Use of a Shack-Hartmann aberrometer to assess the optical outcome of corneal transplantation in a keratoconic eye

Wavefront-guided scleral lens correction in keratoconus

PURPOSE

To examine the performance of state-of-the-art wavefront-guided scleral contact lenses (wfgSCLs) on a sample of keratoconic eyes, with emphasis on performance quantified with visual quality metrics, and to provide a detailed discussion of the process used to design, manufacture, and evaluate wfgSCLs.

METHODS

Fourteen eyes of seven subjects with keratoconus were enrolled and a wfgSCL was designed for each eye. High-contrast visual acuity and visual quality metrics were used to assess the on-eye performance of the lenses.

RESULTS

The wfgSCL provided statistically lower levels of both lower-order root mean square (RMS) (p < 0.001) and higher-order RMS (HORMS) (p < 0.02) than an intermediate spherical equivalent scleral contact lens. The wfgSCL provided lower levels of lower-order RMS than a normal group of well-corrected observers (p << 0.001). However, the wfgSCL does not provide less HORMS than the normal group (p = 0.41). Of the 14 eyes studied, 10 successfully reached the exit criteria, achieving residual HORMS wavefront error less than or within 1 SD of the levels experienced by normal, age-matched subjects. In addition, measures of visual image quality (logVSX, logNS, and logLIB) for the 10 eyes were well distributed within the range of values seen in normal eyes. However, visual performance as measured by high-contrast acuity did not reach normal, age-matched levels, which is in agreement with prior results associated with the acute application of wavefront correction to keratoconic eyes.

CONCLUSIONS

Wavefront-guided scleral contact lenses are capable of optically compensating for the deleterious effects of higher-order aberration concomitant with the disease and can provide visual image quality equivalent to that seen in normal eyes. Longer-duration studies are needed to assess whether the visual system of the highly aberrated eye wearing a wfgSCL is capable of producing visual performance levels typical of the normal population.

Peripheral aberrations and image quality for contact lens correction

PURPOSE

Contact lenses (CLs) reduced the degree of hyperopic field curvature present in myopic eyes and rigid CLs reduced spherocylindrical image blur on the peripheral retina, but their effect on higher order aberrations and overall optical quality of the eye in the peripheral visual field is still unknown. The purpose of our study was to evaluate peripheral wavefront aberrations and image quality across the visual field before and after CL correction.

METHODS

A commercial Hartmann-Shack aberrometer was used to measure ocular wavefront errors in 5° steps out to 30° of eccentricity along the horizontal meridian in uncorrected eyes and when the same eyes are corrected with soft or rigid CLs. Wavefront aberrations and image quality were determined for the full elliptical pupil encountered in off-axis measurements.

RESULTS

Ocular higher order aberrations (HOA) increase away from fovea in the uncorrected eye. Third-order aberrations are larger and increase faster with eccentricity compared with the other HOA. CLs increase all HOA except third-order Zernike terms. Nevertheless, a net increase in image quality across the horizontal visual field for objects located at the foveal far point is achieved with rigid lenses, whereas soft CLs reduce image quality.

CONCLUSIONS

Second-order aberrations limit image quality more than HOA in the periphery. Although second-order aberrations are reduced by CLs, the resulting gain in image quality is partially offset by increased amounts of HOA. To fully realize the benefits of correcting HOA in the peripheral field requires improved correction of second-order aberrations as well.

Validation of a Hartmann-Moiré wavefront sensor with large dynamic range

Our goal was to validate the accuracy, repeatability, sensitivity, and dynamic range of a Hartmann-Moiré (HM) wavefront sensor (PixelOptics, Inc.) designed for ophthalmic applications.

METHODS

Testing apparatus injected a 4 mm diameter monochromatic (532 nm) beam of light into the wavefront sensor for measurement. Controlled amounts of defocus and astigmatism were introduced into the beam with calibrated spherical (-20D to + 18D) and cylindrical (-8D to + 8D) lenses. Repeatability was assessed with three repeated measurements within a 2-minute period.

