Irregular

Astigmatism
 IRREGULAR ASTIGMATISM
• The diagnosis of irregular astigmatism is made by meeting clinical and imaging criteria: loss of spectacle best-corrected
vision but preservation of vision with the use of a gas-permeable contact lens, coupled with topographic corneal
irregularity.

• An important sign of postsurgical irregular astigmatism is a refraction that is inconsistent with the uncorrected visual
acuity.

• Another important sign is the difficulty of determining axis location during manifest refraction in patients with a high
degree of astigmatism.

• Because their astigmatism is irregular (and thus has no definite axis), these patients may achieve almost the same visual
acuity with high powers of cylinder at various axes. Streak retinoscopy often demonstrates irregular “scissoring” in
patients with irregular astigmatism.

• Irregular astigmatism can be thought of as additional shapes superimposed on cylinders and spheres. This corneal
irregularity is then measured and quantified by wavefront analysis.
 Application of Wavefront Analysis in
Irregular Astigmatism
Refractive surgeons derive some benefit from having a thorough understanding of irregular
astigmatism, for 2 reasons. First, keratorefractive surgery may lead to visually significant irregular
astigmatism in a small percentage of cases. Second, keratorefractive surgery may also be able to treat
it. For irregular astigmatism to be studied effectively, it must be described quantitatively. Wavefront
analysis is an effective method for such descriptions of irregular astigmatism.

An understanding of irregular astigmatism and wavefront analysis begins with stigmatic imaging. A
stigmatic imaging system brings all the rays from a single object point to a perfect point focus.
According to the Fermat principle, a stigmatic focus is possible only when the time required for
light to travel from an object point to an image point is identical for all the possible paths that
the light may take.
An analogy to a footrace is helpful. Suppose that several runners simultaneously depart from an object point (A). Each
runner follows a diferent path, represented by a ray. In this case, all the runners travel at the same speed on the ground,
but slow down when running through water. Similarly, light rays will travel at the same speed in air but slow down in
the lens. If all the runners reach the image point (B) simultaneously, the “image” is stigmatic. If the rays do not
meet at point B, then the “image” is astigmatic.
Wavefront analysis is based on the Fermat principle. Construct a
circular arc centered on the paraxial image point and intersecting
the center of the exit pupil. This arc is called the reference sphere.
Again, consider the analogy of a footrace, but now think of the
reference sphere (rather than a point) as the finish line. If the image
is stigmatic, all runners starting from a single point will cross the
reference sphere simultaneously. If the image is astigmatic, the
runners will cross the reference sphere at slightly different times
The geometric wavefront is analogous to a photo finish of the race. It
represents the position of each runner shortly after the fastest runner
crosses the finish line. The wavefront aberration of each runner is the
time at which the runner finishes minus the time of the fastest runner.
In other words, it is the difference between the reference sphere and
the wavefront. When the focus is stigmatic, the reference sphere and
the wavefront coincide, so that the wavefront aberration is zero.
Another interpretation of the Fermat principle
is the point spread function produced by all
rays that traverse the pupil from a single object
point. This image is perpendicular to the
geometric wavefront shown in Figure 7.5B.
For example, keratorefractive surgery for
myopia using surgical removal procedures
reduces spherical refractive error and regular
astigmatism, but it does so at the expense of
increasing spherical aberration and irregular
astigmatism (Fig 7-5).
The cornea subsequently becomes less prolate, and its shape
resembles an egg lying on its side. The central cornea becomes flatter
than the periphery and results in an increase in the spherical
aberration of the treated zone. Generally, keratorefractive surgery
moves the location of the best focus closer to the retina but, at the
same time, makes the focus less stigmatic. Such irregular
astigmatism leads to decreased contrast sensitivity and underlies
many visual complaints after refractive surgery.
Wavefront aberration is a function of pupil position. For example, coma is a
partial defection of spherical aberration. Figure 7-6 shows some typical
wavefront aberrations.

