-old eye
without a cataract when a spherical IOL is used.
In clinical trials of the Tecnis IOL*, patients’ contrast sensitivity improved
by an average of 40% in photopic and mesopic conditions. The improvement
in contrast sensitivity and reduction in glare and halo have been shown to
* AMO Data on File for 202 Cases—+ 0.27 microns for corneal means SA.
Figure 3-5. By age 60, the crystalline lens SA becomes positive, increas-
ing the total ocular SA to ~ +0.40 µm.
Figure 3-6. Halos and glare. SA results in halos seen around point
sources of light, especially in low light conditions.
34 C h a p te r 3
improve the reaction time of elderly drivers by 0.5 seconds in nighttime driv-
ing simulations. (By way of comparison, the third rear tail-light on a vehicle,
which is mandated by the National Highway Traffic Safety Administration,
improves reaction time by 0.3 seconds.)
The Food and Drug Administration approved labeling for the Tecnis IOL,
stating that the lens improves the performance of subjects following cataract
surgery on night driving simulators. (Because of this, the lens received the
status of New Technology IOL [NTIOL] from the Centers for Medicare and
Medicaid Services in February 2006.**) This improved performance will
increase the safety not only of patients implanted with the IOL but also of oth-
ers with whom they share the road.
Other aspheric IOLs that correct for positive SA in the eye are also now
available. These include the AcrySof SN60WF (Alcon Inc., Fort Worth, Texas)
with a SA of –15.0 µm (nominal value; the actual value varies with IOL
power), and the SofPort AO (Bausch & Lomb, Rochester, New York) with a
SA of –0.0 µm.
With these lenses available and others sure to follow because of the dra-
matic improvement in visual performance, this trend will continue to drive
the design of both aphakic and phakic IOLs. It is probable that within the next
3 years, most of the IOLs we implant will incorporate some version of the
aspheric modified-prolate surface IOL. In fact, I predict that we will measure
the exact SA in the patient’s cornea and then order an IOL with the correct
power and correct negative SA for that specific patient.
La ser Abla tion

Similar attention to SA is needed in excimer laser algorithms for refractive
surgery. Standard corneal refractive surgical laser treatments transform the
patient’s prolate cornea into an oblate cornea, inducing SA.
Standard laser ablations, whether delivered on the corneal surface or on a
stromal bed, have been calibrated on flat surfaces, and they do not take into
account that the cornea is a dome, a curved convex surface on which the effect
of the energy is reduced due to the progressive oblique incidence of the energy
as we move peripherally. As a result, early laser refractive treatments had
shrinking optical zones as a function of the amount of treatment, which limited
the degree of correction possible with excimer surgery. Consequently, initial
standard corneal refractive surgery procedures, whether LASIK, LASEK,
PRK or epi-LASIK, induced SA.
** February 2006 Federal Register on NTIOLs

The creation of an oblate corneal surface is the main reason why SA

increases after corneal laser surgery, accompanied by reduced visual perfor-
mance and the appearance of glare and halos. Even when surgical parameters
are excellent, with no complications such as damaged flaps or decentered abla-
tions, SA can still cause disabling nighttime glare and halos.
Modified La ser Trea tments

Recognizing this problem, laser manufacturers have begun to incorporate
radial compensation functions into their ablation profiles to compensate for
undertreatment in the periphery that was seen with original laser algorithms.
These new protocols boost the laser energy delivered to the corneal periphery
and thereby reduce the amount of SA induced by the surgery. (See Chapter
7 for a more complete discussion of the radial compensation function.) An
accurate radial compensation function is a prerequisite for treatments based on
refraction, topography or ocular wavefront.
In recent years, I have encouraged laser manufacturers to include a radial
compensation in all of their ablation profiles—whether refraction based,
topography guided or ocular wavefront guided. Including an accurate radial
compensation function in all of our treatments will allow us to truly evaluate
the differences in treatments based on refraction, topography or ocular wave-
front. It is my opinion that future refractive surgical treatments will use all
these diagnostic modalities to achieve the optimal outcomes in our refractive
surgery patients.
References
Artal P, Chen L, Fernand ez EJ, Singer B, Manzanera S, William s DR. Neural com -
p ensation for the eye’s optical ab errations. J Vis. 2004;4(4):281-287.
Bellucci R, Morselli S, Piers P. Com parison of wavefront ab errations and optical
quality of eyes im p lanted with five different intraocular lenses. J Refract Surg.
2004;20(4):297-306.
Glasser A, Cam pb ell MC. Presbyopia and the optical changes in the hum an crys-
talline lens with age. Vision Res. 1998;38(2):209-229.
Holladay JT, Piers PA, Koranyi G, van d er Mooren M, Norrby NE. A new intraocu-
lar lens d esign to reduce sp herical ab erration of pseudophakic eyes. J Refract
Surg. 2002;18(6):683-691.
Holladay JT, Janes, JA. Top ographic chang es in corneal asphericity and effective
optical zone size following laser in situ keratom ileusis. J Cataract Refract Surg.
2002;28(6):942-947.
36 C h a p te r 3
Guirao A, Gonzalez C, Red ondo M, Geraghty E, Norrby S, Artal P. Average opti-

cal p erform ance of the hum an eye as a function of age in a norm al p op ula-
tion. Invest Ophthalm ol Vis Sci. 1999;40(1):203-213.
Kennis H, Huygens M, Callebaut F. Com paring the contrast sensitivity of a
m odified prolate anterior surface IOL and of two spherical IOLs. Bull Soc Belge
Ophtalm ol. 2004;294:49-58.
Kershner RM. Retinal im age contrast and functional visual p erform ance with
aspheric, silicone, and acrylic intraocular lenses. Prop ective evaluation.
J Cataract Refract Surg. 2003;29(9):1684 -1694.
Mester U, Dillinger P, Anterist N. Im pact of a m odified optic design on visual
function: clinical com parative study. J Cataract Refract Surg. 2003;29(4):652-
660.
Packer M, Fine IH, Hoffm an RS, Piers PA. Prosp ective random ized trial of an ante-
rior surface m odified prolate intraocular lens. J Refract Surg. 2002;18(6):692-
696.
Wang L, Koch DD. Anterior corneal optical ab errations induced by laser in situ
keratom ileusis for hyp eropia. J Cataract Refract Surg. 2003;29(9):1702-1708.
4
Ve rte x Dista n c e ,
Re fra c tio n a n d
Intra o c u la r Le n s
Po we r C a lc u la tio n s
Measuring Vertex Distance
and Performing Over-Refraction
With a Soft Contact Lens
for Higher Prescriptions
Can Reduce Refractive
Surprises After IOL Implantation
Vertex distance is an essential component of any refraction. It should be
considered in power calculations for contact lenses, excimer laser treatments
and phakic IOLs.
For refractive corrections greater than a magnitude of ±4 D, the vertex
distance is extremely important in determining the necessary power because
there is a significant difference between a prescription at the spectacle plane
and the equivalent power at the corneal plane or the phakic IOL plane.
40 C h a p te r 4
Not incorporating the vertex distance (the distance in millimeters from the
posterior vertex of the spectacle lens to the anterior corneal vertex) as a part of
the prescription for large refractive errors can lead to problems with a patient’s
spectacles. Likewise, neglecting the vertex distance as a part of the refraction
can lead to incorrect treatments with the excimer laser and phakic IOLs.
Every eye care professional who fits contact lenses, performs laser ablation,
or implants phakic IOLs should know about vertex distance and the formulas
to calculate the equivalent lens power at another plane. This chapter explains
these formulas and how to use them.
An excellent method to avoid error in power calculations is to perform
over-refraction with a soft contact lens, for which the vertex distance is zero.
When determining the correct lens power for errors greater than 4 D, the
clinician can place a soft contact lens with a power that is near the patient’s
refractive error and then perform an over-refraction with low-powered lenses
to improve the precision of the refraction and eliminate any effect of vertex
distance. Using a soft contact lens for over-refraction guarantees predictability
in excimer surgery and phakic IOL procedures and rules out the largest source
of error—inaccurate vertex distance.
Foca l Length
When performing a refraction with the patient at the phoropter, the lens
power is a function of the distance from the patient’s eye to the phoropter.
Phoropters are calibrated so that when the anterior vertex of the cornea is at
the “reference line,” the patient is at an effective vertex distance of 13.75 mm.
Spectacle lenses are usually closer to the eye (~ 10 to 12 mm), and so even for
spectacles a vertex adjustment is often necessary.
If the patient chooses to wear contact lenses or to undergo corneal refractive
surgery, the treatment changes from the spectacle plane to the corneal plane.
The contact lens sits on the cornea, the excimer correction also takes place
on the cornea, and the phakic IOL sits behind the cornea in the anterior or
posterior chamber. To ensure the accuracy of our correction, this difference
in the position of the refractive correction must be taken into account in our
calculations.
Vertexing from one plane to another requires the use of a simple subtrac-
tion formula to determine the new prescription. In this calculation, the vertex
distance (usually about 12 to 14 mm) is subtracted from the focal length of the
patient’s old lens at the spectacle plane to obtain the focal length of the new
lens at the corneal plane.
Ve rte x Dista n c e , Re fra c tio n , a n d In tra o c u la r Le n s Po we r 41
The formulas are expressed as follows:

Power of any lens = 1000/focal length (in mm) of lens in air
Focal length of new lens = focal length of old lens (in mm) – vertex distance
(in mm)
Power of new lens = 1000/focal length (in mm) of new lens
Using this formula, a patient with –4 D of error and a vertex distance of 12

mm would have a focal length of –3.82 D, as shown here:
Power of any lens = 1000/– 4 = –250 mm

Focal length of new lens = –250 –12 = –262 mm (Note: Focal length and
vertex are both negative)
Power of new lens = 1000/(–262)= –3.82 D
So a patient with a –4 D correction and a 12 mm vertex distance would need

a little less than 0.25 D less power when moving from a spectacle prescription
to a prescription at the corneal plane.
For contact lenses, which are available in 0.25-D steps, the patient would be
fitted for a lens with a power of –3.75 D in this case.
Conversely, a hyperopic patient with a spectacle prescription of +4 D would
have a new contact lens prescription of +4.20 D, as shown here:
Power of any lens = 1000/+4 = + 250 mm

Focal length of new lens = +250 –12 = + 238 mm
Power of new lens = 1000/(+ 238) = +4.20 D
Both myopic and hyperopic spectacle prescriptions become more positive

when vertexed to the corneal plane. The plus lens becomes a bigger number
and the minus lens becomes a smaller number; that is, both move in a positive
direction when vertexed from the spectacle to the cornea.
Higher Powers in the Phoropter

Because prescriptions of 4 D or less have less than a 0.25 D difference
when vertexed to the corneal plane, there is little concern that the difference
in prescription power will be clinically significant for the patient. However,
with errors above 4 D, getting an exact measurement of the vertex distance is
crucial.
42 C h a p te r 4
As mentioned above, phoropters specify a vertex distance of 13.75 mm

when the corneal vertex is aligned properly, but the vertex distance, even when
the cornea is aligned properly, can vary significantly because different combi-
nations of lenses are used in the phoropter to get a specific power.
For higher prescriptions, such as –8 or –10 D, the combination of several
lenses within the phoropter changes the actual effective vertex distance, and
the refraction cannot be trusted. Using multiple lenses in a trial frame is even
worse. The 13.75-mm vertex distance is not accurate, even when the cor-
neal vertex is in the correct position. For this reason, we recommend another
method of calculation for a new prescription at the corneal plane for larger
prescriptions.
Soft Conta ct Lens Method

To calculate a vertexed prescription for patients with higher refractive
errors, place a soft contact lens of confirmed power on the cornea and perform
an over-refraction. The formulas described above are not necessary. The power
obtained in the over-refraction can be added directly to the confirmed power
of the contact lens used, provided it is less than ± 4 D and the vertex distance
is considered to be zero.
To minimize the power of the over-refraction for a myopic prescription,
choose a myopic soft contact lens that is about 80% to 90% of the power of
the patient’s prescription for minus lenses at the spectacle plane and 110% to
120% for plus lenses. The minus contact lens power should always be less than
the spectacle prescription by about 10% to 20%. Conversely, for hyperopic
prescriptions, the power for the plus contact lens should always be greater than
the prescription by about 10% to 20%. Because the corneal vertex distance for
a contact lens is zero, we can be sure our vertex distance is correct.
Determining the exact prescription for a patient with a spectacle prescrip-
tion of –10.00 + 4.00 90 would be done as follows:
Place a –9 D soft contact lens on the patient’s eye (90% of –10 D). The only
requirement for fit is that it centers well.
The over-refraction is +0.25 +3.25 90, and the final prescription at vertex
zero is therefore –8.75 D +3.25 90 (–9 added to +0.25 + 3.25 90°). Notice
that both sphere and cylinder changed.
Ve rte x Dista n c e , Re fra c tio n , a n d In tra o c u la r Le n s Po we r 43
Vertexing Spherocylinder
This example raises the question of how to vertex a spherocylindric pre-
scription. In the above example, let us assume that the vertex is 14 mm for the
spectacle prescription of –10.00 +4.00 90°. Can we vertex the –10 D and
+4 D? No. In spherocylindrical prescriptions, it must be remembered that the
cylindrical component is the difference in the principal powers, not the actual
power in each meridian.
In this example, the prescription in cross-cylinder form is actually –10 D
180° and –6.00 90°. Vertexing the –10 D through 14 mm we get –8.77 D,
and vertexing the –6.00 D through 14 mm we get –5.53 D.
These calculations can be written in three forms:
1. Cross-cylinder = –8.77 180° and –5.53 90°

2. Plus cylinder = –8.77 + 3.24 90°
3. Minus cylinder = –5.53 – 3.24 180°
The three forms are all equivalent, but only the cross-cylinder form has
actual powers, and it is the only one that can be vertexed.
The above example illustrates why “assuming” the measurement of vertex
distance is not wise and measuring the vertex distance for large powers is not
accurate.
If the patient in this example were a candidate for corneal refractive surgery,
a clinician who did not use the soft contact lens over-refraction method could
have a significant refractive surprise as the outcome of surgery.
Pha kic Intra ocula r Lenses

