CLINICAL SCIENCE
Effects of Aging on Anterior and Posterior
Corneal Astigmatism
Jau-Der Ho, MD, PhD,*† Shiow-Wen Liou, MD, PhD,†‡§ Ray Jui-Fang Tsai, MD,†
and Ching-Yao Tsai, MD, PhDঠk
Purpose: To evaluate age-related changes in astigmatism of both
corneal surfaces and the whole cornea.
Methods: The right eyes of 370 subjects were measured with
a rotating Scheimpflug camera (Pentacam). Astigmatisms of the
anterior and posterior corneal surfaces were determined. The total
corneal astigmatism was derived using power vector summation and
vergence tracing. Age-related changes to corneal astigmatism were
evaluated using polar value analysis (both in diopter and millimeter).
Results: For the anterior and total cornea, the proportion of with-
the-rule astigmatisms decreased and those of oblique and against-the-
rule astigmatisms increased with age. For the posterior cornea, most
eyes displayed against-the-rule astigmatisms in all age groups. There
was a significant trend toward against-the-rule astigmatism associated
with increasing age for both anterior and total corneal astigmatisms
(mean changes of 20.18 and 20.16 diopters/5 years, respectively),
and toward with the rule in posterior corneal astigmatism (a mean
change of 0.022 diopters/5 years). Regarding shape changes, a ‘‘flat
meridian toward a more vertical orientation’’ trend with increasing
age for both the anterior and posterior corneal surfaces was observed
(mean changes of 0.0295 and 0.0224 mm/5 years, respectively). The
posterior corneal surface compensated for the astigmatism arising
from the anterior corneal surface in 91.4% and 47.7% of eyes in the
21–30 and $71 years groups, respectively.
Conclusions: There were age-related shifts toward against-the-rule
and with-the-rule astigmatisms for the anterior and posterior corneal
surfaces, respectively. The compensating effects of the posterior
corneal surface on anterior corneal astigmatism decreased with
advancing age.
Key Words: astigmatism, aging effect, pentacam, posterior corneal
surface
(Cornea 2010;29:632–637)
Received for publication March 2, 2009; revision received September 10,
2009; accepted September 17, 2009.
From the *Department of Ophthalmology, Taipei Medical University Hospital,
Taipei, Taiwan; †Department of Ophthalmology, Taipei Medical University,
Taipei, Taiwan; ‡Department of Ophthalmology, Taipei City Hospital, Taipei,
Taiwan; §Department of Ophthalmology, National Taiwan University
Hospital, Taipei, Taiwan; and {Community Medicine Research Center and
k
Institute of Public Health, National Yang-Ming University, Taipei, Taiwan.
The authors have no proprietary or commercial interest in any materials
mentioned in this article.
Reprints: Ching-Yao Tsai, MD, PhD, Department of Ophthalmology, Taipei
City Hospital, 145 Zheng Zhou Rd, Taipei 103, Taiwan (e-mail: dac58@
tpech.gov.tw).
Copyright Ó 2010 by Lippincott Williams & Wilkins
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C orneal astigmatism is a frequently encountered type of
optical aberration in the cornea. It is important for
determining uncorrected visual acuity. It is also a significant
factor in determining the axis and amount of intraoperative
correction of astigmatism. Knowing age-related changes in
corneal astigmatisms is helpful for our understanding of long-
term outcomes of refractive surgery and refractive changes
after cataract surgery. Several previous studies have reported
age-related changes to corneal astigmatism. A shift in the axis
of corneal astigmatism from with the rule toward against the
rule associated with increasing age was found in previous
studies.1–7 However, most of those studies used only anterior
corneal measurements and the keratometric index to derive the
total corneal astigmatism, when in fact, both the anterior and
posterior corneal surfaces contribute to total corneal astigma-
tism. The effect of aging on posterior corneal astigmatism has
been investigated to a limited degree. Lam and Douthwaite7
used a Purkinje imaging technique to measure corneal radii
along 2 meridians (vertical and horizontal) for both the
anterior and posterior corneal surfaces. They found that the
radii in the horizontal meridian of both corneal surfaces
decreased with age.
The Pentacam (Oculus, Inc, Wetzlar, Germany) is
a device using a rotating Scheimpflug camera to image the
anterior segment (including both the anterior and posterior
corneal surfaces).8,9 It measures 25,000 data points from 50
meridians over the cornea in less than 2 seconds.10 Although
previous studies using Scheimpflug photography investigated
astigmatism of the posterior corneal surface, the curvature of
the cornea was only measured along 6 meridians.11 The
magnitude and axis of the astigmatism obtained in that study
might not be as accurate as those obtained by the Pentacam. In
this study, we used Pentacam measurements of the anterior and
posterior corneal surfaces to analyze astigmatisms of both the
corneal surfaces and the total cornea at different stages of life.
