Pentacam Screening for

Keratoconus
with special attention to

Belin / Ambrsio Enhanced

Ectasia Display
M.Khanlari, MD

Reading The Pentacams Maps For Detecting

Keratoconus

Standard Approach

The key to successfully screening patients with the Pentacam is to

create a standardized template that always displays the same maps
in the same order using consistent colors and scales

Routinely we use the Pentacams

Four-map composite report which includes
sagittal curvature maps
anterior elevation (front)
posterior elevation (back)
pachymetry or corneal thickness

Keratoconus Map
Holladay Report
Belin /Ambrosio Enhanced Ectasia Display

4 Map

4 Map

4 Map Curvature map and keratoconus

Curvature measurements are reference based, meaning the

curvature map will change based on the reference axis. Typically,
the reference axis is neither the corneal apex nor the line of sight
but some arbitrary axis made by the normal line that the
keratoscope makes with the corneal surface.
In some images the difference between the topographers reference
axis, the line of sight, and the corneal apex lead to curvature
patterns that may be interpreted as abnormal (eg, asymmetric
bowtie astigmatism, inferior steepening)

4 Map Curvature map and keratoconus

It is important to realize that we cannot rely on corneal

curvature to diagnose keratoconus. Curvature is a
reference-based measurement that changes with the angle of
evaluation.
A decentered apex will always lead to focal areas of
curvature steepening (when no true abnormality exists). True
elevation maps do not make these assumptions and are
independent of the reference axis
Therefore, we suggest examining an eyes elevation and
pachymetry maps first and the curvature map last.

4 Map Curvature map and keratoconus

4 Map Curvature map and keratoconus or PMD

4 Map Elevation and keratoconus

Use best-fit sphere and float and a scale that is 75m

we suggest front elevation first and Look at back elevation and
pachymetry next and at curvature last
Normal values for front elevation are less than +12m.
Differences greater than +15m typically indicate keratoconus
Between +12 and +15m are suspicious.

Normal values for posterior elevation are approximately 5m

higher than those for front elevation,

4 Map Elevation and keratoconus

Keratoconus Map

Keratoconus Map

Indices and Keratoconus Level

Keratoconus Map
ISV =.

Gives the deviation of individual corneal radii from the mean value. Elevated
in all types of irregularity of the corneal surface (scars, astigmatism, deformities caused
by contact lenses, keratoconus etc.).
IVA = Index of Vertical Asymmetry. Gives the degree of symmetry of the corneal
radii with respect to horizontal meridian as axis of reflection . Elevated in cases of
oblique axes of astigmatism, in keratoconus or in limbal ecstasies.
KI = Keratoconus-Index. Elevated especially in keratoconus
CKI = Center Keratoconus-Index. Elevated especially in central keratoconus.
RMin = Radii minimum Gives the smallest radius of curvature in the entire field of
measurement. Elevated in keratoconus.
IHA = Index of Height Asymmetry. Gives the degree of symmetry of height data
with respect to the horizontal meridian as axis of reflection. Analogous to IVA, though
sometimes more sensitive.
IHD = Index of Height Decentration. This index is calculated from Fourier analysis
of height and gives the degree of vertical decentration. Steeper in keratoconus.
ABR = Aberration coefficient.Calculated on the basis of Zernike analysis. If there
are no abnormal corneal aberrations, ABR is 0.0, otherwise ABR becomes 1.0 or
greater, depending on the degree of aberration

Pachymetry Map and Kertaoconus

Keratoconus Map

Keratoconus is a noninflammatory pathologic condition

characterized by progressive thinning and protrusion of the
cornea.
The thinning process occurs in one particular area so that the
surrounding area remains disproportionately thicker.
Physiologically, the normal cornea is thinner in its center and
thicker in the periphery.
The gradual increase of the corneal thickness from the center
toward the periphery in healthy eyes falls within a normal
range and that this characteristic could lead to a criterion for
identifying pathology such as ectasia.

Pachymetry Map and Kertaoconus

Keratoconus Map

Interestingly, there were some cases with early keratoconus

evident on the anterior corneal maps that had normal posterior
elevation maps.
Thus in this situation pachymetric progression data could
provide information to identify ectasia and add to the
surgeons armamentarium in the preoperative screening
process.

Pachymetry Map and Kertaoconus

Keratoconus Map

OD(mmHg)

OS(mmHg)

Normal

Corneal hysteresis

9.8

9.1

11.9 1.97

Corneal resistance Factor

7.74

7.23

11.4 2.07

Holladay Report (6 Maps)

Holladay Report and Keratoconus

The strategy is that when the hot spot on the

tangential Map, relative pachymetry map and back
elevation map using the toric Ellipsoid are all at the
same point, the diagnosis of Forme Fruste
Keratoconus is confirmed.
Relative Pachymetry :Measurements that exceed -3.0%
Back Elevation Map :Elevations above 15 microns above

the Toric Ellipsoid

Tangential map : red nipple and usually above 48 D..