Calculating the power for a phakic IOL is slightly more difficult than cal-
culating powers at the corneal plane because the surgeon must begin with the
prescription at the spectacle plane and vertex back through the corneal plane to
the phakic IOL plane; the anterior chamber, at the iris plane or in the posterior
chamber.
For phakic IOLs, a more complicated vertex calculation formula is neces-
sary, which cannot be done by hand. The formula, which is reproduced in the
accompanying box, was described in full in an article we published in the
American Journal of Ophthalmology in 1993.
44 C h a p te r 4
Vertex Calculation Formula for Phakic IOLs

IO L = effective IO L power in aqueous; ELP = effective lens position in eye; K =
average net keratometric power of cornea; V = vertex of the preoperative refrac-
tion and desired postoperative refraction; PreRx = preoperative refraction at V;
DPostRx = desired postoperative refraction at V
The soft contact lens method with over-refraction can also be used to deter-
mine phakic IOL powers.
It is even more important to have accurate refraction when dealing with
candidates for phakic IOLs because they often have extremely high refractive
errors, up to –25 D. We must be exact when dealing with lens powers of that
magnitude.
If a patient has a –25 D spectacle prescription at exactly 14 mm, the soft
contact lens power would be –18.52 D (74% of the power at the spectacle
plane). If a –20 D soft contact lens is used for over-refraction, the over-refrac-
tion would be approximately +1.50, resulting in –18.50 D.
The surgeon inputs the refraction into a phakic IOL program, noting zero
as the vertex distance, the program calculates the required IOL power. Phakic
IOL power for this patient would be between –23.50 and –24.50, depending on
the lens constant of the phakic IOL—close to the original spectacle refraction,
but not close enough.
This method of calculation can also be used for determining power in sec-
ondary piggyback IOLs, which are placed in front of the primary IOL.
Reference
Holladay JT. Refractive p ower calculations for intraocular lenses in the phakic eye.
Am J Ophthalm ol. 1993;116:63-66.
5
Intra o c u la r Le n s
C a lc u la tio n s Afte r
Re fra c tive Su rg e ry
Surgeons Implanting Intraocular
Lenses in Patients Who Have
Undergone Corneal Refractive
Surgery Must Be Precise in Their
Measurements and Calculations
Calculating the correct IOL power for a patient who has undergone corneal
refractive surgery is a challenge. Measurement errors in these patients can lead
to large “refractive surprises” requiring lens exchange or the implantation of a
secondary piggyback IOL.
To prevent refractive surprises and achieve the best surgical outcome, the
surgeon must obtain precise preoperative measurements, retrieve as much as
possible of the patient’s data prior to refractive surgery and use the correct IOL
power calculation formula.
48 C h a p te r 5
To carry out successful cataract surgery, refractive lens exchange or phakic

IOL implantation after LASIK, PRK, RK or LASEK, the surgeon must have
the right ingredients for IOL power determination. Particularly, we need to
determine the patient’s effective lens position and corneal power. These two
variables are the most difficult to accurately determine of the four preoperative
variables (axial length, keratometry, effective lens position (ELP) and desired
postoperative refraction) necessary to calculate the proper IOL power.
Avera ge Effective Lens Position

The average ELP or manufacturer’s lens constant for each IOL, expressed in
millimeters, is listed on the product packaging, along with the A-constant and
the surgeon factor. Most IOL manufacturers misleadingly refer to the ELP as
the “anterior chamber depth,” or ACD. This label is an antiquated misnomer.
ACD is defined as the depth of the anterior chamber, and, because most
modern IOLs are posterior chamber lenses, the term is confusing in this con-
text. Used correctly, the term anatomic external ACD describes the distance
from the anterior corneal vertex to the anterior vertex of the crystalline lens.
The anatomic internal ACD is measured from the posterior vertex of the
cornea to the anterior crystalline lens vertex and does not include the central
corneal thickness.
The ELP is neither of these. The ELP is the effective position of the IOL (the
principal plane of the thin lens) relative to the anterior corneal vertex (Figure
5-1). For most IOLs, this distance is into the posterior chamber, and hence the
old term ACD is confusing. The ELP value provided by the lens manufacturer
is the average position of the IOL within the eye when measured from the
corneal vertex to the principal plane of the IOL. The ELP value for each lens
model or style is averaged from data collected from many patients, although
the sample size varies from manufacturer to manufacturer.
The ELP and surgeon factor measurements are expressed in millimeters,
while the A-constant is expressed in diopters. Although these factors are in
different units of measure, each can be converted to the other types of mea-
surements, just as a linear distance can be converted from feet to meters.
The formulas for converting A-constant to ELP and to surgeon factor are
as follows:
ELP = (Aconst 0.5663) – 65.600 + 3.595

0.9704
SF = (Aconst 0.5663) – 65.600

In tra o c u la r Le n s C a lc u la tio n s Afte r Re fra c tive Su rg e ry 49
Figure 5-1. The ELP is the effective position of the IO L (the principal
plane of the lens) relative to the anterior corneal vertex. For most IO Ls,
this distance is into the posterior chamber, and hence the old term ACD
is confusing.
Occasionally, inconsistent values for A-constant, surgeon factor and ELP

appear on IOL packaging because the manufacturer has not updated the lens
constants with conversion formulas that were standardized in 1997. When this
occurs, it is usually because the older ACD value was determined for sulcus
implantation and the newer value is for in-the-bag placement. For this reason,
when a discrepancy is found, the largest value is the one that should be used.
Determining Individua l Effective Lens Position

IOL power calculation formulas use the manufacturer’s average ELP to
help predict the specific ELP for each patient. Individual ELP is determined
by starting with the manufacturer’s ELP for the average patient (with an axial
length of 23.5 mm and a K-reading of 43.86) and then using preoperative
anatomic measurements to determine the value for the specific patient (Figure
5-2).
Binkhorst was the first to implement the use of individual ELP for specific
patients in 1980 with his Binkhorst II power calculation formula. If the average
ELP for a posterior chamber IOL is 5.25 mm, and the patient’s axial length is
10% longer than the average 23.5 mm, then Binkhorst would increase the aver-
50 C h a p te r 5
Figure 5-2. Individual ELP is determined by starting with the manufac-

turer’s ELP for the average patient (with an axial length of 23.5 mm and
a K-reading of 43.86) and then using preoperative anatomic measure-
ments to determine the value for the specific patient. The Holladay
II is a fourth-generation IO L formula introduced in 1996 with seven
preoperative values used in the calculation of the patient’s specific ELP:
axial length, keratometry, horizontal corneal diameter (white-to-white),
external anterior chamber depth, lens thickness, preoperative refraction
and age.
age ELP by 10% (5.25 + 0.525 = 5.725 mm) and use this value for that specific
patient. The Binkhorst II formula was therefore referred to as a second-genera-
tion IOL power calculation formula because it used the patient’s axial length to
determine the specific ELP.
In 1988, we introduced the Holladay I formula, which added the K-reading
to the axial length measurement to predict the patient’s specific ELP, and this
was referred to as a third-generation IOL formula (a two-variable ELP predic-
tor). Several formulas were described between 1988 and 2000 (the SRK/T,
Hoffer Q, Haigis, Olsen and others), which are also referred to as third-genera-
tion formulas.
The Holladay II is a fourth-generation IOL formula introduced in 1996
with seven preoperative values used in the calculation of the patient’s specific
ELP: axial length, keratometry, horizontal corneal diameter (white-to-white),
external anterior chamber depth, lens thickness, preoperative refraction and
age. These variables are all used to predict the patient’s specific ELP from the
manufacturer’s average ELP.
In the course of developing the Holladay II formula, we found that the hori-
zontal corneal diameter (commonly called the white-to-white measurement) is
a key anatomic factor that is helpful in predicting individual ELP. The corneal
white-to-white measurement is probably the most important element in judg-
ing the size of the anterior segment and predicting the depth of the IOL within
the eye.
The average horizontal white-to-white measurement in a normal eye is 11.7
mm ± 0.46 mm. Ninety-five percent of people have a white-to-white measure-
ment between 12.5 mm and 10.8 mm. Patients with a measurement of 12.6 mm
or greater are considered to have a large anterior segment, while patients with
10.7 mm or less have a small anterior segment.
Nine Types of Eyes

In doing the research that led to the Holladay II formula, 35 surgeons around
the world were asked to contribute 105 cases each (35 with axial lengths great-
er than 26 mm, 35 with axial lengths less than 22 mm and 35 cases between
these values). In analyzing all of these cases, we found that there is little corre-
lation between the size of the anterior segment—small, normal or large—and
the patient’s axial length. It used to be thought that these two factors, anterior
segment and axial length, were proportional. (This was an assumption of the
Binkhorst II formula.) But we determined that the size of the anterior segment
and the length of the eye are almost independent and are correlated in only
about 10% to 20% of eyes.
This finding led to the conclusion that, instead of three types of eyes (small,
normal and large), there are nine possible types of eyes, with three sizes of
anterior segment and the additional independent variable of short, normal or
long axial length (Figure 5-3).
In the course of our research, we determined that 80% of short eyes and
90% of long eyes, even with extreme axial lengths, have normal anterior seg-
ment sizes. Building these differences in the types of eyes into the Holladay
II formula enabled us to predict ELP more accurately in shorter eyes. This
helps surgeons avoid the “5-D surprise” that was often caused by IOL power
formulas that preceded the Holladay II formula in eyes as short as 15 mm
(Figure 5-4).
Importa nt Va ria ble

The specific ELP, the predicted position of the IOL within a particular eye,
is an important factor in modern IOL formulas because it is the only variable
52 C h a p te r 5
Figure 5-3. The size of the anterior segment and the length of the eye
are almost independent and are correlated in only about 10% to 20%
of eyes. This finding led to the conclusion that, instead of three types
of eyes (small, normal and large), there are nine possible types of eyes,
with three sizes of anterior segment and the additional independent
variable of short, normal or long axial length.
Figure 5-4. The Holladay II formula enabled us to predict ELP more

accurately in shorter eyes. This helps surgeons avoid the “5-D sur-
prise” that was often caused by IO L power formulas that preceded the
Holladay II formula in eyes as short as 15 mm.
Figure 5-5. The vergence formula, which relates the targeted refraction,
IO L power, corneal power, individual ELP and axial length, is more than
140 years old. The only difference among today’s theoretical formulas
is the method of predicting the ELP.
that cannot be directly measured or chosen by the surgeon preoperatively. The

surgeon has no control over the prediction of the ELP for a specific patient
other than choosing the best formula for the calculation.
The additional five measurements used in the Holladay II formula are
especially helpful in precisely predicting the ELP in short eyes (less than 22
mm).
Once the model of IOL has been chosen; the corneal power, axial length,
white-to-white distance, ACD and lens thickness have been measured; age and
current refraction have been determined; and the desired postoperative refrac-
tion chosen, we have all seven necessary variables to determine the patient’s
specific ELP.
The vergence formula (Figure 5-5), which relates the targeted refraction,
IOL power, corneal power, individual ELP and axial length, is more than
140 years old. The only difference among today’s theoretical formulas is the
method of predicting the ELP.
54 C h a p te r 5
Figure 5-6. Myopic staphyloma. Eyes with axial lengths that are 26 mm
or longer usually have a myopic staphyloma. This means that the scleral
fibers in the back of the eye, where the fovea is, are weakened and
bulge out.
Axia l Length in Long Eyes

The surgeon must take extra caution in measuring axial length in long
eyes.
Eyes with axial lengths that are 26 mm or longer usually have a myopic
staphyloma (Figures 5-6 and 5-7). This means that the scleral fibers in the
back of the eye, where the fovea is, are weakened and bulge out. Traditional
ultrasonic measurements, which measure axial length to the deepest point
where the ultrasound wave is perpendicular to the retina, usually measure to
the deepest part of the staphyloma (the anatomic axial length). For IOL cal-
culations, we need the optical axial length, which is from the anterior corneal
vertex to the fovea.
In highly myopic patients with staphyloma, the fovea can be midway up
the staphyloma or on the rim. As a result, the anatomic axial length (from the
anterior pole to the posterior pole of the eye) can be up to 3 mm longer than
the optical axial length (from the anterior pole to the fovea).
For every 1 mm of difference between the optical axial length and the
anatomic axial length, a 2.5 to 3 D error in power prediction is made. In the
Journal of Cataract and Refractive Surgery in 2000, Roberto Zaldivar, MD,
and I reported this finding. We found that patients with axial length measure-
ments greater than 26.5 mm (up to 35 mm) had anatomic and optical axial
Figure 5-7. B-scan of myopic staphyloma. Traditional ultrasonic mea-

surements, which measure axial length to the deepest point where the
ultrasound wave is perpendicular to the retina, usually measure to the
deepest part of the staphyloma (the anatomic axial length). For IO L cal-
culations, we need the optical axial length, which is from the anterior
corneal vertex to the fovea. In highly myopic patients with staphyloma,
the fovea can be midway up the staphyloma or on the rim. As a result,
the anatomic axial length (from the anterior pole to the posterior pole
of the eye) can be up to 3 mm longer than the optical axial length (from
the anterior pole to the fovea). The average error was 0.8 mm.
lengths that differed by up to 3 mm, which could cause an error of up to 9 D

in IOL power. The average error was 0.8 mm.
To avoid this problem, we suggest that surgeons measure patients with long
eyes (26 mm or more in length) with optical coherence tomography (OCT)
instead of ultrasound. A partial interferometry device such as the Carl Zeiss
Meditec IOLMaster (Jena, Germany) measures axial length accurately to the
fovea because the patient must fixate on a target. The IOLMaster is the only
technology currently available to measure axial length that uses light and not
ultrasound.
It is crucial that we measure long, highly myopic eyes using this type of
technology. However, the IOLMaster cannot measure eyes with dense cataract
because opacification prevents the coherent light from forming a measurable
interference pattern. In patients with dense cataract, ultrasound is the only
option.
56 C h a p te r 5
Figure 5-8. Topographers

and keratometers have a
central scotoma of 1.5 to
3.2 mm in diameter where
no measurements are taken.
The central area covered by
the scotoma is not only the
most important area for the
patient’s vision, it is also the
only place to measure the
true central corneal power.
Centra l Cornea l Mea surement