RESULTS

Correlation coefficients between mean wavefront measurements (n = 3) and expected wavefront vergence for both sphere and cylinder lenses were >0.999. For spherical lenses, the sensor was accurate to within 0.1D over the range from -20D to + 18D. For cylindrical lenses, the sensor was accurate to within 0.1D over the range from -8D to + 8D. The primary limitation to demonstrating an even larger dynamic range was the increasingly critical requirements for optical alignment. Sensitivity to small changes of vergence was constant over the instrument's full dynamic range. Repeatability of measurements for fixed condition was within 0.01D.

CONCLUSION

The Hartmann-Moiré wavefront sensor measures defocus and astigmatism accurately and repeatedly with good sensitivity over a large dynamic range required for ophthalmic applications.

Quality of vision and graft thickness in deep anterior lamellar and penetrating corneal allografts

PURPOSE

To compare visual function after deep anterior lamellar keratoplasty (DALK) with visual function after penetrating keratoplasty (PK) for keratoconus and correlate this with corneal thickness.

DESIGN

Retrospective case series.

METHODS

Twenty-three patients (32 eyes) with unilateral or bilateral DALK or PK for keratoconus were analyzed for visual quality after suture removal. Evaluation included measurement of visual acuity, contrast sensitivity, and higher order aberrations (HOAs) (WaveScan; Visx, Santa Clara, California, USA). Readings were performed with both spectacle and rigid contact lens correction of refractive error. Total and residual stromal thickness after DALK was measured using optical coherence tomography (OCT) and correlated to visual quality.

RESULTS

Eyes after PK had better visual acuity than eyes after DALK (P = .018). Subgroup analysis of DALK eyes revealed that the level of visual acuity was related to the thickness of residual recipient corneal stroma. Eyes with a recipient corneal bed thickness of <20 microm had visual acuities similar to eyes with a PK, whereas those with a recipient thickness of >80 microm had a significantly reduced visual acuity (P = .0009). Contrast sensitivity was similar in DALK and PK eyes. There was no significant difference in HOAs between eyes with DALK or PK.

CONCLUSIONS

These data suggest that the main parameter for good visual function after DALK for keratoconus is the thickness of residual recipient stromal bed. An eye with a DALK with a residual bed of <20 microm can achieve a similar visual result as a PK.

Changes of Ocular Higher Order Aberration in On- and Off-Eye of Rigid Gas Permeable Contact Lenses

PURPOSE

To investigate ocular higher order aberration (HOA) changes caused by rigid gas permeable (RGP) contact lens (CL) wear.

METHODS

Twenty-two eyes of 22 myopic patients and 14 eyes of 14 keratoconic patients who were fitted with an RGP CL were enrolled to examine ocular HOAs using a Hartmann-Shack wavefront sensor before and after RGP wear. Root mean square (RMS) values and Zernike coefficients in RGP-on and RGP-off eyes were compared for both myopic and keratoconic eyes, or between patient groups divided according to their prefitted total HOA value (RMS<0.33 microm or>or=0.33 microm in myopic eyes and RMS<0.46 microm or>or=0.46 microm in keratoconic eyes). All HOA values were recomputed for a 4-mm pupil for comparison purposes.

RESULTS

In keratoconic eyes, RGP CL changed the direction of vertical coma from -0.185 to 0.134 microm (p=0.024). In the low HOA myopic group, total HOA increased from 0.23 to 0.35 microm (p=0.006) by RGP CL wear, mainly due to increased coma aberration from 0.0951 to 0.2146 microm (p=0.006). The direction of vertical coma changed from the inferior to superior cornea in the low HOA group (p=0.020). In the high HOA keratoconic group, total HOA decreased from 0.54 to 0.36 microm (p=0.049), and the direction of the vertical coma changed from the inferior to superior cornea (p=0.049).

CONCLUSIONS

RGP CL wear may enhance or reduce HOA based on original existing ocular aberration mainly through directional changes in vertical coma.

Wavefront Aberrations Associated With the Ferrara Intrastromal Corneal Ring in a Keratoconic Eye

PURPOSE

To describe the optical implications of the aberration pattern of a keratoconic eye implanted with an intrastromal corneal ring (Ferrara ring).