Holladay Report and Keratoconus

Holladay Report and Keratoconus

Belin /Ambrosio Enhanced Ectasia Display

Introduction

While measurements such as aberrometry and

curvature can be used in evaluating a patient for
ectatic disease, they are derivatives of elevation.
With subclinical disease, anterior curvature alone
may not provide enough information to detect an
early corneal abnormality.
The goal of the Belin / Ambrsio Enhanced
Ectasia Display is to combine elevation based
and pachymetric corneal evaluation in an all
inclusive display

Role of Elevation Based Approach

In about 5% of the cases, there is significant

asymmetry in that the less involved eye initially
presents with a normal curvature map.
Longitudinal studies have found that about 50%
of such cases progress to clinical keratoconus.
The new elevation based approach has
increased sensitivity to 75% in eyes from
patients previously diagnosed with unilateral
keratoconus (Salomo and Ambrsio,).

Fault of Raw Elevation Data

Actual raw elevation data lacks enough surface

variability for an easy qualitative inspection that
would allow the clinician to separate normal
from abnormal corneas.

Elevation Subtraction Map

By subtracting a known shape the

differences or variance become highlighted
or exaggerated
The term Elevation Maps while ingrained
are technically incorrect. A better term
would be an Elevation Subtraction Map
since we do not look at the actual elevation
data, but only the data after subtracting out
some reference shape

Enhanced Reference Surface

For most clinical situations using a best-fit-sphere gives

the most useful qualitative map (i.e. easiest to read and
understand).
Since the normal eye is an aspherical prolate surface the
central 8 9 mm zone yields a reference surface that
allows for subtle identification of both ectatic disorders
and astigmatism.
Larger zones would typically yield a flatter BFS and
smaller zones a steeper BFS. While other shapes may
have some clinical utility, shapes that more closely
approximate a cone (e.g. toric ellipsoid) will actually
mask the cone as the best-fit-toric ellipsoid more closely
matches the cone contour

Enhanced Reference Surface

Best Fit Sphere vs Toric Ellipse

Enhanced Reference Surface

While the Best-Fit-Sphere (BFS) is qualitatively
useful, the clinician typically assumes that the
reference surface (the shape being subtracted) closely
approximates a normal cornea.
The problem here is that there is such variability in
corneal shape that the normal or average shape
does not represent a clinically useful reference surface
for individual corneal evaluation.
What is typically not appreciated is that the BFS will
be influenced by any abnormal portion of the cornea.

Role of Cone on BFS

In the case of keratoconus or ectasia, the

cone or apical protrusion will have the effect
of steepening the BFS. This stepened BFS
will actually minimize the elevation
difference between the apex of the cone and
the BFS

Exclusion Zone

New screening display of Belin / Ambrsio Enhanced Ectasia

Display try to eliminate this problem.
Their goal is to design a reference surface that more closely
approximates the individuals normal cornea after excluding the
conical or ectatic region.
To do this, they identify a 4.0 mm optical zone centered on the
thinnest portion of the cornea and excluded it from the
reference shape calculation (exclusion zone).
They calculate the new enhanced BFS by utilizing all the
valid elevation data from within the 8.0 mm central cornea, and
outside the exclusion zone

Centering & size of Exclusion Zone?

Earlier investigations looked at centering the

exclusion zone on the apex and also the zone of
minimal radius of tangential curvature, but the
thinnest region turned out to be the most reliable.
They also looked at different optical zone sizes.
Larger zones increased sensitivity at the expense
of specificity, while smaller zones did the
opposite.

Best Exclusion Size

A 4 mm exclusion zone appeared to balance the

need for sensitivity without significant false
positives.
The elevation difference between using a
standard BFS and the new enhanced BFS will
be significant for a conical cornea, while the
difference is minimal in a normal cornea

Standard BFS vs Enhanced BFS

Standard BFS vs Enhanced BFS

Normal Cornea

Standard BFS vs Enhanced BFS

Ectatic Cornea

Average Change In Elevation

BFS vs Modified Shape

Average Change In Elevation

BFS vs Enhanced BFS

The average changes in corneal elevation (when going

from standard to enhanced BFS) were as follows:
Anteriorly
Normal eyes showed an average change in apex and maximum

elevation of 1.861.9m and 1.631.4m.