Myopia, hyperopia, and regular

astigmatism can be expressed as
wavefront aberrations. Myopia
produces an aberration that optical
engineers call positive defocus.
Hyperopia is called negative
defocus. Regular (cylindrical)
astigmatism produces a wavefront
aberration that resembles a saddle.
Defocus (myopia and hyperopia) and
regular astigmatism constitute the
lower-order aberrations.
When peripheral rays focus in front of more central rays, the effect
is termed spherical aberration. Clinically, spherical aberration is
one of the main causes of night myopia following LASIK and PRK.
After keratorefractive surgery, corneas that become more oblate
(after myopic correction) will induce more-negative spherical
aberration, while those that become more prolate (after hyperopic
Another
correction)important aberration
will induce is coma.
more-positive In this
spherical aberration, rays at
aberration.
one edge of the pupil cross the reference sphere first; rays at the
opposite edge of the pupil cross last. The effect is that the image of
each object point resembles a comet with a tail (one meaning of
the word coma is “comet”). It is commonly observed in the aiming
beam during retinal laser photocoagulation; if the ophthalmologist
tilts the lens too far off-axis, the aiming beam spot becomes coma
shaped. Coma also arises in patients with decentered
keratorefractive ablation or keratoconus. These situations may be
treatable with intrastromal rings.
 Higher-order aberrations tend to be less significant than lower-order
aberrations, but the higher-order ones may worsen in diseased or surgically
altered eyes. For example, if interrupted sutures are used to sew in a
corneal graft during corneal transplant, they will produce higher-order,
trefoil or tetrafoil aberrations. These can then be addressed with suture
removal, suture addition, or AK. Also, in the manufacture of IOLs, the lens
blank is sometimes improperly positioned on the lathe; such improper
positioning
Optical can alsohave
engineers produce higher-order aberrations.
Wavefront aberrations can be represented in
found approximately 18 different ways. One approach is to show them
basic types of astigmatism, as 3-dimensional shapes. Another is to
of which only some— represent them as contour plots. Irregular
perhaps as few as 5—are of astigmatism can be described as a
clinical interest. Most combination of a few basic shapes, just as
patients probably have a conventional refractive error represents a
combination of all 5 types. combination of a sphere and a cylinder.
Currently, wavefront aberrations are specified by Zernike polynomials, which
are the mathematical formulas used to describe wavefront surfaces.
Wavefront aberration surfaces are graphs generated using Zernike
polynomials. There are several techniques for measuring wavefront
aberrations clinically.
The most popular is based on the Hartmann-
Shack wavefront sensor, which uses a low-
power laser beam focused on the retina. A
point on the retina then acts as a point source.
In a perfect eye, all the rays would emerge in
parallel and the wavefront would be a at plane;
however, in most eyes, the wavefront is not at.
Within the sensor is a grid of small lenses
(lenslet array) that samples parts of the
wavefront. The images formed are focused
onto a charge-coupled-device chip, and the
degree of deviation of the focused images
The most frequently used technologies today are those based on
measuring wavefront aberrations via a ray-tracing method that projects
detecting light beams sequentially rather than simultaneously, using a
Hartmann-Shack wavefront sensor, further improving the resolution of
wavefront aberration measurements. The application of Zernike
polynomials’ mathematical descriptions of aberrations to the human eye is
less than perfect, however, and alternative methods, such as Fourier
transform,
To are being
normalize used in many
wavefront wavefront
aberration aberrometers. and improve
measurements
postoperative visual quality in patients undergoing keratorefractive
surgery, ophthalmologists are developing technologies to improve the
accuracy of higher-order aberration measurements and treatment by
using “ ying spot” excimer lasers. Such lasers use small spot sizes (<1-mm
diameter) to create smooth ablations, addressing the minute topographic
changes associated with aberration errors.
 CAUSES OF IRREGULAR ASTIGMATISM
• Irregular astigmatism may be present before keratorefractive surgery; it may be caused by the surgery; or it may
develop postoperatively.

• Preoperative causes include keratoconus, pellucid marginal degeneration, contact lens warpage, significant dry eye,
corneal injury, microbial keratitis, and epithelial basement membrane dystrophy (Fig 7-7). All these conditions should
be identified before surgery.

• Common intraoperative causes include decentered ablations

and central islands, and, less commonly, poor laser optics,
nonuniform stromal bed hydration, and LASIK flap
complications (a thin, torn, irregular, incomplete, or
buttonhole flap; folds or striae of the flap; and epithelial
defects).

• Postoperative causes of irregular astigmatism include flap

displacement, diffuse lamellar keratitis and its sequelae, flap
striae, posterior corneal ectasia, irregular wound healing, dry
eye, and flap edema.
 CONCLUSION
Understanding and incorporating optical considerations into
the treatment of patients undergoing keratorefractive surgery
is important to enhance the visual results. Patient
dissatisfaction after surgery, albeit rare, often stems from the
subjective loss of visual acuity or quality, the source of which
can usually be identified through a sound understanding of
how keratorefractive surgery alters the optics of the eye. A
good understanding of key parameters such as corneal shape,
pupil size, the ocular surface, spherical and astigmatic errors,
higher-order aberrations, laser centration and the angle
kappa, and irregular corneal astigmatism can help optimize
visual outcomes for keratorefractive surgery.
THANK
YOU