METHODS

A 32-year-old man with bilateral keratoconus had a Ferrara intrastromal corneal ring implanted in his right eye. Surgery was uneventful and both uncorrected (UCVA) and best spectacle-corrected (BSCVA) visual acuity improved. Corneal topography was performed before and after surgery. Wavefront measurements were performed 1 month after the procedure in both eyes for comparison. The point spread function, modulation transfer function (MTF), and convolved acuity chart were analyzed.

RESULTS

The right eye--implanted with the intrastromal Ferrara ring--had high root-mean-square (RMS) values for higher order aberrations. The left eye-keratoconus without an intrastromal ring-had moderate values. Point spread function, MTF, and convolution acuity charts are presented for each eye, with the latter two showing improved visual function in the implanted eye, despite a higher aberration value.

CONCLUSION

The wavefront measurement device captured aberrations even in a highly aberrated eye. Despite better UCVA and BSCVA, the Ferrara ring notably increased higher order aberrations compared to the fellow eye, but with a more uniform central pattern. In this case, the larger RMS value was a poor predictor of good visual function; other metrics better predicted the patient's subjective response. Metrics other than RMS error may be necessary to better correlate aberration value with visual satisfaction in some eyes.

Quality of vision following clinically successful penetrating keratoplasty

PURPOSE

To evaluate visual function following clinically successful penetrating keratoplasty (PKP).

SETTING

Department of Ophthalmology, Ege University, School of Medicine, Izmir, Turkey.

METHODS

Patient group (PG) included 9 patients (12 eyes) who had clinically successful PKP in our department. The control group (CG) included 12 people (18 eyes) who had no ocular disease other than refractive errors. Those with a visual acuity level less than 20/25 were not included in the study. Contrast sensitivity levels and light threshold values of the central retina were measured; scanning-slit corneal topography-pachymetry and aberrometric analysis were performed.

RESULTS

There were no statistical difference in terms of age (32.55 years +/- 9.25 (SD) in PG, 36.75 +/- 5.85 years in CG; P =.53), cylinder power in plus form (2.60 +/- 1.25 diopter (D) in PG, 2.79 D +/- 2.51 D in CG; P =.88), and spherical equivalent of refractive errors (-3.66 +/- 3.57 D in PG, -5.52 +/- 3.37 D in CG; P =.29) between the PG and CG. Cambridge low-contrast grating scores were 96.5 +/- 41.1 in grafted eyes and 148 +/- 27.7 in CG (P =.004). Central retinal light sensitivity was measured as 29.91 +/- 2.39 db in PG and 33.08 +/- 1.56 db in CG (P =.001). In corneal topographic analysis, mean kappa intercept was 0.69 +/- 0.37 mm in PG and 0.55 +/- 0.24 mm in CG (P =.20). Lower-order Zernike root mean squares (RMS) were 7.30 +/- 3.89 microm for PG and 8.58 +/- 3.46 microm for CG (P =.37). However, higher-order Zernike RMS were 2.15 +/- 0.78 in PG and 0.38 +/- 0.10 in CG, which is a statistically significant difference (P<.001).

CONCLUSIONS

Even though the clinically successful PKP patients have correctable amount of spherocylindrical refractive errors with spectacle lenses, they still have reduced visual quality because of the significantly high amount of higher- order aberrations when compared with naturally occurring refractive errors.

Validation of a combined corneal topographer and aberrometer based on Shack-Hartmann wave-front sensing

A corneal aberrometer based on Shack-Hartmann wave-front sensing was developed and validated by using calibrated aspheric surfaces. The aberrometer was found to accurately measure corneal reflective aberrations, from which corneal topography and corneal refractive aberrations were derived. Measurements of reflective aberrations correlated well with theory (R2 = 0.964 to 0.994). The sag error root mean square (RMS) was small, ranging from 0.1 to 0.17 microm for four of the five calibrated surfaces with the fifth at 0.36 microm as a result of residual defocus. Measured refractive aberrations matched with theory and whole-eye aberrometry to within a small fraction of a wavelength. Measurements on three human corneas revealed very large refractive astigmatism (0.65-1.2 microm) and appreciable levels of trefoil (0.08-0.47 microm), coma (0.14-0.19 microm), and spherical aberration (0.18-0.25 microm). The mean values of these aberrations were significantly larger than the RMS in repeated measurements.