Keratoconus eyes showed anterior apex and maximum elevation
changes of 20.423.1m and 20.921.9m. (P<.0001).
Posteriorly,
Normal eyes showed an average change in apex and maximum

elevation of 2.861.9m and 2.271.1m.

Keratoconus eys showed posterior apex and maximum elevation
changes of 39.938.1m and 45.735.9m. (P<.0001).

Elevation Display Interpretation

Baseline Elevation Maps

The first two elevation maps

front surface (left map)
back surface (right map)
Above each map
The radius of curvature of the BFS in
mm
The diameter of the zone used to
compute the BFS
The diameter of the circle (in mm)
centered on the corneal apex inside
In this sample map
The radius of curvature of the BFS for
the front surface is 8.17mm
The radius of curvature of the BFS for
the back surface is 6.63 m

Exclusion Maps

Immediately below the standard

elevation maps are
The anterior exclusion map
The posterior exclusion map

for the front of the cornea

Baseline BFS is 8.17 mm,
Enhanced BFS is 8.18mm.
The size of the BFS changed very little,
as did the elevation map, when going
from the baseline to the exclusion map.

For the back of the cornea

Baseline elevation was 6.63mm.
Enhanced BFS was 6.84mm

Difference Map

The bottom 2 maps are

relative change in elevation from the baseline

elevation map to the exclusion map.

The bottom maps contain only 3 colors,

The green represents a change in elevation of
Less than 6 microns on the front and
Less than 8 microns on the back surface of the
cornea and are
Typically within the range seen in normal eyes.
The red represents areas where the difference is
12 microns anteriorly or
20 microns posteriorly and
The magnitude typically seen in eyes with known
keratoconus.
The yellow areas represent a change
Between 6 and 12 microns for the front surface
and
Between 8 to 20 microns for the back surface

Pachymetric Evaluation
.

The pachymetric portion of the display

includes
The pachymetry map (Corneal Thickness),
The two graphs and
The pachymetric indices.
It identifies
the corneal thickness at the apex (center of
the exam),
the thinnest point (TP) and the location and
distance of the thinnest point relative to the
apex.
The direction of the TP is displayed as
temporal (T), nasal (N), superior (S) and
inferior (I) or intermediate (e.g. IT inferiotemporal).

Pachymetric Evaluation

In only about 12% of normal corneas, the pachymetric

difference between the TP and the apex is > 10m.
They also found a positive correlation (r2 = 0.61) comparing
the distance difference and the pachymetric difference between
the apex and thinnest point (TP).
In eyes with keratoconic the distance between the apex and the
thinnest point is significantly higher (1.52 0.58mm) than
normals (0.9 0.23mm) (p<0.05).
Along with the thinnest point evaluation, the pachymetric
display evaluates the thickness profile of the cornea

Pachymetric Evaluation

The CTSP displays the average

thickness measurements along
twenty-two concentric circles
centered on the thinnest point
with increasing diameters of
0.4mm steps
In addition to the average
values, the standard deviations
of the pachymetry along each
circle are calculated.

Pachymetric Evaluation

The second graph (percentage of

thickness increase (PTI)) is
calculated using a simple
formula: (CT@x - TP)/TP, where
x represents the diameter of the
imaginary circle centered on the
TP with increased diameters as
provided by the CTSP.
Each graph displays the examined
eye data in red and three broken
dark lines, which represent the
upper and lower double standard
deviation (95% - confidence
interval) and the average values
from a normal population

Pachymetric Evaluation
keratoconus patients have thinner corneas and a
faster and more abrupt increase of the CTSP and
PTI than normal corneas.
CTSP and PTI graphs were designed to enable the
rapid identification of very early forms of ectasia,
increasing sensitivity and specificity for screening
candidates for refractive surgery.
The thickness profile also enables clinical
differentiation of a normal thin cornea from an
ectatic cornea, and a normal thick cornea from an
edematous cornea.

Pachymetric Evaluation

Normal corneas typically have an

Average progression index < 1.2 and a CTSP and
PTI lines within the 95% CI limits.

However there is some overlap between normal and keratoconic eyes.

About 7% of normal eyes have
1.2 < average progression index <1.8
Current hypothesis is that these cases may have higher susceptibility to

develop ectasia if stressed such as intensive eye rubbing and/or subjected

to lamellar refractive surgery.

In addition, 11% of the cases with clinical keratoconus have

average progression index < 1.2 and
CTSP and PTI within the normal limits.
It's also hypothesize that these cases have lower odds for ectasia

progression and, in some conditions, may benefit from advanced

customized surface ablation procedures.

Conclusion

The Pentacam is improving ophthalmic

diagnostics by providing valuable
information in screening for keratoconus.
These improvements will help achieve better
surgical outcomes and enhance patient
satisfaction