Corneal power is another anatomic factor that must be accurately measured
for correct IOL power calculation. It is particularly difficult to determine the
corneal power of an eye that has undergone corneal refractive surgery such as
LASIK, PRK or RK because the traditional instruments surgeons use to mea-
sure corneal power (keratometry and topography) are inadequate; they were
created to measure the corneal power of an unaltered cornea.
The first problem with keratometers and topographers is that they are lim-
ited in their ability to measure surgically treated corneas because they take
paracentral measurements and do not measure the center of the cornea. There
is little correlation between paracentral measurement and the true measure-
ment at the center of the cornea in postrefractive-surgery patients.
Topographers and keratometers have a central scotoma of 1.5 to 3.2 mm in
diameter where no measurements are taken. The central area covered by the
scotoma is the most important area for the patient’s vision; it is also the most
important for determining true central corneal power (Figure 5-8).
So we have a problem: The center of the cornea is the most critical area for
calculating the corneal power of a patient who has had refractive surgery, and
yet it is the one area that is not truly measured by keratometry and topography.
This critical zone increases in size with the amount of refractive surgical cor-
rection.
On the average patient with a 44-D cornea, the keratometer measures at
spots that are 3.2 mm apart in diameter. This means, at the corneal center,
everything less than 3.2 mm in diameter is lost. This is not a problem in a
patient who has not had corneal refractive surgery, but for a patient after refrac-
tive surgery it can cause a significant error.
For example, a patient with a keratometry reading of 36.5 D after –10 D
laser surgery actually has a central anterior corneal power that is flatter by
15% of his refractive change (–10 D 15% = –1.5 D) than a patient with a 36.5
D cornea who has not had surgery. The central anterior corneal surface for a
–10 D LASIK measures 36.5 D and is actually ~ 35 D (36.5 D – 1.5 D).
Deriving Net Power

A second limitation of keratometers and topographers is that they fail to
measure the posterior surface of the cornea, a measurement that is needed for
calculating net corneal power (Figure 5-9).
Topographers and keratometers measure only the front surface of the cor-
nea. They assume that the back and front surface powers of the cornea are
equal. This is not true, of course. The back radius of the cornea is steeper than
the front, approximately 82.2% of the front radius of the cornea.
Most IOL formulas and programs use a keratometric index of 1.3375 when
converting from corneal power to radius, using this keratometric formula:
337.5/radius of curvature of the cornea (in mm) = power of the cornea
Using this formula, a 7.5 mm anterior central corneal radius yields 45 D of

power.
The authors of IOL formulas have compensated for the front-and-back cor-
neal ratio by reducing the keratometric power (1.3375) of the cornea to a net
power using a net index of refraction. Unfortunately, there is no exactly agreed-
upon value for this, so the net index of refraction varies from 1.3315 to 1.3333
depending on the IOL formula.
58 C h a p te r 5
Figure 5-9. A second limitation of keratometers and topographers is that

they fail to measure the posterior surface of the cornea, a measure-
ment that is needed for calculating net corneal power. Topographers
and keratometers measure only the front surface of the cornea. They
assume that the back and front surface powers of the cornea are
equal. (Courtesy of Benjamin F. Boyd, MD, FACS, Editor-in-Chief,
HIGHLIGHTS O F O PHTHALMO LO GY, "Refractive Surgery with the
Masters," 30th Anniversary Edition, Vol. II, 1987.)
Therefore, this calculation, depending on the formula used, could reduce the
keratometric power of the cornea by 0.3315/0.3375, to 98.22% of the measured
power, or by 0.3333/0.3375, to 98.76% of the measured power.
For a keratometric power of 44 D, then, the net value would be from 43.22
to 43.45 D, depending on the formula used, which is 0.55 D to 0.78 D less than
the measured keratometric power. The power has to be reduced; otherwise the
power of the cornea will be overestimated.
After corneal refractive surgery, the back surface of the cornea is no longer
82.2% of the front surface, as it is in a normal cornea. Therefore, there is a
second error in the net corneal power, which is 10% of the refractive change
(from the above example, –10 D 10% = 1 D). This value represents the over-
estimate of the patient’s actual corneal power due to the change in the ratio of
the back-to-front surface radii assumed by current IOL formulas.
The peripheral sampling error, as noted above, equals 15% of the refractive
surgery treatment, and the change in the ratio of the back to front surface adds
another 10%, so the total error in the keratometric reading of our patient after
–10 D LASIK is 25% (15% + 10%) of the effect of the refractive surgery. So
the true central keratometry value of a patient with a keratometry reading of
36.5 D after a –10 D LASIK is actually 34 D (36.5 – (25% 10 D).
If the keratometric reading were used without taking this difference into
account, it would result in a 2.5-D hyperopic surprise because the actual cen-
tral power of the cornea is 2.5 D less than the measured K-reading.
Cornea l Power Ca lcula tions

Because, on their own, keratometric and topographic measurements of the
cornea are inadequate in patients after corneal refractive surgery, I have pub-
lished four mathematical methods to determine and validate the true power
of the cornea in these patients: the historical method, two modified historical
methods and the hard contact lens method. While none of these is perfect, they
are better than using the straight keratometric or topographic readings.
In the examples that follow, the same corneal power measurement (39.50
D) is derived as would be obtained by each of the four methods. In a perfect
world, the results with all four methods would always be equivalent, making
it easy for the surgeon to choose the corneal power to utilize in the vergence
formula. However, in real life the corneal powers derived from the historical
and contact lens methods are rarely the same numeric value when calculated
for a single patient.
After myopic refractive surgery, the surgeon should always use the flattest
power derived from four formulas. This will avoid a refractive surprise later
on, which occurs when the cornea is estimated to be steeper than it actually
was. After hyperopic refractive surgery the reverse is true, and the steepest
power should be chosen because the true corneal power is greater than the
measured value.
HISTORICAL METHODS
Using the historical method, the surgeon subtracts the patient’s surgically
induced refractive change from the preoperative keratometry reading to deter-
mine the current corneal power.
For example, if the patient was a –4 D myope with 44 D of corneal power
before surgery and ended up +0.50 D after surgery, he underwent a –4.5 D
change. If we subtract this refractive change from the preoperative K-read-
ing, we arrive at a corneal power of 39.50 D (Figure 5-10). Theoretically, the
refraction should be vertexed back to the corneal plane (see Chapter 4), but
for myopia, this will reduce the SIRC and increase the risk of hyperopic sur-
prise.
If a patient underwent refractive surgery at another center, the surgeon may
not have a record of the patient’s prerefractive-surgery K-readings. In this case,
one of the modified historical methods can be used.
60 C h a p te r 5
Figure 5-10. Historical calculation method. Keratometry before refractive

surgery and amount of refractive change are necessary for the calcula-
tion.
In the first modified historical method, the current (after refractive surgery)
keratometry reading is used along with the surgeon’s “best guess” at the refrac-
tive change (Figure 5-11). In the example in Figure 5-11, 24% of the power of
the refractive change was used to compensate for paracentral sampling and
the change in front and back ratio of the corneal surfaces. Therefore, 24% of
the power of the refractive change is subtracted from the current keratometric
measurement.
The keratometer after myopic refractive surgery overestimates the corneal
power by 25% of the refractive change. If the patient has a K-reading of 40.58,
with 4.5 D of refractive change, we take 25% of that value, which is 1.08. We
subtract this value from the current K-reading of 40.58, and again we get 39.50
D. This is the corneal power that we enter into the IOL program.
For the second modified historical method, topography is used instead of
keratometry. Topography gets closer to the center of the cornea than does kera-
tometry, so the topography reading needs to be reduced by only 15% of the
refractive change, rather than 24%.
If the central refractive power measured by the topographer is 40.18, and the
refractive change is –4.50 D, then 15% of the refractive change is –0.68 D. So
the calculated power would again be 39.50 D (Figure 5-12).
In the second modified historical method, using topography measurements,
the surgeon must be careful not to use the simulated K from the topographer.
The simulated K measurements are the same as keratometry measurements.
Figure 5-11. Modified historical method with present K-readings.

Measurements are taken with a standard keratometer and the mean K is
reduced by 24% of the refractive change from the refractive surgery.
Figure 5-12. Modified historical method using topography. Topography

gets closer to the center of the cornea than does keratometry, so the
topography reading needs to be reduced by only 15% of the refractive
change, rather than the 24% used with keratometry. The central power
in the zone must be used from the topographer, not the simulated Ks.
Simulated Ks are the same as the keratometry readings.
62 C h a p te r 5
Figure 5-13. Corneal topography map. In the second modified

historical method, using topography measurements, the surgeon
must be careful not to use the simulated Ks from the topogra-
pher. The simulated K measurements are the same as keratometry
measurements. The central refractive power as reported by the
topographer is the value to use in this modified historical method.
Even though the topographer does not take central corneal mea-
surements, it extrapolates them. If this measurement does not
automatically appear on the topography map, the user can click on
the central area with the mouse a few times and take an average
of those values.
The central refractive power as reported by the topographer is the value to use
in this modified historical method. Even though the topographer does not have
data centrally, it extrapolates them. If this measurement does not automatically
appear on the topography map, the user can click on the central area with the
mouse a few times and take an average of those values (Figure 5-13).
CONTACT LENS METHOD

In the fourth calculation method, a rigid contact lens is used to perform an
over-refraction (Figure 5-14).
Take a patient whose refraction is +0.50 D after refractive surgery. If the
refraction changes to –0.50 D with a 41 D contact lens in place on the cornea,
the front corneal curvature must be 1 D flatter than 41 D, or 40 D (41 D – 1
D = 40 D).
Figure 5-14. Contact lens method. The base curve and power of the
gas permeable contact lens (GPCL), refraction with and without
the GPCL and refractive change from the refractive surgery must
be known.
The contact lens method does not compensate for the change in back-to-
front surface ratio. Once this value (40 D) is obtained, you still need to reduce
by 10% of the refractive surgery effect (as with topography) because the back
surface of the cornea does not have the same curvature as the front. This
results in a value of 39.55, the calculated power for this patient.
Mea suring Front a nd Ba ck

The Pentacam (Oculus, Inc., Lynwood, Wash.) overcomes the two problems
of keratometry and topography described above by measuring the central cor-
nea and the back surface of the cornea (Figure 5-15).
The Pentacam measures the tomography of the cornea by taking 50 meridi-
onal Scheimpflug images (Figure 5-16). The instrument is far more accurate
than any other tomographer.
In a study we conducted, we determined that the net power of the cornea can
be measured by the Pentacam to within ±0.55 D. So with this instrument we
can measure a cornea that has undergone corneal refractive surgery to within
±0.5 D of its actual power (Figure 5-17).
64 C h a p te r 5
Figure 5 -15. The

Pentacam overcomes
the two problems
of keratometry and
topography previously
described by measur-
ing the central cornea
and the back surface
of the cornea.
Figure 5-16. The Pentacam measures

the tomography of the cornea by tak-
ing 50 meridional Scheimpflug images
with a common center.
Oculus has incorporated a display into the Pentacam called the Holladay
Report*, which will accurately calculate the front and back central surface
powers of the cornea, adjust for any power overestimate and report a term
called the equivalent keratometric reading, or EKR (Figure 5-18). With this
report in the Pentacam software, surgeons will be able to use the EKR in IOL
calculation software just as they would a standard keratometry reading. The
* Pentacam Interpretation Guideline, Holladay Report, pg. 30-31, Oculus.

Figure 5-17. The net power of the cornea can be measured by the
Pentacam to within ± 0.55 D after LASIK or PRK.
Figure 5-18. O culus has incorporated a display into the Pentacam

called the Holladay Report, which will accurately calculate the front
and back central surface powers of the cornea, adjust for any power
overestimate and report a term called the equivalent keratom etric
reading, or EKR. With this report in the Pentacam software, surgeons
will be able to use the EKR in IO L calculation software just as they
would a standard keratometry reading.
66 C h a p te r 5
Figure 5-19. The frequency distribution plot for the anterior cornea fol-
lowing radial keratotomy. The corneal power ranges from 37.2 to 48.1
and because of this extreme range the actual refractive power is almost
impossible to determine.
software will also display a frequency distribution of corneal power that is also
helpful (Figure 5-19).
References
Holladay JT. Intraocular lens p ower calculations for the refractive surgeon.
Operative Techniques in Cataract and Refractive Surgery. 1998;1:105-117.
Holladay JT. Standardizing constant s for ultrasonic biom etry, keratom etry, and
intraocular lens p ower calculations. J Cataract Refract Surg. 1997;23(9):1356 -
1370.
Holladay JT, Prag er TC, Chandler TY, Musgrove KH, Lewis JW, Ruiz RS. A three-
part system for refining intraocular lens p ower calculations. J Cataract Refract
Surg. 1988;14:17-24.
Zaldivar R, Shult z MC, Davidorf JM, Holladay JT. Intraocular lens p ower calcula-
tions in patients with extrem e m yopia. J Cataract Refract Surg. 2000;26;668 -
674.
6
Su rg ic a l C o rre c tio n
o f Pre sb yo p ia
Some Newer Refractive Surgeries
Take Advantage of Pupil Size
Changes and Other Factors
to Provide Good Near and
Distance Vision
The number of prospective patients for surgical correction of presbyopia is

projected to grow rapidly in the coming decades. In 2006, the baby boomer
generation falls between the ages of 42 and 60 years old. This population is
estimated to be 90 million in the United States and 73 million in Europe,
according to Harvard’s Generations Policy Journal. By 2030, the over-65 U.S.
population is expected to grow to almost 70 million.
To attract this patient base, a satisfactory surgical solution to presbyopia is
needed, but that has been an elusive goal.
70 C h a p te r 6
Options for Presbyopia