Variability of wavefront aberration measurements in small pupil sizes using a clinical Shack-Hartmann aberrometer

BACKGROUND

Recently, instruments for the measurement of wavefront aberration in the living human eye have been widely available for clinical applications. Despite the extensive background experience on wavefront sensing for research purposes, the information derived from such instrumentation in a clinical setting should not be considered a priori precise. We report on the variability of such an instrument at two different pupil sizes.

METHODS

A clinical aberrometer (COAS Wavefront Scienses, Ltd) based on the Shack-Hartmann principle was employed in this study. Fifty consecutive measurements were performed on each right eye of four subjects. We compared the variance of individual Zernike expansion coefficients as determined by the aberrometer with the variance of coefficients calculated using a mathematical method for scaling the expansion coefficients to reconstruct wavefront aberration for a reduced-size pupil.

RESULTS

Wavefront aberration exhibits a marked variance of the order of 0.45 microns near the edge of the pupil whereas the central part appears to be measured more consistently. Dispersion of Zernike expansion coefficients was lower when calculated by the scaling method for a pupil diameter of 3 mm as compared to the one introduced when only the central 3 mm of the Shack - Hartmann image was evaluated. Signal-to-noise ratio was lower for higher order aberrations than for low order coefficients corresponding to the sphero-cylindrical error. For each subject a number of Zernike expansion coefficients was below noise level and should not be considered trustworthy.

CONCLUSION

Wavefront aberration data used in clinical care should not be extracted from a single measurement, which represents only a static snapshot of a dynamically changing aberration pattern. This observation must be taken into account in order to prevent ambiguous conclusions in clinical practice and especially in refractive surgery.

The effect of punctal occlusion on wavefront aberrations in dry eye patients after laser in situ keratomileusis

PURPOSE

To compare the wavefront aberrations in post-laser in situ keratomileusis (LASIK) dry eye patients before and after punctal occlusion.

DESIGN

Prospective, comparative, nonrandomized study.

METHODS

Wavefront aberrometry was performed on 16 eyes of eight patients with dry eyes after LASIK surgery. Wavefront measurements were taken before and 1 month after punctal plug placement and compared with 10 eyes of post-LASIK patients without clinically dry eyes measured twice 1 month apart. Student t tests were used to assess the statistical significance of differences between pre- and post-punctal plug measurements.

RESULTS

Punctal occlusion in the post-LASIK dry eye patients significantly reduced total, lower, and higher order wavefront aberrations by 47% to 63% (P <.01). Among higher-order aberrations, there were significant reductions in coma and spherical aberration but not in trefoil, after punctal occlusion. The reduction of wavefront aberrations by punctal occlusion in post-LASIK dry eye patients resulted in a significant improvement in quantitative visual acuity assessed using an Early Treatment of Diabetic Retinopathy Study chart and in subjective qualitative vision, confirmed by convolutional analysis using image simulation. No statistically significant differences in any of these metrics were found in the post-LASIK control group without clinically dry eyes measured twice at a similar time interval.

CONCLUSIONS

Wavefront aberrometry provides a useful, objective assessment of post-LASIK dry eye patients before and after punctal plug placement. Aggressive treatment of dry eyes may be important before obtaining wavefront measurements that serve as the basis for planning refractive corneal laser treatments and retreatments.

Validation of a clinical Shack-Hartmann aberrometer

PURPOSE

To validate the accuracy, tolerance, and repeatability of the complete ophthalmic analysis system aberrometer (COAS, Wavefront Sciences Inc.) with model eyes and normal human eyes.

METHOD

Model eyes were constructed from six polymethyl methacrylate, single-surface lenses with known characteristics. Accuracy of second-order aberrations was verified by measuring defocus and astigmatism induced by series of spherical and cylindrical trial lenses. Accuracy of higher-order aberrations was evaluated by comparing ray-tracing predictions with measured spherical aberration and coma of the aspheric model eyes. Tolerance to axial and lateral misalignment was measured by controlled displacements of the model eye relative to the aberrometer. Repeatability was tested on the same model eyes with repeated measurements taken within 1 s or within half an hour with realignment between each trial. Analyses were based on a 5-mm pupil diameter.