METHODS
After approval from the institutional review board,
subjects were randomly selected from the Taipei City Hospital
ophthalmology clinic. We excluded those who had corneal,
eyelid, or orbit diseases or who previously underwent ocular
surgery. Eyes with a corrected visual acuity worse than 0.3
logMAR (Snellen equivalent 20/40), a spherical equivalent
outside the 23.0 to +3.0 diopters (D) range, a history of
wearing contact lenses, or poor-quality Pentacam scans was
also excluded. Data were collected from the right eyes of the
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subjects. During examination, the Pentacam detects most of
the eye movements with a second camera and compensates
for it. Therefore, the Pentacam maintains a fixed point on the
cornea vertex and maintains the central point of each meridian
in the sample images.12 Measurements were performed in the
automatic mode by the same experienced examiner. All
scanning was done during a specific period, between 11:00 and
14:00, to minimize the effects of diurnal variations in corneal
thickness.13–15 It has been shown that corneal curvature
measurements by the Pentacam possess excellent repeatabil-
ity.16 Data obtained included the flat central radius (Rf), steep
central radius (Rs) on the 3-mm ring on the anterior and
posterior corneal surfaces, and meridian of the Rf on the 3-mm
ring on both corneal surfaces. The rationale for choosing the
3-mm ring was that it was found that points on the 3-mm ring
were sufficient to analyze astigmatism patterns.3,4
The anterior corneal surface powers in the flat and steep
meridians (Pf,front and Ps,front) were, respectively, calculated
nc 1 nc 1
by ðRf of anterior corneal surfaceÞ and ðRs of anterior corneal surfaceÞ, where
nc is the refractive index of the cornea (=1.376).17 The
posterior corneal surface powers in the flat and steep
meridians (Pf,back and Ps,back) were, respectively, calculated
na nc na nc
by ðRf of posterior corneal surfaceÞ and ðRs of posterior corneal surfaceÞ, where
na is the refractive index of aqueous humor (=1.336).17 We
used the power vector method proposed by Thibos et al18 to
convert the spherocylindrical refractive data of the anterior
and posterior corneal surfaces [S (sphere), C (cylinder), and
A (axis)] into power vector coordinates with a set of 3
independent components of the spherical equivalent (SE),
Jackson cross cylinder at 0 and 90 degrees (J0) and Jackson
cross cylinder at 45 and 135 degrees (J45), using the formulas
SE = S + C/2, J0 = (2C/2) cos (2A), and J45 = (2C/2) sin (2A).19
To calculate the total corneal astigmatism (at the anterior
corneal surface plane), we applied the algorithm of vergence
tracing (vergence transformation).20,21 The vergence power
(created by the posterior corneal surface) at the anterior
corneal surface plane in the flat meridian of the posterior
corneal surface is ncnc d, where d is corneal thickness. The
Pf ;back
vergence power (created by the posterior corneal surface)
at the anterior corneal surface plane in the steep meridian of
the posterior corneal surface is ncnc d. The power vector
Ps;back
representing the actual total corneal refractive power was then
obtained by vector summation of the power vector represent-
ing the refractive power at the anterior corneal surface plane,
which was created by the posterior corneal surface, and the
power vector representing the refractive power of the anterior
corneal surface. We obtained total corneal astigmatism by
converting the power vector representing the total corneal
power back into its spherocylindrical form.18,19
When analyzing the astigmatisms of both corneal
surfaces and total cornea, we classified the astigmatism as
‘‘with the rule’’ when the meridian of the maximal convergent
power (or least divergent power) was within 90 6 30 degrees.
In contrast, astigmatism was classified as ‘‘against the rule’’
when the meridian of the maximal convergent power (or least
divergent power) was within 0 6 30 degrees. Otherwise, the
astigmatism was classified as oblique.