1
-
6
Options Considerations
e
l
b
Spectacles, contacts Patient dissatisfaction
a
T
Monovision LASIK Risks of flap creation, dry eye, healing
problems, DLK; possible reduced contrast
sensitivity, stereo acuity, and depth percep-
tion
Presbyopic LASIK In development => ~ to aspheric IO L
Multifocal IO Ls (AcrySof Decreased contrast sensitivity, night driving

ReSTO R [Alcon Inc., Fort performance
Worth, Texas], Risks of intraocular surgery
ReZoom [Advanced Medical
O ptics, Santa Ana, Calif.], and
Tecnis multifocal IO L
[Advanced Medical O ptics,
Santa Ana, Calif.])
Accommodating IO Ls No UV protection
Limited accommodation
Risks of intraocular surgery
NearVision CK Monovision tolerance assessment required

before procedure
Acufocus Ultrathin 20/15 at distance and near in 98%

Corneal Inlay
It may be that optical physics, not surgical skill, presents the greatest chal-
lenge to achieving successful surgical correction of presbyopia. The greatest
surgeon’s skill cannot change the fact that a multifocal IOL divides light
between two or more foci and consequently reduces contrast sensitivity, creat-
ing halos.
Some newly developed technologies for correction of presbyopia take
advantage of the optical characteristics of the eye, the built in “f-stop” of the
iris and other physiologic factors, to provide promising results. It may be that
these new approaches will provide the best results to date in the effort to cor-
rect presbyopia surgically.
This chapter reviews some of the benefits and compromises of current
surgical options for correction of presbyopia and describes some promising
technologies for the future (Table 6-1).
Su rg ic a l C o rre c tio n o f Pre sb yo p ia 71
Alterna te Versus Simulta neous Ima ges

Spectacles and contact lenses can correct presbyopia successfully, but some
patients desire freedom from spectacles and some are intolerant of contact
lenses. For these patients, surgical solutions to date have involved compro-
mise.
Some contact lenses and spectacles can create true bifocality, in which the
patient looks through different regions of the lens alternately to see distant
and near objects. That is contrasted with bifocal IOLs and some types of bifo-
cal contact lenses, which produce both distant and near images on the retina
simultaneously.
The difference between alternate and simultaneous viewing of distance and
near is a key concept in presbyopia correction. In glasses and contacts with a
discrete bifocal for alternate viewing, the wearer can look through the distance
portion and see a perfect distant image and through the bifocal portion and see
a perfect near image.
Image quality is always better with alternate rather than simultaneous view-
ing because there is no defocused image falling on top of the focused image on
the retina to reduce the contrast. There is no reduction in contrast, no dyspho-
topsia, no halos, no rings, because with alternate viewing we have two different
lenses to produce the two images.
In contact lenses, both simultaneous and alternate viewing designs are avail-
able, and the alternate designs are more popular. There are more people wear-
ing a bifocal rigid weighted contact lens with two zones than there are people
wearing soft multifocal contacts that create a simultaneous image.
Monovision
Another technique for surgical correction of presbyopia that has been
adapted from contact lens practice is monovision for LASIK or refractive lens
exchange.
Monovision, in which one eye is corrected for distance viewing and the
other for reading or other near activity, is a common strategy in contact lens
fitting. More contact lens wearers prefer monovision to multifocal simultane-
ous- or alternate-vision contact lenses because of the loss of contrast and dys-
photopsia with multifocal contact lenses.
Another consideration is that contact lens patients remove their lenses from
time to time and thus are continually reminded of the loss of contrast and dys-
photopsia that are caused by the lenses. This does not occur with LASIK or
IOL surgery, so the long-term success is much greater.
72 C h a p te r 6
The monovision strategy can also be used with LASIK or IOL surgery, cor-
recting one eye for distance and the other for reading vision, but the disadvan-
tages of monovision include reduced stereoacuity and a resultant reduction in
depth perception. That is a big sacrifice. A person’s ability to function with one
eye is less than half his ability with two eyes because of some loss of depth per-
ception. The synergy of two eyes with equally good vision providing a three-
dimensional image is the basis of stereopsis and is greater than the sum.
An advantage of monovision LASIK or IOL surgery in comparison with
monovision contact lenses is that the patient cannot compare monovision to
stereo vision. When contact lens patients take out their lenses at night, they
are reminded of the world of stereo vision, and for some patients the monovi-
sion modality suffers by comparison. Patients after bilateral LASIK or IOL
implantation cannot make that comparison, and they usually adapt to their new
vision with a tincture of time.
Presbyopic LASIK
Several surgeons have pioneered techniques for multifocal LASIK for cor-
rection of presbyopia. A number of surgeons in Europe and North and South
America are gathering increasing experience with these techniques, all of
which involve creating an aspheric corneal surface similar to a zonal multifo-
cal lens. In some of the techniques, near focus is in the periphery of the cornea
and distance focus by the center of the cornea, while with other techniques the
reverse occurs.
The chief proponent of presbyopic LASIK in North America has been
W. Bruce Jackson, MD, of Ottawa. Dr. Jackson’s technique, which parallels
that of Luis Ruiz, MD, of Bogotá, Colombia, is designed to steepen the cen-
tral cornea to provide an area of near vision, while distance vision is in the
peripheral cornea.
These techniques show promise, but I believe there is more at work than
the zonal division between far and near vision similar to a multifocal IOL.
The multifocal LASIK technique works for additional reasons. The exagger-
ated prolate central cornea created by these techniques provides good distance
vision and better near vision when the pupil constricts with a near stimulus.
However, if the asphericity created on the cornea by these techniques is too
great, the patient’s contrast sensitivity will suffer, and it is much more difficult
to make an exact aspheric surface on the cornea than on an IOL. More investi-
gation is needed to see how these techniques perform in the long term.
Figure 6-1. O ptical principles of IO Ls. A monofocal lens shows one focal
point, diffractive multifocal lenses show two main focal points and a
refractive multifocal has multiple points of focus between the near and
far focus. The light from the diffractive lens (in this case a CeeO n 811E
lens [Pfizer Inc., New York, N.Y.]) shows two main light bundles, one
going to the near focal point and the other to the far focal point. The
lens has two light bundles that are independent of pupil size for pupils
greater than 1.5 mm. A first-generation zonal-refractive multifocal lens
(in this case the Array SA40N [Advanced Medical O ptics, Santa Ana,
Calif.]) shows numerous small light bundles coming from the different
refractive zones and going to two main focal areas. Large pupils show
more bundles than small pupils. If the pupil size is smaller than approxi-
mately 2.5 mm, the lens has only one far focal point.
Multifoca l Intra ocula r Lenses

The same approaches that are used to create simultaneous distance and near
vision in contact lenses are also used in multifocal IOLs. An alternate viewing
design cannot be used in an IOL because the IOL moves with the eye and there
is no way to have the eye look through different zones.
Diffractive and aspheric multifocal designs have been used in both contact
lenses and IOLs for simultaneous image production. Recent multifocal IOL
designs using these concepts have been more successful than the early genera-
tion of multifocals that appeared in the 1980s, but the new designs still carry
the inherent problem of reduced retinal image contrast, reduced contrast sensi-
tivity and halos at night (Figure 6-1). This is because the total amount of light
74 C h a p te r 6
Figure 6-2. Rings and halos around lights at night taken through
a camera using IO Ls as the focusing lens. Simultaneous
vision creates a halo or ring around lights at night from the
defocused image. The images always appear worse in a pho-
tograph than they appear to the patient because of neural
adaptation. But the images do represent the image formed on
the patient’s retina.
entering the eye is divided between two or more images, near and distance
and in some lenses intermediate, which are all simultaneously images on the
retina.
It is always true that the amount of multifocality in a lens is proportional to
the reduction in contrast sensitivity experienced with that lens. This is a law
of physics that even the best refractive surgeon cannot overcome. Some of the
current designs are more equally weighted for distance and near vision than
earlier designs, but they still carry the tradeoff of reduced contrast. Problems
related to multifocality, such as halos around lights and dysphotopsias, are now
minimized, but they can never be eliminated (Figure 6-2).
Neura l Ada pta tion

The positive side for multifocal IOLs is the neural adaptation that takes place
over time in patients implanted with the lenses. Between 6 and 12 months after
implantation of a multifocal lens, 98% of patients neurally adapt to the new
visual information and are extremely satisfied.
It is vital to perform bilateral implantation of similar multifocal lenses in
order to allow neural adaptation to take place. One should strongly consider
the implantation of multifocal IOLs in both eyes. By 6 months to 1 year, neural

adaptation will occur, and the percentage of unhappy patients should dwindle
to less than 2%. (For a more complete discussion of neural adaptation, see
Chapter 10.)
Despite this neuroadaptive effect, multifocal IOL implantation carries the
risk of intraocular surgery and an inherent sacrifice in contrast sensitivity, so
there is a tenuous risk-benefit ratio in performing refractive lens exchange with
multifocal IOLs in a person with a clear lens.
Accommoda ting Intra ocula r Lenses

Another modality is the crystalens (eyeonics, Aliso Viejo, Calif). It is the
only IOL approved for use in the United States that claims accommodation for
the correction of presbyopia.
The term accommodating IOL is a misnomer in relation to the crystalens.
According to a report by Oliver Findl and colleagues, the IOL appears to move
less than 1 mm axially, which is not enough movement to explain the amount
of accommodation that clinicians have reported.
The principal optical reason for the crystalens’ performance is its increased
depth of focus due to the smaller-diameter optic. The crystalens’ optic is 4.5
mm in diameter, 25% smaller than the 6-mm diameter of most IOLs implanted
today. By the laws of optical physics, a 25% smaller aperture provides 25%
greater depth of focus.
With a standard monofocal IOL, about 50% of people can achieve 20/40
equivalent near vision using both eyes. With the accommodating lens, that per-
centage increases to about 80%. Depth of focus and size of the lens aperture
are sufficient to explain that effect. But still about 15% of people implanted
with the crystalens need reading glasses for small print. However, they also
have no halos at night.
Nea rVision CK
NearVision CK is a technique for presbyopia correction introduced in 2004
by Refractec (Irvine, Calif.), the maker of the ViewPoint CK system for con-
ductive keratoplasty.
NearVision CK is a “mini-monovision” technique. It is the only corneal
surgical treatment for presbyopia that does not sacrifice an equal amount of
distance vision to gain near vision.
The CK treatment creates a ring at a nominal diameter of 7 mm (6 to 8
mm) where the cornea is flattened. That ring essentially forms an annular
76 C h a p te r 6
Figure 6 -3. NearVision CK anterior surface curvature map. The CK treat-

ment creates a ring at a nominal diameter of 7 mm (6 to 8 mm) where
the cornea is flattened. That ring essentially forms an annular multifocal
cornea, with a flat spot in the very center of the cornea, a steeper zone
outside that and the flatter 7-mm ring.
multifocal cornea, with a flat spot in the very center of the cornea, a steeper
zone outside that and the flatter 7-mm ring (Figure 6-3).
In bright light, the CK patient’s pupil reduces to 3 or 4 mm in diameter,
and the patient can use the steep zone of the cornea for reading. In very bright
light, the pupil comes down further and takes advantage of the depth of field
provided by the central flat zone. In dim light, the pupil dilates beyond the flat
zone to the steeper periphery and again allows reading.
In other words, the technique creates an annular, aspheric multifocal anterior
cornea, which uses the physiologic change in pupil size to get the best results.
The characteristics of the multifocal cornea minimize the reduction on dis-
tance vision and contrast sensitivity and yet still provide good near vision.
To achieve the best effect, the surgeon must be sure that the ring of CK
spots falls outside the patient’s pupil diameter in scotopic conditions in order
to avoid halos at night.
Figure 6-4. The 3.9-mm-diameter, 10-µm-thick inlay is placed

under a LASIK flap after laser distance vision correction is
performed or in a corneal pocket in an emmetropic patient.
The device has a 1.6-mm central clear aperture. This is sur-
rounded by an area 3.9 mm in diameter that is shaded but
not opaque; it lets about 10% of light through the annulus.
The device creates a pinhole effect to provide both distance
and near vision using depth of field.
Another caution is that patients must be tested for their tolerance for mono-
vision before NearVision CK is employed, even though their reduction in dis-
tance vision in the treated eye may be minimal.
Intra cornea l Inla y

A new device for presbyopia correction that is extremely promising is a
small-diameter, ultra-thin intracorneal inlay currently in development by
Acufocus Inc. (Irvine, Calif.).
The 3.9-mm-diameter, 10-µm-thick inlay is placed under a LASIK flap after
laser distance vision correction is performed or in a corneal pocket in an emme-
tropic patient (Figure 6-4). The device has a 1.6-mm central clear aperture. This
is surrounded by an area 3.9 mm in diameter that is shaded but not opaque; it
lets about 10% of light through the annulus. The device creates a pinhole effect
to provide both distance and near vision using depth of field. The position
of the inlay can be seen clearly using the Visante OCT (Carl Zeiss Meditec,
Dublin, Calif.) (Figure 6-5). The limit of vision with a 1.6-mm pinhole is
78 C h a p te r 6
Figure 6 -5. Visante color O CT of Acufocus corneal inlay. The inlay has
a central 1.6-mm pinhole and a 3.9-mm outer diameter and in this case
is under a 200-µm IntraLase (IntraLase Corp., Irvine, Calif.) flap that is
9.0 mm in diameter.
~ 20/12.5 (Figure 6-6). The depths of focus with a 1.6-, 4.0- and 6.0-mm pupil
are illustrated in Figures 6-7 to 6-9.
In clinical trials in Istanbul, Turkey, 51 patients have had the device implant-
ed for 1 year, and 98% of those patients are 20/15 for both distance and near
vision, uncorrected, with no contrast sensitivity loss.
The device works when the pupil is large in mesopic or scotopic conditions
by allowing light to pass around it and through it. In a brighter situation, when
the pupil reduces to 3.9 mm or below, it reduces the effective pupil size to 1.6
mm. The retina becomes more sensitive, and both distance and near vision are
excellent without loss of apparent brightness.
References
The Age Explosion: Baby Boom ers and Beyond. Harvard Generations Policy
Journal. 2004.
Boerner CF, Thrasher B. Results of m onovision correction in bilateral pseudo -
phakes. J Am Intraocul Im plant Soc. 1984;10(1):49-50.
Koepp l C, Findl O, Menapace R, et al. Pilocarp ine-induced shift of an intraocular
lens: AT-45 crystalens. J Cataract Refract Surg. 2005;31(7):1290 -1297.
Figure 6 -6. At 1.6 mm, the limiting vision is 20 /12.5 based on diffrac-
tion. (Reprinted with permission from Holladay JT, Lynn MJ, Waring
GO, Gemmill M, Keehn GC, Fielding B. The relationship of visual
acuity, refractive error, and pupil size after radial keratotomy. Arch
O phthalm ol. 1991;109:70-76.)
Figure 6-7. Depth of focus with a 1.6-mm pupil. Twelve targets are leg-
ible.
80 C h a p te r 6
Figure 6 -8. Depth of focus with a 4.0-mm pupil. Three targets are leg-
ible.
Figure 6 -9. Depth of focus with a 6.0-mm pupil. O ne target is legible.