RESULTS

Defocus and astigmatism were accurately measured within the working range of the instrument automatic focus adjustment (e.g., measured defocus was within +/-0.25 diopters over a -6.50 to +3.00 D range of refractive error). Accuracy of spherical aberration and coma agreed closely with theoretical predictions (e.g., for all six aspheric models, the mean absolute difference between predicted and measured Z(4)0 was 0.007 microm). Axial displacements over the range +/-2.5 mm had little effect on measurements for myopic and emmetropic model eyes. Also, lateral displacements over the range +/-1.5 mm did not produce significant coma. The standard deviations of repeated measurements of higher-order root mean square on model eyes were <1% of the mean with repeated measures within 1 s and 10% of the mean for five individual measurements with realignment in between each. Tolerance to small lateral displacements was also observed for human eyes.

CONCLUSION

The complete ophthalmic analysis system aberrometer can measure second-, third-, and fourth-order aberrations accurately and repeatedly on model eyes.

Hartmann-Shack technique and refraction across the horizontal visual field

We compared refractions across the horizontal visual field, based on different analyses of wave aberration obtained with a Hartmann-Shack instrument. The wave aberrations had been determined for 6-mm-diameter pupils up to at least the sixth Zernike order in five normal subjects [J. Opt. Soc. Am. A 19, 2180 (2002)]. The polynomials were converted into refractions based on 6-mm pupils and second-order Zernike aberrations (6 mm/2nd order), 3-mm pupils and second-order aberrations (3 mm/2nd order), 1-mm pupils and second-order aberrations (1 mm/2nd order), and 6-mm pupils with both second- and fourth-order aberrations (6 mm/4th order). The 3-mm/2nd-order and 6-mm/2nd-order refractions differed by as much as 0.9 D in mean sphere on axis, but the differences reduced markedly toward the edges of the visual field. The cylindrical differences between these two analyses were small at the center of the visual field (<0.3 D) but increased into the periphery to be greater than 1.0 D for some subjects. Much smaller differences in mean sphere and cylinder were found when 3-mm/2nd-order refractions and either the 1-mm/2nd-order refractions or the 6-mm/4th-order refractions were compared. The results suggest that, for determining refractions based on wave aberration data with large pupils, similar results occur by either restricting the analysis to second-order Zernike aberrations with a smaller pupil such as 3 mm or using both second- and fourth-order Zernike aberrations. Since subjective refraction is largely independent of the pupil size under photopic conditions, objective refractions based on either of these analyses may be the most useful.

On-eye measurement of optical performance of rigid gas permeable contact lenses based on ocular and corneal aberrometry

PURPOSE

Our aim was to obtain a complete description of the interactions of rigid gas permeable (RGP) contact lenses with the optics of normal eyes.

METHODS

We measured total and anterior-surface aberrations in four subjects, who were all long-term RGP contact lens wearers. The anterior-surface wave aberration was obtained from videokeratographic elevation maps, and ocular wave aberration was measured with a laser ray-tracing technique. Measurements were performed with and without their own spherical contact lenses.

RESULTS

With this methodology, we evaluated the optical performance with RGP lenses compared with the natural optics. We estimated the contribution of the anterior surface of the contact lens, the internal ocular optics, flexure, and the tear lens aberrations to the optical performance of eyes wearing RGP contact lenses. We found that in three of four subjects, the contact lens significantly improved the natural optics of the eye. For the subject with higher dominance of corneal aberrations, root mean square (second-order and higher) decreased from 1.36 microm to 0.46 microm. Third- and higher-order aberrations decreased from 0.77 microm to 0.39 microm. The internal optics and lens flexure imposed limits on aberration compensation. Spherical RGP contact lenses did not produce spherical aberration potentially due to a compensatory role of the tear lens.

CONCLUSIONS

Aberration measurements are useful to understand the fitting of contact lenses and the interaction with tear, cornea, and internal optics of the eye. Aberrometry can help to choose the best standard RGP lens parameters to improve the optics of individual eyes.

