KERATOMETRY

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KERATOMETRY / OPHTHALMOMETRY

In keratometry, the refracting power of the cornea is determined in each of the two principal corneal meridians. Keratometry
therefore, provides the practitioner with information about the astigmatism of the eye but no information on spherical
ametropia (myopia or hyperopia).

Optical Principles
The Doubling Principle. The cornea is both a convex refracting surface and a convex mirror. To gather information about
the refracting power of the cornea, the practioner need only reflect an object of known size and at a known distance off of
the patient’s corneal surface,determine the size of the reflected image with a measuring telescope, and calculate the
refracting power on the basis of an assumed index of refraction. Unfortunately, the small nystagmoid movements of the eye
make such measurement impossible,
Suppose the object to be reflected from the cornea is an illuminated circle with a small cross on either side. If one
attempts to measure the size of the reflected image of this object, or mire, with a telescope reticle, the zero position of the
reticle scale would first be lined up with the left-hand cross; but by the time the scale reading could be made at the position
of the right-hand cross, the eye would have moved enough that an accurate reading would be impossible.
However, if the illuminated object is double - by a prism, for example - it will be necessary only to superimpose the
right-hand cross belonging to one image with the left-hand cross belonging to the other to obtain an accurate measurement
of the image size.
Helmholtz was the first to use the doubling principle. He used two small glass plates with plane parallel faces, placed
at an angle, to cause a doubling of the reflected image seen through the telescope. Using this arrangement, the amount of
doubling could be varied by varying the angle between the two glass plates.
Helmholt’z original instrument was not sufficiently accurate for clinical use. The first clinically useful instrument, known
as Javal-Schiotz keratometer (later manufactured as the Universal ophthalmometer and currently available as the
Haag-Streit keratometer), used a Wollaston prism as a doubling device. The original American Optical ophthalmometer
(also known as the Chamber-Inskeep ophthalmometer) used biprism as a doubling device.
The Bausch & Lomb (B&L) keratometer makes use of two prisms, one oriented horizontally and the other oriented
vertically; so that horizontal and vertical doubling occur simultaneously. This method of doubling is also used in the newer
American Optical instrument (the CLC) ophthalmometer) and in many Japanese keratometers.

Keratometers
 Measure the front surface corneal radii. They can give the total corneal power on the assumption that the back surface
of the cornea has 10% of the power of the front surface, using a calibration/refractive index of 1.3375.
 Main function is the measurement of the radius of curvature of the central portion (optic cap).

Clinical Use of Keratometric Information


 CL fitting, choice of trial lens
 Monitoring corneal shape
 Verification of contact lens parameters
 Measure corneal power
For fitting rigid contact lenses this information is accurate enough, especially because keratometry is used to provide a
starting point that is refined empirically. Multiple attempts over nearly half a century to automate the fitting process
completely by relying on either keratometry or topography have failed.
Since the advent of intraocular lenses (IOLs), the keratometer has been used to measure corneal power, which
requires additional assumptions. The keratometer and Placido disc topographers assess only the anterior corneal surface,
but corneal power depends on both anterior and posterior surfaces and, to a much lesser degree, on thickness. The
keratometer makes an assumption about the posterior corneal surface. Because the posterior surface has minus power,
most keratometers compensate by using a smaller refractive index in the lens maker’s formula. The typical, but not
universal, formula is an equation in which P is the corneal power (D, diopter) and r is the radius (m). This formula assumes
a corneal refractive index of 1.3375 instead of Gullstrand’s value of 1.376.

0.3375
P= r

What Does the Keratometer Actually Measure?


 The keratometer gives the apparent front corneal surface curvature (central 3 mm):
- tear lens does not fully negate the refractive effect of the front cornea, only 90% or 0.336/0.376 of its power is
neutralised.
- it is difficult to tell if the back surface of the cornea matches the contour and shape of the front surface. Rivett and Ho
(1991) have measured the posterior corneal topography. Their study showed that the posterior corneal surface is
hyperbolic and the radius of curvature measurements were
6.16 + 0.29 mm (RE) and
6.10 + 0.30 mm (LE).
 Determines the power and location of the steepest meridian and the meridian 90o away, based on the assumption that
the cornea is sphero-cylindrical.
 The keratometer gives the sagittal radius reading.