Holladay JT, Lynn MJ, Waring GO, Gem m ill M, Keehn GC, Fielding B. The rela-
tionship of visual acuity, refractive error, and pup il size after radial keratoto -
m y. Arch Ophthalm ol. 1991;109:70 -76.
Yilm az OF. Late breaking developm ents: Acufocus. Pap er presented at: 2006
ISRS/AAO Meeting: International Refractive Surg ery: Art and Science;
Istanbul, Turkey; May 26, 2006.
7
O p tic a l Im p ro ve m e nts
in Exc im e r La se r
Su rg e ry
Refinement of the Radial
Compensation Function
and Other Optical Concepts
Have Helped to
Improve LASIK Outcomes
The optics of excimer laser surgery are extremely important for ophthalmol-
ogists to understand if we are to improve the quality of vision of our patients.
There is no question that the results of wavefront-guided treatments today
are better than the results we had earlier with conventional ablation protocols,
but the improvement has to do not only with the wavefront measurements, but
also with other improvements that were introduced at the same time.
The modern excimer laser system improvements include 1) increased
minimum diameter of the optical zone in astigmatic corrections, 2)
84 C h a p te r 7
Figure 7-1. All three ellipsoids have the same curvature at the north pole
of 45 D (7.5 mm radius). As we move away from the north pole, the
curvature becomes flatter with the prolate ellipsoid, does not change
with the sphere and becomes steeper with the oblate ellipsoid. The
prolate ellipsoid with a flatter curvature in the periphery bends light
less and reduces SA.
improved radial compensation function, 3) refined central anti-island treat-

ments, 4) customized wavefront-guided and topographic-guided treatment and
5) iris registration. All of these factors together have made possible the excel-
lent outcomes available today.
Preserving the Prola te Sha pe

The cornea is prolate in 99.9% of the human population. The cornea is
steeper in the center than in the periphery (Figure 7-1).
Despite its prolate shape, the normal cornea has positive SA, which is bal-
anced in a young individual by an equal amount of negative SA in the crystal-
line lens. (For a thorough discussion of SA and the human visual system, see
Chapter 3.)
For young people, up to age 19, the coupling of +0.27 µm of SA in the
cornea and –0.27 µm in the crystalline lens balances out so that young people
have little total ocular SA, and the best performance of the human eye is at age
19 (Figure 7-2). Although there is a great deal of variation in SA at any age
(similar to refractive error), zero SA provides the best optical image.
O p tic a l Im p ro ve m e n ts in Exc im e r La se r Su rg e ry 85
Figure 7-2. The average age of a patient having cataract surgery is 72.
Severe SA causes disabling halos.
With aging, the crystalline lens SA becomes more positive; by age 40 years
it is zero and by age 60, the average is ~ +0.13 µm. When the positive SA in
the lens is combined with the positive SA in the cornea, the SA of the entire
eye goes from 0 µm at age 19 to about +0.40 µm by age 60 (Figure 7-3).
This is why vision is poor at night at age 60. Although their daytime vision
may be good through a small pupil, when their pupil dilates and they have a
black background, as when driving at night, they see halos around headlights
because of the excessive positive SA in their visual system (Figure 7-4).
Ra dia l Compensa tion Function

Refractive surgical treatments must be designed not only to correct sphere
and cylinder, but also to address the eye’s SA. Earlier versions of refractive
laser systems did not take SA into account and often made it worse, resulting
in an oblate cornea with increased SA postoperatively.
Early excimer systems removed less tissue than intended peripherally,
resulting in greater positive SA in the cornea. The early systems ablated less
efficiently in the periphery of the cornea because they were not calibrated on
spheres; they were calibrated on flat surfaces. The cornea is nearer a sphere
than a flat surface. The only time the laser strikes the cornea perpendicularly
86 C h a p te r 7
Figure 7-3. The SA of the cornea remains constant in the absence of

corneal disease. The lens increases in SA with age, and consequently
the SA in the entire eye increases also.
Figure 7-4. SA creates a halo around a point source of light. (Top images
reprinted with permission from Guirao A, Gonzalez C, Redondo
M, Geraghty E, Norrby S, Artal P. Average optical performance of
the human eye as a function of age in a normal population. Invest
O phthalm ol Vis Sci. 1999;40:203-213 © Association for Research in
Vision and O phthalmology.)
Figure 7-5. The effective laser energy decreases as the beam moves
peripherally (flying spot or broad beam).
is at vertex normal—the apex of the cornea. As the beam moves peripherally,

the effectiveness of the laser diminishes because it is striking the surface more
and more obliquely (Figure 7-5).
The oblique incidence of the laser on the periphery of the cornea causes a
decrease in the efficacy of ablation for several reasons (Table 7-1). First, the
corneal surface reflects more and ablates less when the light strikes it oblique-
ly. Second, whether delivered in a broad beam or a flying spot, the energy
is spread out over a larger area (an oval rather than a circle), so the effective
fluence delivered to the cornea is diminished. Third, the reduction in tissue
removal is greater than the reduction in fluence. That is, when the fluence of a
laser is reduced by 25%, the laser may remove 50% less tissue than intended.
As a result, the reduction in tissue removal is greater than would have been
predicted by just the difference in reflectance, transmittance and delivered
fluence to the cornea. There are also biomechanical and healing factors that
affect the outcome.
These five elements are all part of the radial compensation function.
Because manufacturers did not anticipate the need for a radial compensation
function, early excimer systems decreased the size of the effective optical zone
with increasing amounts of refractive correction. The greater the treatment,
the greater the discrepancy between the intended amount of ablation in the
periphery and what was achieved.
88 C h a p te r 7
1
Factors Influencing Loss of Energy
-
7
as the Laser Moves Peripherally on the Cornea
e
l
b
a
T
• ablation, reflectance
• cross-sectional area (oval)
• effective fluence, ablation
• biomechanics
• healing—epithelium
SA is the most significant aberration that we have to deal with after the
lower order sphere and cylinder. With the early standard treatments, we did not
reduce SA; we actually made it worse because the early radial compensation
function in the standard treatments was insufficient.
Improvement Introduced
After I first described the radial compensation function in 1999 in the
Keynote Lecture at the RSIG/AAO Subspecialty Day, several excimer laser
system manufacturers outside the United States modified their ablation pro-
files. Laser manufacturers including Visx, Schwind, Meditec, WaveLight,
LaserSight and Nidek, all empirically, through an iterative process, refined
their standard treatments to compensate for this peripheral reduction in laser
energy.
During the same period of time, the concept of wavefront-guided custom-
ized refractive surgery was introduced, and this generated a lot of interest.
When the three major U.S. ophthalmic excimer laser system manufacturers,
Visx (now Advanced Medical Optics), Bausch & Lomb and Alcon, introduced
their wavefront-guided systems, they reported improvements in outcomes over
their older, conventional excimer refractive systems. Other factors contributed
to the improvement when wavefront was introduced, so it is difficult to know
the contribution of each factor.
The first factor is that the U.S. manufacturers have now taken the radial
compensation function into account and included it in their ablation profiles.
Second, the manufacturers have been required by the Food and Drug
Administration to specify the diameter of the minor axis of astigmatism as the
size of the optical zone in astigmatic treatments, which are oval. In previous
standard systems, the major axis of astigmatism was the one specified in laser
software for astigmatic corrections. If we wanted to perform a plano –4.00
90 treatment, for instance, and specified a 6-mm optical zone on the laser, we
would get a 4.5-mm by 6-mm optical zone. But the 4.5-mm axis is the one
that is critical and can contribute to halos and glare. So in that example above,
with the newer software, a plano –4.00 90 yields a 6-mm by 7.5-mm optical
zone.
Third, the manufacturers have now learned how to create a smoother central
cornea and avoid the central islands that older systems induced.
All three of these corrections were included in the new wavefront treatment
protocols from the U.S. manufacturers, so there is no question that the wave-
front-guided treatments are better, but the improvements are multifactorial.
Wha t To Do
For most patients, wavefront-guided treatment is the best treatment today
because it implements all of the improvements listed above as well as employ-
ing wavefront measurements.
In people who have significant higher-order aberrations in the cornea (70.5
µm), it is imperative to perform wavefront-guided treatment. This group also
includes patients who have had poor outcomes from previous laser treatment.
The wavefront-guided treatment can provide improvement in people who have
moderately aberrated eyes.
It should be noted that treatment on the cornea of an aberration that is in
the crystalline lens can make the problem worse. If trefoil is present in the
crystalline lens (which is the typical location), creating the inverse on the
cornea works for one point in space, like a star at infinite distance. We should
not correct lenticular aberrations above the SA and coma on the cornea. If
a patient’s higher-order aberrations are in his lens, refractive lens exchange
would be a better surgical choice. Even astigmatic correction on the cornea
can be problematic if a large component of the astigmatism is in the lens. This
is why many experts consider a large amount of lenticular astigmatism to be
problematic in corneal refractive surgery.
90 C h a p te r 7
References
Guirao A, Gonzalez C, Red ondo M, Geraghty E, Norrby S, Artal P. Average opti-
cal p erform ance of the hum an eye as a function of age in a norm al p op ula-
tion. Invest Ophthalm ol Vis Sci. 1999;40(1):203-213.
Holladay JT. Barraquer Lecture: Optical quality after refractive surgery: Corneal
vs. phakic IOLs. Pap er presented at: Am erican Academ y of Ophthalm ology
and Europ ean Society of Ophthalm ology Joint Meeting; Octob er 26, 2004;
New Orleans, La.
Holladay JT. Keynote sp eech, Refractive Surg ery Interest Group Subsp ecialty Day,
Am erican Academ y of Op hthalm olog y m eeting, 1999.
Mrochen M, Seiler T. Influence of corneal curvature on calculation of ablation
patterns used in p hotorefractive laser surgery. J Refract Surg. 2001;17(5):
S584 -S587.
Wang L, Koch DD. Ocular higher-order aberrations in individuals screened for
refractive surg ery. J Cataract Refract Surg. 2003;29(10):1896 -1903.
8
Ze rn ike a n d Fo u rie r
Po lyn o m ia ls
Describing Surfaces
What is the difference between the Zernike and Fourier expansion series
polynomials, and how much should we be concerned about them?
The answer to the second question is, “not much.” Both Zernike and Fourier
do what they are intended to do: describe complex three-dimensional surfaces
in mathematical terms, making it possible to design customized corneal abla-
tions.
The answer to the first question is more complex, involving long-established
concepts from mathematics and physics. Given infinitely fast computers, the
two expansion series, Zernike and Fourier, are equally good at describing
wavefront aberrations and corneal surfaces. In the real world of ophthalmol-
ogy, Fourier is faster and more accurate. But the practical difference for the
ophthalmologist may be less important than some may have been led to
believe. Just like pressing the square root button on a calculator, as long as
you get the right answer, understanding what the calculator is doing to get that
answer is not important to the user. Only the engineer writing the code needs
to know the details.
94 C h a p te r 8
This subject may be the least important clinically of anything addressed in

this book, but it is one that we hear a lot about, so it is helpful to understand
the controversy.
In optics, the Zernike and Fourier formulas are ways of describing three-
dimensional surfaces. The general term for these formulas is expansion
series.
Expansion series can be relatively simple, like the formulas used by comput-
ers and calculators to derive sines, cosines and other trigonometric functions.
Before hand calculators were available, we used trigonometry tables to find the
values for sines, cosines and tangents. We could look up 30°, and find that the
sine of that angle is 0.500. The number of decimal places (precision) would
determine the number of pages necessary for the table. Calculators and com-
puters do not store trigonometry tables in memory; they calculate these values
“on the fly” using expansion series.
The expansion series to calculate the sine of an angle takes the form:
Sin x = x – x3 /3! + x5 /5! – x7 /7!+...
In working with these types of equations, angles must be expressed in radi-

ans, not in degrees. This is similar to working in strabismus, where we use
prism diopters, not degrees.
The circumference of a circle, which is 360°, is C = 2 r, where C is circum-
ference, is a constant and r is the radius of the circle.
360° = 2 r
r =360°/2 = 57.3° (1 radian = 57.3°)
To find the sine of 30° using the expansion series above:

30° = /6 radians = 0.5236 radian
Sin (30°) = Sin (0.5236) = 0.5236 – (0.5236) 3 /6 + (0.5236) 5 /120 = 0.5236

– 0.0239 + 0.0066 = 0.5063
The actual sine of 30° is exactly 0.5000. With three terms in this expansion
series, the calculation is accurate to almost three decimal places. More terms
are added to the formula depending on the precision required.
The general equation for an expansion series using a polynomial takes the
following form:
Y = a + b(x) + c(x2) + d(x3) + ….