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Anterior and Posterior Corneal Astigmatisms
To analyze changes in the corneal astigmatism with age,
we used a method described by Naeser22 in which the
spherocylindrical data were converted to polar values. For the
spherocylindrical refractive data (S, C, and A), the polar
value (in diopter) is defined as C(sin2A 2 cos2A). The polar
value calculates the balance between the with-the-rule and
against-the-rule components of any net astigmatism. A posi-
tive value indicates with-the-rule astigmatism, whereas a
negative value indicates against-the-rule astigmatism.2,22
The negative dioptric power of the posterior corneal
surface, and the relatively small difference in the refractive
indices across the posterior corneal surface (1.336 2 1.376 =
20.04) compared with that across the anterior corneal surface
(1.376 2 1 = 0.376) render the Naeser-developed polar value
(in terms of dioptric power) unsuitable for comparing age-
related changes with astigmatism between the anterior and
posterior corneal surfaces. To resolve this problem, we devised
a ‘‘shape polar value’’ (also termed ‘‘polar value in
millimeter’’; whereas the conventional Naeser-developed
polar value is a ‘‘polar value in diopter’’). The ‘‘shape polar
value’’ = DR 3 (sin2a 2 cos2a), where DR = radius of
curvature in the flat meridian 2 radius of curvature in the steep
meridian and a is the angle of the flat meridian. A positive
‘‘shape polar value’’ indicates that the surface has a ‘‘flat
meridian in a more vertical orientation.’’ Meanwhile, a negative
‘‘shape polar value’’ indicates that the surface has a ‘‘flat
meridian in a more horizontal orientation.’’
The x2 test for trend was employed to examine if there
was a statistically significant trend among age groups. The
Kolmogorov–Smirnov test was used to test the normality of
distribution. A simple linear regression was used to establish
the correlation between the age and polar values (both in
diopter and millimeter). Statistical analyses were performed
with SPSS 13.0 for Windows (SPSS, Inc, Chicago, IL) and
Prisim 4 for Windows (version 4.03; GraphPad Software, Inc,
La Jolla, CA).
RESULTS
The right eyes of 225 males and 145 females were
included in this study. The mean age of these subjects was
50.5 6 16.7 (21–97) years. The age and sex distributions are
given in Table 1. The mean spherical equivalent of the eyes
was 21.43 6 1.35 (23.0 to 2.875) D. The mean SE, J0, and
J45 components for both corneal surfaces and the total cornea
are presented in Table 2.
Figure 1 presents the distributions of different kinds of
astigmatisms of both corneal surfaces and total cornea in
TABLE 1. The Age and Sex Distributions of the Subjects
Age Group Male Female
21–30 44 14
31–40 34 22
41–50 41 18
51–60 42 37
61–70 41 33
$71 23 21
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Ho et al
TABLE 2. The Spherical Equivalent (SE), Jackson Cross Cylinder at 0 and 90 Degrees (J0), and Jackson Cross Cylinder at 45 and
135 degrees (J45) Components for Both Corneal Surfaces and Total Cornea (in Diopter)
SE
Anterior corneal surface 49.68 6 1.73 (46.11–53.21)
Posterior corneal surface 26.32 6 0.27 (26.98 to 25.73)
Total cornea 43.36 6 1.55 (40.36–46.30)
different age groups. For the anterior corneal surface and total
cornea, there was a statistically significant trend of decreasing
fraction of with-the-rule astigmatism associated with in-
creasing age (both P , 0.0001). For the anterior and total
cornea, there was a statistically significant trend of increasing
fractions of oblique and against-the-rule-astigmatisms asso-
ciated with increasing age (P , 0.0001 and P = 0.0089 for
oblique astigmatism; both P , 0.0001 for against-the-rule
astigmatism).
For the posterior corneal surface, most eyes showed
against-the-rule astigmatism in all age groups (note that the
dioptric power of the posterior corneal surface was negative;
therefore, an against-the-rule astigmatism means that the flat
meridian of the posterior corneal surface was within 0 6 30
degrees). However, there was still a significant trend of
increasing fraction of with-the-rule posterior corneal astigma-
tism with increasing age (P = 0.0008). On the other hand, there
was a significant tendency for older subjects to have a lower
proportion of against-the-rule astigmatism in the posterior
cornea (P = 0.0047).
Figure 2A presents the distribution of the effect of the
‘‘vector summation of the refractive power of the posterior
corneal surface to that of the anterior corneal surface’’ on the
magnitude of astigmatism arising from the anterior corneal
surface. In the majority of younger age group eyes, the anterior
corneal astigmatism magnitude was reduced (compensated) by
the refractive power (astigmatism) arising from the posterior
corneal surface. There was a statistically significant declining
trend with aging for eyes having such compensatory effects
(P , 0.0001). Figure 2B presents the average percentage of
compensation or augmentation of the anterior corneal astigma-
tism magnitude caused by the ‘‘vector summation’’ in different
age groups. The average compensation percentage progres-
sively declined with aging. In fact, in the 61–70 and $71 age
groups, there was actually augmentation rather than compen-
sation in the average percentage.