Instrumentation
In the Bausch & Lomb keratometer, the light beam reflected from the patient’s cornea passes through four apertures. The
left and right apertures contain a horizontally placed prism and a vertically placed prism, respectively, whereas the upper
and lower aperture contains no prism.
The upper and lower apertures constitute a Scheiner’s disk mechanism, enabling the operator to keep the instrument
in sharp focus. If the instrument in not in focus, the image formed by these apertures will be double.
Because horizontal and vertical doubling can be accomplished simultaneously, the instrument is referred to as a
one-position keratometer. In contrast, instrument equipped with a Wollaston prism or a biprism, which enable doubling in
only one direction, must be rotated 90 degrees between the horizontal and vertical measurements. Therefore, they are
referred to as two-position keratometers. When the meridians of greatest refraction and least refraction are found, the
difference in refracting power between the two meridians represents the corneal astigmatism.
Once the telescope has been clearly focused on the mire images, it is necessary to rotate the barrel of the instrument
to locate one of the two principal meridians. As the barrel is rotated, a position will be found where the horizontal limbs of
the two crosses will appear to be continuous with one another rather than obliquely oriented. When this occurs, the
base-apex lines of the two doubling prisms will be parallel to the two meridians of the cornea.

The whole instrument can be moves toward or away from the patients’s cornea by turning the knurled knob. This is the
knob that monitors focusing of the instrument via the Scheiner’s disk. When the instrument is used, one hand is needed to
control the measuring drum, but the other hand should always be placed on the focusing knob to make sure the undeviated
image is kept.
The eyepiece of the telescope includes a crosshair reticle, which is focused before the patient is seated in front of the
instrument. Once this has been done, the images of the mires will be viewed in the plane of the reticle.

Calibration. The instrument should be calibrated on a regular basis as a “cornea” a bright 5/8-inch steel ball bearing. The
bearing can be mounted on the back of the occluder, using modeling clay, or on a commercially available attachment called
a contactometer. The 5/8-inch ball has a radius of 0.794mm (5/16 inch), which converts (using the keratometer’s index of
refraction of 1.3375) to 42.50D.

Procedure
The procedure for determining the refracting power of a patient’s cornea in the two principal meridians involves the
following steps:
1. Focusing the eyepiece. The occluder is placed in front of the patient’s end of the keratometer (before the patient is
seated at the instrument), and the light switch is turned on. Starting with the eyepiece turned all the way out, it is
turned inward slowly until the crosshairs are in sharp focus. The reason for starting with the eyepiece all the way out is
to relax the operator’s accommodation.
2. Adjusting the instrument to the patient. The patient’s chair or stool should be adjusted so that he or she will have to
lean forward slightly to place the chin in the chin rest. The patient is asked to place the chin firmly on the chin rest and
the forehead against the forehead rest and to grasp the base of the instrument with both hands.
3. Aligning the instrument. The body of the instrument has two horizontally placed “spears”, which are useful in adjusting
the instrument to approximately the correct height. While looking outside the instrument, the knurled knob is adjusted
until the right spear is at the level of the outer canthus of the patient’s right eye. If the instrument is then aimed at the
bridge of the patient’s nose, a shadow will be seen on the bridge of the nose. The focusing knob should the be turned
back and forth until the shadow appears at its darkest. The instrument is then swung over to the right eye, and the
three mire images will be seen in relatively clear focus. The instrument then should be aligned so that the crosshairs
are in the center of the undeviated mire images.
4. Instructing the patient. The patient is instructed to keep his or her eyes open wide (but told it is alright to blink) and to
watch the image of the eye in the center of the instrument. However, a patient with a large refractive error may not see
the eye’s reflection and should be told to look at the center of the instrument.
5. Finding the primary meridian. The primary meridian is defined as the meridian closest to 180 degrees, as measure by
the plus signs of the mire image; the secondary meridian is 90 degrees from the primary meridian and is measured by
the minus signs of the mire image. Holding one hand on the focusing knob and making sure that the lower right mire
images coincide, the operator rotates the barrel of the instrument approximately 30 degrees in each direction, finding
the position at which the crosses are continuous.
6. Taking the readings. In taking the horizontal reading, the operator’s right hand is kept on the focusing knob to make
sure the undeviated mire image remains single, while the left hand is used to bring the two crosses in superimposition.
When this has been completed, the reading in the vertical meridian is taking while keeping the left hand on the
focusing knob and using the right hand to bring the two minus signs into superimposition. The instrument is then
aligned for the patient’s left eye, and the left eye readings are taken.
7. Recording the findings. By convention, the power in the horizontal meridian is recorded first, followed by the power in
the vertical meridian. Typical findings would be recorded as follows:

R: 42.00 at 180; 43.00 at 90


L: 42.25 at 170; 43.50 at 80
Interpreting the Findings
The difference in power between the two principal meridians indicates the power of the cylindrical lens necessary to correct
the patient’s corneal astigmatism, and the meridians of least refracting power indicates the position of the minus axis of the
correcting cylinder.

Example:
R: 42.00 at 180 L: 42.25 at 170
43.00 at 90 43.50 at 80
----------------------- -----------------------
-1.00cyl x 180 -1.25cyl x 170

With-the-rule (W/R) - when the weakest corneal meridian is at or near 1800 (the minus axis of the correcting cylinder is at
or near 180 degrees).

Against-the-rule (A/R) - when the weakest corneal meridian is at or near 900 (minus axis of the correcting cylinder is at or
near 90 degrees).

Oblique - if the principal meridians are between 30 and 60 degrees or between 120 and 150 degrees.

 In the great majority of eyes, the weakest meridian of the cornea is within 300 of 1800 and the corneal astigmatism is
with-the-rule.

Corneal vs. Refractive Astigmatism: Javal’s Rule

Refractive Astigmatism (Total Astigmatism) - determined by retinoscopy or subjective refraction (both corneal and internal
astigmatism)

Internal Astigmatism - due to the toricity of the back surface of the cornea and tilting of the crystalline lens with respect to
the optic axis of the cornea.

Javal’s Rule - determines the relationship between corneal and refractive astigmatism)
At = p(Ac) + k

Where: At = total (refractive astigmatism)


Ac = corneal astigmatism
P = approximately 1.25
K = 0.50D against-the-rule astigmatism

Substituting the value of p and k, relationship becomes: At = 1.25 (Ac) + (-0.50cyl x 90)

Example:
R = -1.00cyl x 180

At = p(Ac) + k
= 1.25 (-1.00cyl x 180) + (-0.50cyl x 90)
= (-1.25cyl x 180) + (-0.50cyl x 90)
At = -0.75cyl x 180

L = -1.25cyl x170

At = p(Ac) + k
= 1.25 (-1.25cyl x 170) + (-0.50cyl x 90)
= (-1.56cyl x 170) + (-0.50cyl x90)
At = -1.06cyl x 170 or -1.00cyl x 170

 In with-the-rule astigmatism, the amount of the ophthalmometry cylinder is decreased by the physiological
astigmatism, estimated to be 0.50D.
 In against-the-rule astigmatism, the amount of ophthalmometry cylinder is increased by 0.50D.
 In oblique astigmatism, the physiological astigmatism is ignored.
 The ophthalmometry and physiological cylinders are always written in the form of minus cylinders.

Javal himself proposed this as a temporary measure and recognized that other factors such as age, spherical state and
accommodation might have to be considered. Mote and Fry (1939a), in a survey of Javal’s rule as compared to clinical
results, found that while the statistical averages between actual results and the results of Javal’s rule agreed fairly closely,
individual discrepancies as high as 1.50D were possible.

A simplified Javal’s Rule

At = (keratometric astig) + (-0.50cyl x 90)

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