The two-dimensional formula (x and y) used to generate a sine wave can
Ze rn ike a n d Fo u rie r Po lyn o m ia ls: De sc rib in g Su rfa c e s 95
be made to describe a three-dimensional surface by adding a third term (z)

for height. Any three-dimensional surface, whether the surface of the cornea
or the wavefront from an entire eye, can be represented using a polynomial in
which the height is z and the coordinates are x and y.
A general quadratic equation to represent any three-dimensional surface
would look like the following:
z = a(x2) + b(xy) + c(y2) + d(x) + e(y) + f
The graph of this equation can be a circle, ellipse, parabola, hyperbola, etc.
depending on the values for the 6 coefficients a through f. These are often
referred to as conic sections when they can be obtained as the intersection of
a plane and a circular cone.
Well-Known Concepts
The Zernike and Fourier polynomials are also expansion series, but the
individual terms in the series are more complex than the terms in the poly-
nomial series outlined above. While these concepts are relatively new to most
ophthalmologists, the formulas themselves have been around for decades—in
the case of the Fourier series, for over 200 years.
Jean Baptiste Joseph Fourier, born in 1768, first elucidated the concept of the
Fourier series in the early 1800s. He said that any function can be described in
terms of an infinite series of sines and cosines.
The most general form of the Fourier series, for any bounded periodic func-
tion of period 2L is:
Using this formula, any two-dimensional waveform or surface can be

described exactly, given an infinite number of terms. For example, a square
wave can be described using the Fourier series that follows. With an infinite
number of terms, the square wave can be described exactly by the equation that
follows, which is illustrated graphically in Figure 8-1:
96 C h a p te r 8
Figure 8-1. The square wave has been approximated using seven sine
waves. Notice that the higher frequencies are necessary to make the
“sharp” edges of the square wave. There is still an “over-shoot” at the
corners with seven terms, but more and more terms will ultimately make
the corner square. Just like the square root formula, the number of terms
actually used depends on the precision necessary for the wave. In laser
treatments, once the precision of the wavefront using the series exceeds
the precision of the laser, additional terms are not necessary. Most soft-
ware will use the number of terms that has at least twice the precision
of the hardware, so the latter will always be the limiting factor.
Square wave (Period 2L) =
In a similar way, describing z (height) as a function of x and y, any three-

dimensional surface can be represented exactly using an infinite number of
terms.
The precision of the description can never be more than half the highest
frequency of the sample as dictated by the Nyquist sampling theorem. So if
we want the height of the cornea or the wavefront to be accurate to within
1 µm, we would need 64 terms for the Fourier equation to give that level of
accuracy.
Because sine waves are simple forms, and because the Fourier equation is
so useful in fields such as engineering and physics, over the years a number
of shortcuts, called fast Fourier transforms, have been developed to make the
calculations faster. The whole basis for electrical engineering designs is based
on fast Fourier transforms.
Another series used primarily in optics is the Zernike polynomial, named
after Dutch physicist Frits Zernike. It is more recent in origin, having been
described in the first half of the 20th century. Like Fourier, Zernike is also
an expansion series that lets us represent any three-dimensional surface. The
advantage of Zernike over Fourier is that the first terms in the series—tilt,
prism, sphere, cylinder, SA and coma—are all aberrations that we have been
using for years to describe optical systems. This group is often referred to as
Seidel aberrations.
In contrast, in the Fourier series, no single term exists to represent astig-
matism, SA and so on, although they can be described by the sums of certain
terms. But this involves a second set of calculations in addition to the calcula-
tions that went into generating the Fourier series in the first place.
For wavefront-guided treatments, this is a disadvantage of the Fourier equa-
tion. First we have to calculate the series itself, and then we need a second set
of terms to extract the cylinder, sphere and other optical aberrations.
Complex Surfa ces

While the Zernike series has the advantage of describing basic low-order
optical errors such as sphere and cylinder easily, that advantage is lost when
dealing with a complex, irregular surface because the severe irregularity is not
easily described accurately.
To describe an irregular surface that does not conform to one of the terms
of the Zernike equation, we have to use many terms. An infinite number of
terms would give us a perfect description of the wavefront, but the complexity
of the mathematical calculation goes up exponentially, much more so than with
the 64 terms needed for the Fourier series. These calculations are not fast, and
they take a lot of computer power. Both the Zernike and Fourier series can be
used to describe the actual corneal surface, the actual wavefront of an eye and
the actual wavefront error.
The Zernike polynomials were developed as a convenient set for represent-
ing wavefront aberrations over a circular pupil. The following equation is the
Zernike Polynomial in Polar coordinate system ( , ):
Wavefront ( , ) of degree k =
98 C h a p te r 8
Figure 8-2. First six levels (mode) of Zernike terms in two dimensions.
Green is in focus, red is behind (hyperopic) and blue is in front (myo-
pic).
where, is the radial variable and is the angular variable. In a Cartesian

coordinate system using x and y,
2= x2 + y2 and Tan = y/x
The Zernike terms can be seen in two dimensions in Figure 8-2 and three-
dimensions in Figure 8-3. The Zernike polynomial for some common aberra-
tions are:
Astigmatism (vertical or horizontal) = Z(2,-2)= 2cos 2

Defocus= Z(2,0) = 2 2-1
3rd order vertical coma= Z(3,-1) = (3 3 – 2 ) cos
3rd order SA= Z(4,0) = 6 4-6 2 +1
Notice that defocus and 3rd order SA have no because they are radially
symmetric (same curve in all semi-meridians). Looking at Figure 8-3, we can
see that the defocus Z(2,0) is a bowl and SA Z(4,0) is a sombrero that have
radial symmetry. Astigmatism and coma are not radially symmetric and need
to describe astigmatism (potato chip) and coma.
Figure 8-3. First four levels (mode) of Zernike terms in three dimen-
sions. Green is in focus, red is behind (hyperopic) and blue is in front
(myopic).
As a result of the complexity of the description, the Zernike equations can-

not map irregularities in detail, especially those in the periphery of the area
being analyzed. So when we compare the 64 terms in Fourier to the 12th-order
Zernike, we get more precision with the Fourier for an extremely irregular
surface.
By now we are all familiar with the illustrations that show the Zernike
shapes (two-dimensional in Figure 8-2 and three-dimensional in Figure 8-3).
The aberrations are all regular. If we have a patient with keratoconus, with a
protrusion or bump at 6 o’clock on the cornea, the first term in the Zernike
series that can describe that protrusion is coma. But coma, in addition to that
inferior bump, also has a superior valley. So to cancel out that valley created
by coma in the superior cornea, we have to add a second Zernike term, tre-
foil, with three bumps. Now the trefoil has introduced extra bumps at 4 and
8 o’clock. So we have to add quadrafoil, with two valleys, to counteract those
bumps. But quadrafoil adds two additional valleys, so we have to add pentafoil.
As you can see, we need to add more and more terms to describe the original
error, which was keratoconus—one inferior bump.
This complexity is also deceptive in a way because the patient never had
trefoil, quadrafoil, pentafoil and so on to begin with. These are just terms used
to cancel out parts of the lower terms that were not wanted. These higher-
order terms were added to compensate for the fact that coma did not describe
100 C h a p te r 8
Figure 8-4. Zernike 10th order (mode) and Fourier with 64 terms. The
Fourier series can duplicate complex shapes much more accurately.
the corneal surface properly. So the calculation, which gets exponentially

more complex and time- and energy-consuming, must go far enough up into
the higher-order aberrations to describe the surface accurately. This is why
Zernike is not optimal to describe complex surfaces for the clinician.
Figure 8-4 illustrates the 10th order fit of the Zernike to a facial profile and
the Fourier series of the same profile. The higher the degree of irregularity, the
closer the approximation of the Fourier series. In Figure 8-5, clinical examples
of three patients with irregular wavefronts are shown. The 8th-order Zernike
still smooths the wavefront so that it does not match the actual wavefront.
Although there is a limit to the precision of the excimer laser, there should
never be smoothing of the planned ablation; the laser hardware should always
be the limiting factor, not the software.
The True Mea sure of the Fit

No matter which series is used, the true measure of the fit is how well the
transform describes the corneal surface or wavefront in question.
As with the facial profile, the greater the irregularity, the greater the error in
the Zernike approximation. The real question is, what is the root-mean-square
(RMS) error of the difference between the actual surface and the surface as
described by Zernike or Fourier? If the RMS error is the same, the result is the
Figure 8-5. Clinical examples of three patients with irregular wavefronts.

The 8th-order Zernike still smooths the wavefront so that it does not
match the actual wavefront.
same. The RMS error of the fit is the true measure of the fit. From a theoretical
standpoint, if computers were as fast and precise as necessary, there should be
no difference between Fourier and Zernike in describing three-dimensional
surfaces. But with real computers in the real world, Fourier transforms can do
it more rapidly and more accurately.
Finally, using Zernike and Fourier terms to make clinical decisions is usu-
ally not helpful. They are used by the engineer, mathematician and physicist
for describing the surface or ablation profile, but they really have very little
application for the ophthalmologist. We can tell much more by looking at
the actual wavefront map or height or curvature map of the corneal surface.
Evaluating specific terms in the Zernike transform can lead to the conclusion
that aberrations are present that are not really there, such as seeing coma and
trefoil in the keratoconus patient discussed above. Most wavefront analyzers
and topographers use up to 8th-order Zernikes. Truncating the series at this
order may not describe the wavefront or surface accurately, depending on the
amount of irregularity; certainly anything lower than 8th order is not accept-
able and in some cases not enough.
From a theoretical standpoint, if computers were as fast and precise as
necessary, there should be no difference between Fourier and Zernike in
describing three-dimensional surfaces and with Zernike the traditional opti-
cal aberrations, such as defocus, coma, SA, etc. are easily determined. In fact,
102 C h a p te r 8
with near diffraction limited systems with almost no aberrations, such as the
Hubble Telescope II and powerful mainframe computers, Zernikes work very
well. However, with personal computers and wavefronts from human eyes that
are at best 40% of the performance of a diffraction limited system, Fourier
transforms can be calculated more rapidly and describe the wavefront or cor-
neal surface more accurately than Zernike.
References
Dai G-m . Zernike ab erration coefficient s transform ed to and from Fourier series
coefficient s for wavefront representation. Optics Letters. 2006;31(4):501-
503.
Dai G-m . Zernike com parison of wavefront reconstructions with Zernike p olyno-
m ials and Fourier transform s. J Refract Surg. 2006;22(6). In press
Klyce SD, Karon MD, Sm olek MK. Ad vantages and disad vantages of the Zernike
expansion for representing wave ab erration of the norm al and ab errated eye.
J Refract Surg. 2004;20(5):S537-S541.
Sm olek MK, Klyce SD. Zernike p olynom ial fitting fails to represent all visually
significant corneal ab errations. Invest Ophthalm ol Vis Sci. 2003;44(11):4676 -
4681.
Sm olek MK, Klyce SD. Goodness-of-prediction of Zernike p olynom ial fitting to
corneal surfaces. J Cataract Refract Surg. 2005;31(12):2350 -2355.
Sm olek MK, Klyce SD, Sarver EJ. Inattention to nonsup erim p osable m idline sym -
m etry causes wavefront analysis error. Arch Ophthalm ol. 2002;120(4):439-
447.
9
O c u la r a n d
To p o g ra p h ic
Wa ve fro nt
Ocular wavefront measures the error in the optical system of the entire eye,
while topographic wavefront isolates the error in the patient’s anterior cornea.
Both are needed for customized laser treatment.
For the best results with customized corneal refractive surgery, we must
use a combination of ocular and topographic wavefront to achieve the best
outcome. This is a solution that is increasingly being recognized by clinicians
and by manufacturers that make refractive surgical laser systems.
By taking into account both ocular wavefront and corneal wavefront (from
topography), we can truly provide customized ablation that is tailored to our
patients’ needs. Laser systems that include both modalities will be the norm
in the future.
No systems using both wavefront and topography are currently available in
the United States, but integrated systems using both diagnostic modalities are
on the horizon for U.S. surgeons and will be coming to the market in the near
future.
106 C h a p te r 9
This chapter explores why we need both modalities to best serve our patients
with truly customized treatments.
Incrementa l Improvements
Significant improvements have been seen in excimer laser systems for
refractive surgery since their regulatory approval in the United States in 1995
and earlier in the rest of the world.
The most significant improvement in excimer laser treatment in the past 10
years is an improved radial compensation function so that the energy delivered
by the laser in the periphery of the cornea is sufficient to achieve the intended
tissue removal. (For more on the concept of the radial compensation function,
see Chapter 7.) Improved radial compensation functions have allowed us to
achieve prolate corneas with the desired effective optical zone following myo-
pic refractive surgery. Removing the intended amount of tissue over the entire
treatment area is a prerequisite of a truly customized treatment.
A second improvement is related to the size of the optical zone in astigmatic
treatments. When we put an astigmatic treatment on the cornea, the ablation
zone by definition must be elliptical (an oval). In 2002, the Food and Drug
Administration required manufacturers to specify the smaller axis of the oval
to be the optical zone size rather than larger diameter. Before this change,
when an astigmatic patient with a refraction of plano –4 D 90° was treated
with a 6-mm optical zone, the dimensions of the actual treatment on the cornea
would have been 4.5 mm by 6.0 mm. This would induce halos and glare in
the shorter axis in a patient with a 6-mm pupil. Because an elliptical treatment
is not symmetrical, the unwanted optical effects are even more bothersome
because the patient actually sees an asymmetrical halo around lights. Today,
the FDA mandates that a 6-mm treatment for the same astigmatism is 6.0 mm
by 7.5 mm, so that for the patient with a 6-mm pupil, the entire pupil is covered
by the optical zone. The amount of tissue removed is significantly greater with
the larger optical zone, but the coverage of the scotopic pupil is complete. (This
concept is also discussed in Chapter 7.)
A third improvement has to do with the quality of the surface in the center
of the optical zone. Refinements of both broad-beam and flying spot lasers
have allowed us to make a much smoother central optical zone area, which
ultimately relates to the quality of vision our patients have in the long term.
A fourth improvement is the introduction of eye trackers. The first genera-
tion of eye trackers followed the pupil at 60 Hz. The tracking speed has been
increased, and systems now use iris registration and recognition, which takes
into account both torsional and saccadic movements of the eye. Enhanced
O c u la r a n d To p o g ra p h ic Wa ve fro n t 107
tracking means we are putting laser energy exactly where it is intended on the
cornea.
The fifth and final ingredient in this series of incremental improvements
has been the introduction of wavefront aberrometry measurements. Use of
wavefront-guided treatments has been shown to improve outcomes in people
with higher-than-average preoperative aberrations (more than 0.40 µm of RMS
wavefront error).
All of these ingredients, taken together, explain why the outcomes of our
refractive laser surgery have improved dramatically over the past few years.
Ocula r a nd Topogra phic Wa vefront