Figure 3 presents the results of analyzing changes with
age in astigmatisms using the polar value method.22 Both
anterior corneal and total corneal astigmatisms showed a signifi-
cant against-the-rule change with age. The average changes in
against-the-rule astigmatism every 5 years for the anterior and
total corneal astigmatisms were 0.18 and 0.16 D, respectively.
On the other hand, posterior corneal astigmatism displayed
significant with-the-rule changes with age, with an average
change of 0.022 D in with-the-rule astigmatism every 5 years.
Figure 4 presents the results of analyzing changes in
shape of the anterior cornea and posterior cornea with age
using the ‘‘shape polar value (in millimeter).’’ Both the anterior
and posterior corneal surfaces demonstrate a significant trend
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Cornea
Volume 29, Number 6, June 2010
J0 J45
20.41 6 0.65 (22.55 to 2.30) 0.00 6 0.32 (21.43 to 0.95)
0.20 6 0.11 (20.20 to 0.56) 0.00 6 0.07 (20.30 to 0.31)
20.20 6 0.60 (22.44 to 2.10) 0.00 6 0.30 (21.42 to 1.01)
of ‘‘flat meridian toward a more vertical orientation’’ with
advancing age (The anterior corneal surface has a positive
dioptric power and the posterior corneal surface has a negative
dioptric power; therefore, the effect of an identical trend in
surface shape changes is completely opposite for the anterior
and posterior corneal surfaces, in terms of changes in
refractive astigmatism.). The average changes to the ‘‘shape
polar value’’ were 0.0295 and 0.0224 mm per 5 years on the
anterior and posterior corneal surfaces, respectively.
DISCUSSION
In this study, we used a rotating Scheimpflug camera
(the Pentacam) to measure the curvature of the anterior and
posterior corneal surfaces. The results of this study should not
be interpreted as longitudinal changes in the astigmatism of
the human cornea. However, they provide a pool of clinical
data on astigmatisms for both corneal surfaces and the
interactions between them at different life stages in patients
attending an eye care facility. We demonstrated against-the-
rule changes with age for both anterior and total corneal
astigmatisms and with-the-rule changes with age for posterior
corneal astigmatism. In terms of shape change, both the
anterior and posterior corneal surfaces showed a trend of ‘‘flat
meridian toward a more vertical orientation’’ with increasing
age. We also showed that in the vast majority of young eyes,
the posterior corneal surface compensated for astigmatism
arising from the anterior corneal surface. However, this
compensatory effect decreased with age.
Several studies have reported a shift in the axis of
corneal astigmatisms from with the rule toward against the rule
with increasing age.1–6 All those studies used only anterior
corneal measurements to derive total corneal astigmatism.
Therefore, the trend toward against the rule found in those
studies was actually a trend of anterior corneal astigmatism.
Our study found a trend toward against the rule in the anterior
corneal astigmatism compatible to previous studies. Using the
polar value method and a linear regression, the average
changes to against the rule were 0.13 D per 5 years in
a longitudinal study and 0.14 D per 5 years in 2 cross-sectional
studies.2,5,6 Our study featured an average change of 0.16 D
per 5 years in the polar value of total corneal astigmatisms.
To the best of our knowledge, there is only 1 study that
addresses the effect of aging on the posterior corneal curvature
by using a Purkinje imaging technique.7 It found that aging
had a significant effect on the horizontal meridian but not the
vertical meridian. The radii in the horizontal meridian of both
corneal surfaces decreased with age. Yet, meridians besides the
horizontal and vertical ones were not measured. By taking
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FIGURE 1. Distributions of different kinds of astigmatism by
age group. A, The anterior cornea. The proportions of with-the-
rule, oblique, and against-the-rule astigmatisms are 91.4%,
5.2%, and 3.4% in the 21–30 age group and 31.8%, 29.5%,
and 38.6% in the $71 age group. B, The posterior cornea. The
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Anterior and Posterior Corneal Astigmatisms
FIGURE 2. The effects of the ‘‘vector summation of the
refractive power of the posterior corneal surface to that of the
anterior corneal surface’’ on the magnitude of the anterior
corneal astigmatism by age group. A, Distribution of effects.