Aberrations of the human eye in visible and near infrared illumination

PURPOSE

In most current aberrometers, near infrared light is used to measure ocular aberrations, whereas in some applications, optical aberration data in the visible range are required. We compared optical aberration measurements using infrared (787 nm) and visible light (543 nm) in a heterogeneous group of subjects to assess whether aberrations are similar in both wavelengths and to estimate experimentally the ocular chromatic focus shift.

METHODS

Ocular aberrations were measured in near infrared and visible light using two different laboratory-developed systems: laser ray tracing (LRT) and Shack-Hartmann. Measurements were conducted on 36 eyes (25 and 11 eyes, respectively), within a wide range of ages (20 to 71 years), refractive errors (-6.00 to +16.50), and optical quality (root mean square wavefront error, excluding defocus, from 0.40 to 9.89 microm). In both systems, wave aberrations were computed from the ray aberrations by modal fitting to a Zernike polynomial base (up to seventh order in laser ray tracing and sixth order in Shack-Hartmann). We compared the Zernike coefficients and the root mean square wavefront error corresponding to different terms between infrared and green illumination.

RESULTS

A Student's t-test performed on the Zernike coefficients indicates that defocus was significantly different in all of the subjects but one. Average focus shift found between 787 nm and 543 nm was 0.72 D. A very small percentage of the remaining coefficients was found to be significantly different: 4.7% of the 825 coefficients (25 eyes with 33 terms) for laser ray tracing and 18.2% of the 275 coefficients (11 eyes with 25 terms) for Shack-Hartmann. Astigmatism was statistically different in 8.3% of the eyes, root mean square wavefront error for third-order aberrations in 16.6%, and spherical aberration (Z4(0)) in 11.1%.

CONCLUSIONS

Aerial images captured using infrared and green light showed noticeable differences. Apart from defocus, this did not affect centroid computations because within the variability of the techniques, estimates of aberrations with infrared were equivalent to those measured with green. In normal eyes, the Longitudinal Chromatic Aberration of the Indiana Chromatic Eye Model can predict the defocus term changes measured experimentally, although the intersubject variability could not be neglected. The largest deviations from the prediction were found on an aphakic eye and on the oldest subject.

Comparison of monochromatic ocular aberrations measured with an objective cross-cylinder aberroscope and a Shack-Hartmann aberrometer

Repeated measures of wavefront aberrations were taken along the line-of-sight of seven eyes using two instruments: an objective, cross-cylinder aberroscope (OA) and a Shack-Hartmann (SH) aberrometer. Both instruments were implemented on the same optical table to facilitate interleaved measurements on the same eyes under similar experimental conditions. Variability of repeated measures of individual coefficients tended to be much greater for OA data than for SH data. Although Zernike coefficients obtained from a single measurement were generally larger when measured with the OA than with the SH, the averages across five trials were often smaller for the OA. The Zernike coefficients obtained from the two instruments were not significantly correlated. Radial modulation-transfer functions and point-spread functions derived from the two sets of measurements were similar for some subjects, but not all. When average Zernike coefficients were used to determine optical quality, the OA indicated superior optics in some eyes, but the reverse trend was true if Zernike coefficients from individual trials were used. Possible reasons for discrepancies between the OA and SH measurements include difference in sampling density, quality of data images, alignment errors, and temporal fluctuations. Multivariate statistical analysis indicated that the SH aberrometer discriminated between subjects much better than did the objective aberroscope.

On-eye evaluation of optical performance of rigid and soft contact lenses

A Shack-Hartmann aberrometer was used to assess the optical performances of eyes corrected with rigid or soft contact lenses compared with spectacles. Metrics of optical quality derived from the measured wave aberrations were consistent with the subjective rating of visual clarity by subjects. Optical aberration analysis illustrated the differences in aberration structures of eyes wearing different optical corrections. For our subjects, correction with a rigid gas-permeable lens yielded significantly better optical quality than did the soft contact lens or spectacle lens. This was due to a reduction in the eye's asymmetric (odd-order) aberrations and a reduction in the amount of the eye's positive spherical aberration. These observations can be explained by theoretical calculations of the aberrations of the eye plus lens optical system. We conclude that aberrometry provides a better understanding of the optical effects of contact lenses in situ and could be useful for optimizing future designs of contact lenses.