The next improvement in U.S. refractive laser systems will be the introduc-
tion of corneal wavefront from topography coupled with ocular wavefront for
guiding customized ablations. Internationally, systems that use both ocular
and topographic wavefront are already available. In some parts of the world,
topography-guided custom ablation systems alone have already demonstrated
successful outcomes, but both measurements are needed for the ideal result.
Topography helps us relate our treatment directly to the surface being treat-
ed, the anterior cornea. If a patient has a decentered ablation zone or another
abnormality clearly limited to the cornea that is a consequence of an earlier
laser treatment, a topographic measurement of that problem is much more pre-
cise, has many more data points and has a higher resolution (between 14,000
and 20,000 points depending on the specific topographer) than an ocular wave-
front analysis, which employs a maximum of 255 points over a 7-mm zone.
The information from topography allows us to design a treatment that restores
the cornea to a more symmetrical shape because we are directly measuring the
surface on which the problem exists. However, even greater advantages will be
realized when both topography and ocular wavefront are used in tandem.
Figures 9-1 to 9-3 show the ocular, topographic and internal wavefronts
of an eye, respectively. In Figure 9-1, the total and higher-order ocular wave-
fronts are shown in diopters. In the left pane, the entire wavefront map (optical
path difference [OPD]) is seen in diopters. The color green is –7.00 D, with a
refraction of –6.84 –1.25 176°. The symmetric horizontal bow tie is consis-
tent with the patient’s cylinder. Above, the colors turn warmer to ~ –8.75 D,
whereas below there is very little change. This indicates that there is ocular
SA superiorly of ~ –1.75 D. In contrast, there are cooler colors as we move
along the horizontal meridian. The RMS error at the 3-mm and 5-mm zones is
0.33 D and 0.59 D, indicating that the variation in refraction over these zones
is between 0.25 and 0.5 D. In the right pane are the higher-order aberrations
108 C h a p te r 9
Figure 9-1. The total and higher-order ocular wavefront in diopters. In

the left pane, the entire wavefront map (O PD) is seen in diopters. The
color green is –7.00 D, with a refraction of –6.84 –1.25 176°. The
symmetric horizontal bow tie is consistent with the patient’s cylinder.
Above, the colors turn warmer to ~ –8.75 D, whereas below there is
very little change. This indicates that there is ocular SA superiorly of
~ –1.75 D. In contrast, there are cooler colors as we move along the
horizontal meridian. The RMS error at the 3-mm and 5-mm zones is
0.33 D and 0.59 D, indicating that the variation in refraction over these
zones is between 0.25 and 0.5 D. In the right pane are the higher-order
aberrations (sphere, cylinder, tilt etc. removed) illustrating what cannot
be corrected with spectacles (sphere and cylinder).
Figure 9-2. Refractive and instantaneous topographic maps. Left pane: In

the refractive power map, the horizontal “bow tie” and warmer colors
seen superiorly are similar to the ocular wavefront maps in Figure 9-1.
The source of these aberrations is therefore determined to be on the
anterior cornea, not in the internal optics. Right pane: In the instanta-
neous (local radius of curvature) map, the actual local radii of curvature
can be seen. The instantaneous map is always the most sensitive and
gives the greatest detail in the geometry of the anterior cornea.
Figure 9-3. Internal wavefront (O PD). The internal optics of the eye con-
sist of the crystalline lens and posterior surface of the cornea. In cases in
which the cornea does not have a thinning disorder (keratoconus, pellu-
cid marginal degeneration) this map primarily reflects aberrations in the
crystalline lens. Notice that in the 3-mm zone, the cylinder is +0.72 D.
In the ocular wavefront, this value was –1.11 D and the anterior cornea
is –1.73 D. The ocular astigmatism (–1.11) is less than the cornea (–1.73)
because the crystalline lens is compensating (+0.72).
(sphere, cylinder, tilt, etc. removed) illustrating what cannot be corrected with
spectacles (sphere and cylinder).
In Figure 9-2, notice that the topography has warmer colors toward the
periphery, which indicates positive SA.
The refractive and instantaneous topographic maps are for the same patient.
In the left pane, in the refractive power map, the horizontal “bow tie” and
warmer colors seen superiorly are similar to the ocular wavefront maps in
Figure 9-1. The source of these aberrations is therefore determined to be on the
anterior cornea, not the internal optics (back cornea and crystalline lens). In
the right pane in the instantaneous (local radius of curvature) map, the actual
local radii of curvature can be seen. The instantaneous map is the most sensi-
tive and gives the greatest detail in the geometry of the anterior cornea.
Figure 9-3 is the internal wavefront (OPD) from the same eye. The internal
optics of the eye consists of the crystalline lens and posterior surface of the
cornea. In cases in which the cornea does not have a thinning disorder (kerato-
conus, pellucid marginal degeneration), this map primarily reflects aberrations
in the crystalline lens. Notice that in the 3-mm zone, the cylinder is +0.72 D
internally. In the ocular wavefront, this value was –1.11 D and the anterior
cornea is –1.73 D. The ocular astigmatism (–1.11) is less than the cornea (–1.73)
because the crystalline lens is compensating (+0.72).
110 C h a p te r 9
Ocular and topographic wavefront measurements provide important infor-

mation about aberrations in the entire eye’s optical system and specifically
the contribution of the anterior cornea. Using wavefront measurements from
both can assure that a custom laser treatment leaves the cornea with the right
amount of SA to match the existing crystalline lens or predictable changes to
the lens in the future.
For example, we know that the human cornea has ~ +0.270 µm of positive
SA over a 6-mm zone. We also know that when we are young, the crystalline
lens has negative SA (average of ~ –0.270 when very young), adding up to a
total of no SA in the entire eye on the average at age 19. So, for an individual
in his or her 20s, an ablation that preserves the SA of the cornea would be
ideal because it would maintain that balance of no total SA in the entire eye.
Matching the postop result to the cornea’s preop shape maintains that balance
of positive SA in the cornea and negative SA in the lens. This is the ideal target
in a patient without presbyopia.
But these are simply average values in the population. If we measure a 50-
year-old person who is 5 D myopic and whose ocular wavefront is +0.150 µ of
SA and the anterior cornea is +0.250 µ of SA, we know that the internal SA is
–0.100 µ (+0.150 – 0.250). Our goal would be to flatten the cornea by 5 D to
achieve emmetropia and reduce the anterior corneal SA to ~ +0.150 to match
the internal SA. In short, although the amount of SA in the eye is related to
age, it is not always the case that a 20 year old will have no ocular SA and a 50
year old will have +0.27 µm of SA. These are averages in the population that
vary from individual to individual like many other things in the human body.
There are some 50 year olds who have no ocular SA and some 20 year olds
who have significant positive ocular SA. We need the wavefront measurement
so that we can determine the aberrations of the eye and the cornea such that
the appropriate treatment can be delivered.
Using both ocular and topographic wavefront measurements also allows
us to localize the aberrations in an eye. Aberrations in the cornea are stable
throughout our lives, provided we do not have anterior corneal disease or
dry eye. Correcting all corneal aberrations is appropriate, provided they are
stable. Lenticular aberrations are not stable. Studies have shown that SA in the
crystalline lens increases almost linearly with age, and coma remains fairly
constant until cataract formation. Other higher-order aberrations in the lens,
such as trefoil, secondary astigmatism, etc., are not stable.
Treating the aberrations above SA and coma that are in the crystalline lens
with corneal refractive surgery is not appropriate. The result is only temporary
because the lens is changing all the time due to the addition of lens fibers,
which thicken the lens as we age. In addition, correcting aberrations present
in the crystalline lens on the cornea only works for a single point in space (a
star). Any other object that is slightly off-axis does not match the cornea with
the crystalline lens, resulting in compounding of the aberration.
In the presbyopic patient, creating negative ocular SA may be a better solu-
tion than zero. Negative ocular SA simply means the power of the eye in the
central optical zone is stronger than in the periphery, the opposite of positive
ocular SA. When focusing at near, the synkinetic reflex results in accom-
modation, convergence and miosis of the pupil. The smaller pupil increases
our depth of field through the pinhole effect, but it also isolates our vision in
the center of the eye, where the power is stronger than in the periphery when
negative SA is present. This technique is the basis for presby-LASIK, which in
effect creates a hyperprolate cornea. The presbyopic patient therefore achieves
better near vision than the patient with either zero or especially positive SA.
Clinicians have observed this for years when comparing emmetropic
patients that underwent hyperopic versus myopic treatments. The previously
hyperopic patients almost always have better reading vision than their myopic
counterparts. The reason for this is that hyperopic treatments induce negative
SA and myopic treatments induce positive SA before the radial compensation
functions were improved. Tailoring the amount of negative SA to the patient’s
age will be an underlying theme of presbyopic corneal refractive surgery in the
future to provide better near vision and emmetropia.
Figure 9-4 shows topography (refractive and instantaneous radius of curva-
ture map) and ocular wavefront after LASIK in a presbyopic patient who had
a laser refractive treatment of ~ –7.00 –1.00 90° with a 7.3-mm optical zone.
All maps show negative SA (more power centrally). This 50-year-old patient
has 20/20 vision at distance and J2 vision at near without correction due to the
negative SA. The results for a specific patient will depend on the change in the
pupil size when focusing at near, but the principle is the same.
Bibliogra phy
Glasser A, Cam pb ell MC. Presbyopia and the optical changes in the hum an crys-
talline lens with age. Vision Res. 1998;38(2):209-229.
Guirao A, Artal P. Corneal wave ab erration from videokeratography: accu-
racy and lim itations of the procedure. J Opt Soc Am A Opt Im age Sci Vis.
2000;17(6):955-965.
112 C h a p te r 9
Figure 9-4. Corneal topography maps (instantaneous and refractive

power) and ocular wavefront. Top preop and bottom post-LASIK of a
presbyopic patient who had a laser refractive treatment of ~ –7.00 –1.00
90° with a 7.3-mm optical zone. All postoperative maps (topography
and ocular wavefront) show “cooler” colors illustrating negative SA
(more power centrally). This 50-year-old patient has 20/20 vision at
distance and J2 vision at near without correction because of the nega-
tive SA.
10
Un d e rsta n d in g
Ne u ra l Ad a p ta tio n
Image-Enhancement Software
in the Human Occipital Cortex
Is a Key Component
in Vision Correction
The software in the occipital cortex of the human brain is more sophisti-
cated than the best image-enhancing computer. Understanding that software
and the process of neural adaptation is a key element in setting proper goals
for vision-correcting surgery.
Refractive surgeons and clinicians often forget that the visual system is
composed of an optical component, which comprises the cornea, the crystal-
line lens and the media between them, and a sensory component that begins at
the retinal photoreceptors and ends at the occipital cortex. Recent work in the
area of the sensory component of the visual system is helping us to determine
exactly how the human visual system functions.
The sensory component begins with the sensory retina and proceeds
through the optic nerve and radiations, which relay visual information back
to the occipital cortex. The visual information is first received at Brodmann’s
116 C h a p te r 10
area 17, compared with stored images in Brodmann’s 18 from experience, and
the final “recognized” image is produced in Brodmann’s 19.
We must think of the occipital cortex as an image-enhancing computer that
is more sophisticated than any software program available today. Before we
adopt specific refractive surgical treatments aimed at reducing higher-order
aberrations in our patients, or determine the appropriate endpoint measure-
ments such as visual acuity or contrast sensitivity, we must understand the
human computer’s image enhancements both spatially and temporally to make
sure that our optical goal is actually what is best for our patients’ visual system.
Spatial enhancements are just like scenes in movies where a blurred, low-qual-
ity image is enhanced in order to read the characters of a license plate. The
temporal aspect relates to the time it takes for the visual system to make the
enhancement.
Two Pha ses of Ada pta tion