The ratio of eyes in which the anterior corneal astigmatism
magnitude is compensated by the posterior corneal astigma-
tism decreased with age from 91.4% in the 21–30 age group
to 47.7% in the $71 age group. B, The average percentage of
compensation or augmentation on the magnitude of the
anterior corneal astigmatism caused by the posterior corneal
surface (negative value indicates compensation; positive value
indicates augmentation). The average percentage changes
from 23.6% of compensation in the 21–30 age group to
11.2% of augmentation in the $71 age group.
proportions of with-the-rule, oblique, and against-the-rule
astigmatisms are 0%, 1.7%, and 98.3% in the 21–30 age
group and 9.1%, 2.3%, and 88.6% in the $71 age group. C,
The total cornea. The proportions of with-the-rule, oblique,
and against-the-rule astigmatisms are 89.7%, 6.9%, and 3.4%
in the 21–30 age group and 25.0%, 18.2%, and 56.8% in
the $71 age group (ATR: against the rule; Obl: oblique; WTR:
with the rule).
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Ho et al
FIGURE 3. Scattergrams of polar values described by Naeser22
(in diopter) versus age and the linear regression model. A, The
anterior cornea. B, The posterior cornea. C, The total cornea.
measures in 50 meridians, we found a definite trend of ‘‘flat
axis toward a more vertical orientation’’ with age in the
posterior corneal surface.
It was found in previous studies that astigmatism of the
posterior corneal surface resulted in an average compensation
of 12.9%–31% in the anterior corneal astigmatism.11,23–25
However, these studies did not address age-related changes to
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Cornea
Volume 29, Number 6, June 2010
FIGURE 4. Scattergrams of ‘‘shape polar values (in millimeter)’’
versus age and the linear regression model. A, The anterior
cornea. B, The posterior cornea.
this ‘‘compensatory effect.’’ In our study, the posterior corneal
astigmatism compensated for astigmatism arising from the
anterior corneal surface in 91.4% of eyes in the 21–30 age
group. This ratio progressively decreased with advancing age.
In the $71 age group, 47.7% of eyes featured this com-
pensatory effect. The average percentage of compensation was
23.6% in the 21–30 age group, progressively declining with
age. Moreover, in the 61–70 and $71 age groups, there was
actually augmentation (9.0% and 11.2% of augmentation,
respectively) rather than compensation in average percentage.
Some procedures for correcting astigmatism (eg, limbal relaxing
incision or toric intraocular lens implantation) depend on
accurate estimation of the total corneal astigmatism. Total
corneal astigmatism estimation relying solely on anterior
corneal surface measurement would not take the different
effects with age on this ‘‘compensation/augmentation effect’’
into consideration. Therefore, if a nomogram based on anterior
corneal astigmatism measurement is accurate for younger
eyes, it would not be as accurate for older eyes.
The cause of the shift to against-the-rule corneal
astigmatism with age remains unclear. It has been suggested
that pressure from the eyelids on the cornea results in corneal
astigmatism. Grosvenor proposed a hypothesis regarding the
cause of corneal astigmatism in which band-like pressure from
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the upper eyelid on the cornea leads to with-the-rule astigma-
tism (as occurs in the majority of young adults). The shift to
against the rule with aging is caused by a reduction in the lid
tension.26 Results of several studies support this hypothesis.27–29
Other mechanisms have been proposed for the age-related
shifts in the astigmatism axis, including age-related changes to
extraocular muscle tension,30 increases in intraocular pres-
sure,31 and changes to corneal structure.3
We found that both the anterior and posterior corneal
surfaces display a trend of ‘‘flat meridian toward a more
vertical orientation’’ with aging. Average changes in the
‘‘shape polar value (in millimeter)’’ were 0.0295 and 0.0224 mm
per 5 years for the anterior and posterior corneal surfaces,
respectively. This shows that the shape changes resulting from
aging were greater for the anterior corneal surface than for the
posterior corneal surface.
In summary, this study observed a trend toward against
the rule for both anterior and total corneal astigmatisms with
increasing age and a trend toward with the rule for posterior
corneal astigmatism. With regard to age-related changes to
corneal shape, both anterior and posterior corneal surfaces
show a trend of ‘‘flat meridian toward a more vertical
orientation’’ with increasing age. We also found that the
posterior corneal surface compensated for astigmatism arising
from the anterior corneal surface in the great majority of young
eyes, with this effect declining with age. Our findings may be
helpful for improving optical modeling of the eye and
understanding the long-term refractive outcomes after re-
fractive and cataract surgeries.
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