Neural adaptation is the process that takes place as the brain adapts over
time (temporal) to changes in the visual information being supplied by the
eye’s optical component. There are two types of temporal neural adaptation: a
quick phase that can occur over a few seconds or minutes, and a longer phase
of adjustment that can take several months to a year (Figure 10-1).
The short phase of neural adaptation can be illustrated by Figures 10-2
and 10-3. In the first set of images, the picture of the little girl is sharp and of
equal contrast on the left and the right. When we fixate on the green dot in the
center, the images look equal. Now look at Figure 10-3, in which the left side
is blurred and low contrast, whereas the right is sharp and at higher contrast.
After about 5 seconds of fixation on the green dot in Figure 10-3, when we
look back at the original figures, the images appear different; the one on the
left is clear and the one on the right is blurred. After a few seconds, they come
back to appearing equal.
It takes from 5 to 10 seconds for the brain to readjust itself so that the two
images look the same again. This is because our brain’s computer has adapted
to the blur, knowing that both of our eyes should see the same image when
they are looking at the same object. Our computer is always trying to get rid
of “noise” when a signal is not present in both eyes, to help us see the best
quality image possible.
The longer phase of neural adaptation has been demonstrated in trials of
aspheric versus spherical IOLs, multifocal IOLs and refractive corneal surgery.
In these studies, the patient satisfaction level is much better at the end of 1
year than it is a few weeks after surgery, even though there has been no optical
Un d e rsta n d in g Ne u ra l Ad a p ta tio n 117
Figure 10-1. These data suggest it takes ~ 10 weeks for the visual
system to adapt to a new state of blur following refractive surgery.
Studies of the time course of neural adaptation show a much shorter
time. This raises the possibility that there may be two phases of
adaptation—a rapid phase, as demonstrated in studies where the
visual system is challenged with lens-induced blur, and a slower
phase, perhaps involving the embedding of an adaptation response
to a constant level of blur.
Figure 10-2. The right and left images above are identical and appear the
same when fixating on the green dot. However, after viewing Figure 10-
3 for 5 seconds or more and then returning to the green dot, they will
no longer appear equal. They return to normal after a few seconds.
118 C h a p te r 10
Figure 10-3. The images above are identical to Figure 10-2 except that
the image on the left has blur and reduced contrast and the image
on the right is sharp with increased contrast compared to the original
images. Fixate on the green circle for ~ 5 seconds and then return to
viewing the green dot in Figure 10-2. Initially, the original image will
appear sharper on the left and blurrier on the right. After a few seconds
the images will return to normal and appear equal.
change during this period, as measured by wavefront aberrometry. Complaints

of halos, glare and dysphotopsia are common in the early postop period. Yet
by the end of the year, 99% of patients with multifocal IOLs, or who have
increased higher order aberrations after refractive surgery (which clearly
reduces contrast sensitivity and produces halos and glare), are happy with their
vision and have adapted to the induced aberrations.
An example of this adaptation is illustrated in a study by Steven S.
Schallhorn, MD. At 1 and 3 months after excimer surgery, there was a cor-
relation between the quality of the image on the patient’s retina and subjec-
tive visual complaints. But by 6 months and 1 year, there was no correlation
between subjective complaints and induced optical aberrations as shown by
wavefront or topography. By 6 months, the subjective complaints were not
statistically significantly related to the image quality, even though there was
no change in the optics between 3 and 12 months.
Some have argued that this study by Dr. Schallhorn and colleagues sug-
gests that visual complaints after laser refractive surgery are related not to
optical aberrations, but rather to a lack of neural adaptation, and the success of
patients’ outcomes continues to improve during the first year postoperatively
as they adapt to the aberrations. The bottom line seems to be that we do not
want optical aberrations in the eyes of our patients, but patients can do well
despite them due to neural adaptation over time.
The opposite phenomenon, taking time to adapt to reduced optical aberra-

tions, also occurs. In a study by Ulrich Mester and colleagues, patients who
underwent cataract surgery and had the Advanced Medical Optics (AMO)
Tecnis modified prolate IOL implanted immediately experienced significant
reductions in SA as measured by ocular wavefront, but the contrast sensitiv-
ity results in these patients continued to improve for 3 to 6 months after the
cataract surgery. The neural component of the patients’ visual systems had to
adapt to the new retinal image before the benefits of an improved retinal image
were actually transformed into better visual performance.
In the long-term phase of neural adaptation, it appears to take from 3 to 12
months for patients to adapt to changes in the optical component of the visual
system, especially when the change is abrupt as opposed to the slow changes
that occur with cataract and aging.
The Best Vision

Recent work by Pablo Artal, PhD, and colleagues in Spain has shed interest-
ing light on the process of neural adaptation.
Dr. Artal held a contest at his university, offering a $300 reward for the
student with the best visual acuity. Anyone with visual acuity of 20/20 or bet-
ter could enter the contest. More than 300 students participated. Among those,
three people with visual acuity of 20/9 were identified. (The best vision ever
reported is 20/8. The theoretical limit of resolution of the human retina is 20/5,
with a perfect optical system.)
Dr. Artal performed two studies with these subjects. He began by measuring
their wavefront aberrometry and plotting each person’s point spread function
(PSF) versus their visual acuity.
The PSF, in an ideal optical system, should look like a point. If it looks
like a triangle, a polygon or a cobweb, that indicates what the patient actually
sees when looking at a point in space such as a star or a single LED on a car
dashboard.
The remarkable thing is that those people in Dr. Artal’s study with the best
PSF were not the ones who had the 20/9 visual acuity. Rather, people with
PSFs that looked like cobwebs, etc. were the ones who had the best visual acu-
ities. The visual acuities of those with the PSFs that were a single point were
not as good: between 20/16 and 20/20—still excellent, but not the best in the
study. There was no correlation between the best wavefront aberrometry and
the best visual acuities.
The lesson of this study is that it was not the subjects with the best optical
components in their visual systems who had the 20/9 vision, it was the people
with the best computer enhancement software in their sensory components
120 C h a p te r 10
filtering and enhancing the optical aberrations. The computer software is evi-
dently the limiting factor in our vision, not the optical excellence and the level
of aberrations present in our eyes.
This study asks us to make a big adjustment in our concept of how the visual
system works, and it has practical implications for what we should be doing
for our patients.
Dr. Artal performed a second experiment using the subjects in that first
study who saw extremely well. Using extraocular optical correction, he rotated
their aberrations optically in 30° increments from the orientation of their origi-
nal aberrations. He found that when a subject’s aberrations were rotated by just
30°, their contrast sensitivity and visual acuity measurements dropped to about
60% to 80% of their performance with their own eye’s natural error and their
own neural adaptation.
This shows that the neural computers in these subjects has adapted over the
years to filter out the noise of their own particular optical systems, to enhance
the contrast of the image using the software of the occipital cortex to provide
a better image than their eyes could provide optically.
We have all seen crime movies in which the heroes take a blurry image,
enhance it, and—all of a sudden!—the face of the criminal jumps out and they
can recognize who it is. The human brain actually does this, and our brain’s
computer uses its image-enhancement software to create a much better image
than is present on our retinas. The refinements and the adjustments that each
person’s brain has made over the years are specifically adapted to improve the
quality of the input from that person’s own specific optical component.
When we as refractive surgeons change the nature of that individualized
input, suddenly our patient’s image-enhancing computer is no longer work-
ing appropriately. This is why we must be careful in making decisions about
reducing higher-order aberrations and making other “improvements” in our
patients’ visual systems that may have unintended effects on their visual pro-
cessing systems. At least, we must inform our patients that their final vision
after the procedure may not be realized for 6 to 12 months.
NeuroVision Tra ining

Another recent study that is relevant to the issue of neural adaptation was
presented at the Refractive Surgery Subspecialty Day at the 2005 American
Academy of Ophthalmology meeting.
The study, presented by Donald T. H. Tan, FRCS, evaluated the NeuroVision
NVC system (NeuroVision Inc., Singapore), which employs a Gabor patch for
visual processing exercises to sharpen visual acuity.
Dr. Tan has been able to show that, in adults with amblyopia and 20/200
vision, contrast sensitivity and visual acuity can be improved to almost normal
levels. This is remarkable because it has been believed that if a young child
lacks good vision during the imprinting period, there is no chance of reversing
amblyopia or training the brain to have better stereopsis or contrast sensitivity.
These absolutes turn out not to be true.
In a related phenomenon, Dr. Tan has also shown that among people with
small refractive errors (on the order of –0.25 or –0.5 D) who never wear glasses
have better contrast sensitivity and visual acuity without correction than those
with similar errors who wear glasses and are tested without correction.
We hear this from our low myopic patients all the time. They say, “I don’t
want to wear my glasses because when I take them off I see worse than I do
if I never wear them at all.” We thought that was just a comparison the patient
was making. But in fact it turns out that it is true. A patient with low myopia
of –1 D or less who routinely does not wear glasses will have better unaided
visual acuity than a patient with the same error who wears glasses all the time.
This is because the brain of the patient who does not wear glasses has adapted
to that amount of optical blur. The brain learns to enhance the quality of the
image, and the person who is –1 D, who should be seeing 20/40, sees 20/25
uncorrected. The –1 D patient who wears glasses all the time sees only 20/40
without his correction because his computer has not learned to enhance the
image because it is not seeing the blur all the time.
Pra ctica l Implica tions

What do these findings mean, practically, for the refractive surgeon and
clinician? There are three points to consider.
First, we must ask, if each person’s neural computer has become attuned
to the small higher-order aberrations in his or her own eyes, is it wise to try
to correct those higher-order aberrations during refractive surgery? It appears
that if we change the aberrations, we may actually make visual performance
worse, so maybe we should rethink our goal. Maybe we should specify that we
want to eliminate the lower-order aberrations, sphere and cylinder and perhaps
SA and coma, but leave the other higher-order aberrations as they are. Only
time and experience will tell us the best course of action in this regard.
Second, neural adaptation seems to explain the improvement over time of
patients’ unwanted visual phenomena with multifocal lenses or suboptimal
excimer laser treatments and the desired improvements with aspheric IOLs.
Clearly, this seems to be the result of the long-term type of neural adaptation,
which not only reduces the patient’s symptoms, but also actually improves the
optical performance of the eye by software enhancements in the brain.
122 C h a p te r 10
Third, for patients with small refractive errors, either after refractive surgery
or in unoperated eyes, when they say they function better without glasses, we
must listen to these patients because studies have begun to show that it is true,
that the person who does not wear correction has a software program that is
enhancing his image with blur, and if he does not wear glasses his brain’s
computer is going to do a better job. This concept would also be applicable
to the patient with a small residual refractive error after refractive surgery;
no correction may be better than enhancement or spectacle correction of that
residual error.
This does not mean that what we have been doing in the past is not correct,
but it does mean that we now have to begin considering the brain’s computer
as part of the optical system and understanding the consequences of what we
do. If a patient has had LASIK and is left with –0.5 D in both eyes, we should
weigh the risks and benefits of retreating to correct that 0.5 D of myopia. If
the patient were to live with that small amount of error, he could end up with
a little better near vision, still achieve 20/20 at distance, avoid the need for
additional surgery and avoid wearing glasses.
References
Artal P, Chen L, Fernand ez EJ, Singer B, Manzanera S, William s DR. Neural com -
p ensation for the eye’s optical ab errations. J Vis. 2004;4(4):281-287.
Artal P, Chen L, Fernandez EJ, Singer B, Manzanera S, William s DR. Adaptive
optics for vision: the eye’s adaptation to p oint spread function. J Refract Surg.
2003;19(5):S585-S587.
Mester U, Dillinger P, Anterist N. Im pact of a m odified optic design on visual
function: clinical com parative stud y. J Cataract Refract Surg. 2003;29(4):652-
660.
Package insert. Tecnis Foldab le Posterior Cham b er Intraocular Lens. Ad vanced
Medical Optics, Inc.
Schallhorn SC, Kaupp SE, Tanzer DJ, Tid well J, Laurent J, Bourque LB. Pupil size
and quality of vision after LASIK. Ophthalm ology. 2003;110(8):1606 -1614.
Tan DTH. What is still lacking in refractive surgery is the role of neuroprocessing.
Pap er presented at: ISRS/AAO Refractive Surg ery Subsp ecialty Day; Octob er
14, 2005; Chicago.

Quality of Vision (Essential Optics)

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Quality of Vision (Essential Optics)

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SLACK Incorporated

J ack T. Hol l aday

Delivering the best in health care information

Copyright © 2007 by SLACK Incorporated

Published by: SLACK Incorporated

About the Author ...................................................................................... xi

Foreword by Richard L. Lindstrom, MD ............................................. xvii

Chapter 1 Understanding Optics..................................................1

Chapter 2 Astigmatism Analysis

Chapter 3 Aspheric Treatments Reduce Spherical Aberration

Chapter 4 Vertex Distance, Refraction and Intraocular Lens

Chapter 5 Intraocular Lens Calculations After Surgery

Chapter 6 Surgical Correction of Presbyopia

Chapter 7 Optical Improvements in Excimer Laser Surgery

Chapter 8 Zernike and Fourier Polynomials

Chapter 9 Ocular and Topographic Wavefront ........................ 105

Chapter 10 Understanding Neural Adaptation

Qua lity of Vision

Pa rt 1: Introduction to the Optics of the Eye

LIMITATIONS OF PUPIL SIZE

HIGHER-ORDER ABERRATIONS VERSUS CHROMATIC ABERRATIONS

aberrations in the eye’s visual system. These higher-order aberrations balance

ASSESSING VISUAL ACUITY

EVALUATING CONTRAST SENSITIVITY

Contrast sensitivity also varies depending on lighting conditions. A patient

Figure 1-5. Wavefront map showing 0.404 µm of root mean square

Figure 1-6. Modulation transfer function (MTF). The y-axis is a measure

Astig m a tism An a lysis

Assessing Astigma tic Cha nge

Equation 1. DEQ = SEQ + 0.5 Cyl

Figure 2-1. Equivalency

It is important for clinicians to understand the theories behind the calculation

Ca lcula ting From Refra ction

If our surgery fails to completely correct an eye’s preoperative refraction to

SIRC = postoperative refraction – preoperative refraction

Vertexing the Refra ctive Error

This difference is insignificant for refractions less than ±4 D at normal

When we perform this calculation, the vertex distance is considered to be

Ca lcula ting With Kera tometry

To calculate the SIRC using corneal topography or keratometry, we subtract

Assessing Residua l Sphere

Assessing Cha nge in Cylinder Axis

Mathematical Solution to Obliquely Crossed Cylinders

Given: Spherocylinder 1 = SC1

Find: Spherocylinder 3 = SC3

Step 2. SC1 must be chosen so the value of A1 is smaller than A2.

Step 3. Find angle , the difference between A2 and A1.

Step 4. Find angle 2 from the formula:

Step 5. Find angle from the follow ing formula:

A. Alternate spherocylindrical form (SC4) of SC3:

Plotting Astigma tic Errors

Figure 2-4. Centroid and stan-

For the Middle-Aged Eye

Figure 3-3. An indirect ophthalmoscopic viewing lens with a parabolic

Q = +1.00 8 cut RK, –5 D PRK

Q = +2.00 16 cut RK, –12 D PRK

Aspheric Intra ocula r Lenses

La ser Abla tion

** February 2006 Federal Register on NTIOLs

The creation of an oblate corneal surface is the main reason why SA

Modified La ser Trea tments

Guirao A, Gonzalez C, Red ondo M, Geraghty E, Norrby S, Artal P. Average opti-

The formulas are expressed as follows:

Using this formula, a patient with –4 D of error and a vertex distance of 12