Wavefront A Text and Atlas

WAVEFRONT
A Text and Atlas

Wavefront
A Text and Atlas
Editor
Roberto Pinelli MD
Scientific Director
Istituto Laser Microchirurgia Oculare
Brescia, Italy
Foreword
Tangwa Martin Neville
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Wavefront: A Text and Atlas
First Edition: 2014
ISBN 978-93-5152-247-8
Printed at
Dedicated to
All my colleagues
Contributors
Alfredo Vega Estrada MD Luis Antonio Ruiz MD

Ophthalmologist (Cornea and Refractive Surgery) Scientific Director
Division of Ophthalmology Centro Oftalmológico Colombiano
Universidad Miguel Hernández Bogotá, Colombia
Vissum Corporación Oftalmológica
Alicante, Spain Pablo Peña-García MD
Researcher
David S Chu MD Vissum Corporación Oftalmológica
Assistant Professor Division of Ophthalmology
Department of Ophthalmology Universidad Miguel Hernández
University of Medicine and Dentistry of New Jersey (UMDNJ) Alicante, Spain
New Jersey Medical School
New Jersey
Ocular Disease Specialist
Peter S Hersh MD
The Cornea and Laser Eye Institute—Hersh Vision Group Professor
Teaneck, New Jersey, USA Department of Clinical Ophthalmology
Director
Cornea and Refractive Surgery Division
Elena Scaffidi MA
New Jersey Medical School
Clinical Psychologist
The Cornea and Laser Eye Institute—Hersh Vision Group
Vision Psychology Service
Istituto Laser Microchirurgia Oculare Teaneck, New Jersey, USA
Brescia, Italy
Roberto Pinelli MD
Scientific Director
Jesús Andrés Rosas Apráez MD
Professor
Refractive Surgery Unit Brescia, Italy
University Sanitas of Bogotá, Colombia
Tangwa Martin Neville MD
José Luis Güell MD
Brescia, Italy
Professor
Department of Cornea and Refractive Surgery
Istituto de Microchirurgia Ocular Vance Thompson MD
Barcelona, Spain Scientific Director
Refractive Surgery
Vance Thompson Vision
Jorge L Alio MD PhD
Founder of Vissum Corporation Sioux Falls, South Dakota, USA
Professor and
Chairman of Ophthalmology Yazan A Zahran MD
Vissum Corporación Oftalmológica Ophthalmologist and Refractive Surgeon
Alicante, Spain Dr Yazan Zahran Eye Clinic
Amman, Jordan
Juan Pablo Castañeda Borrero MD
Ophthalmic Surgeon Yinfei Xu BS
Clinical Colsanitas SA The Cornea and Laser Vision Institute—Hersh Group
Bogotá, Colombia Teaneck, New Jersey, USA
Foreword
Wavefront: A Text and Atlas will give a personal light to the readers. Personal because it is
showing personal experiences of refractive surgeons, clinical activity, and also, because it is
showing a “panorama” or wavefront and aberrations “planet” without preconcepts, but based
on elementary opinions, descriptions and cases.
To the reader the final judge, hopefully uncontaminated.
Tangwa Martin Neville MD

Brescia, Italy
Preface
In our daily activity, the ophthalmologists as well as the optometrists have dealt with refractive errors—myopia, hyperopia,
presbyopia, and various forms and combinations of astigmatisms. In terms of eye aberrations, they are part of the lower-order
aberrations precisely of the second-order. Lower eye aberrations include piston tilt/prisms which are zero- and first-order,
and together with the second-order are estimated to form 80/85% of all eye aberrations.
The second leg of this topic—the higher-order aberrations, have come into frequent use, and with the advent of and
consolidation of refractive surgery, together with the commercialization of aberrometers. further knowledge and insight into
these aberrations has been attained.
However, aberrations are newcomer in our language and practice. The effort herein, which is quite elementary seeks to deal
with and offer a handy consultation atlas, simple to read and easier to consult in our offices. While lower-order aberrations are
manageable with spectacle glasses, contact lenses and refractive surgery. higher-order aberrations though quite known and
understood still have treatment far from offhand.
In the atlas, the readers will find a fluent descriptive part, some clinical examples and cases. At the end of all, a few graphical
elaborations and clinical pictures retrieved from present and updated literature. The topic is in full debate and evolution.
My desire was that simple—provide a manual and I hope that I have met the task.
Roberto Pinelli
Acknowledgment
Special thank to the entire team of Istituto Laser Microchirurgia Oculare, Brescia, Italy.
Contents
Section 1 the Project of Vision: Hypothesis for a Functional Structure
1. A New Winning Philosophy 3

Roberto Pinelli
• The Vision Institute 3
• Structure of the New Vision Institute 4
– The Medical Staff 4
– The Front Desk Staffm 4
– The External Relations Department between Information and Marketing 5
– Breaking News: The Patient Care Staff 7
• A Management Hypothesis on Daily Briefing: Contacts between Medical
and Nonmedical Staff (Analyzing the Daily Patients’ Agenda) 7
2. Highlights on Statistics and Clinical Research 10

Roberto Pinelli
• External Relations for Surgical and Clinical News 10
• Cooperation with National and International Scientific Societies 11
3. New Operative Tools to Improve the Structure 14

Elena Scaffidi
• Psychology of Vision 14
– Specificity of the Ophthalmic Setting 14
– Introducing the Concept of Satisfaction as a Multidimensional Variable 17
• Evaluation of Patient’s Satisfaction Questionnaire 19
– Preliminary Phase: Investigation Objectives 20
– Executive Plan 21
– Execution 24
Section 2 Overview
4. Eye Aberrations: Overview 29

• Clinical Controller—Istituto Laser Microchirurgia Oculare 29
5. An Approach to the Wavefront Technology: Aberrometry Basis 32

Jesús Andrés Rosas Apráez, Juan Pablo Castañeda Borrero, Luis Antonio Ruiz
• Overview and History 32
• Zernike Polynomials 34
• Constant Aberrations 35
• Low Order Aberrations 35
xvi Wavefront: A Text and Atlas
• Higher-Order Aberrations 36
– Objective Visual Quality Measures 38
– Pupil Level 38
– Retinal Level 39
– Aberrometry Limitations 40
– Tear Film 40
– Pupil Size 40
– Chromatic Aberration 40
– Aberrometer Sensors Resolution 40
6. Wavefront Aberrations from A to Z 43

Yazan A Zahran
• Factors Affect the Optical Quality of the Retinal Image 43
– Wavefront Basics 43
– Classification of Aberrations 44
– Representing Wavefront Aberrations 45
– Measurement of Wavefront Aberrations 45
– Metrics to Define Image Quality 46
– Relationships between Wavefront Aberrations,
Point Spread Function and Optical Transfer Function 49
7. Basic Wavefront Optics and Ocular Aberrations 52

Vance Thompson
• Wavefront Technology in Clinical Practice 52
• Wavefront Measuring Devices: Aberrometers 53
• Analysis of the Wavefront Data 55
Section 3 Clinical Cases
8. Corneal Aberrometry Changes Following Intracorneal Ring Segment Implantation 67

Jorge L Alio, Alfredo Vega Estrada, Pablo Peña-García
9. Monocular Diplopia 79
José Luis Güell
10. Wavefront Analysis and Scheimpflug Imagery in Diagnosis of Anterior Lenticonus 84

Peter S Hersh, Yinfei Xu, David S Chu
11. P-curve Clinical Cases 90

Roberto Pinelli
Section 4 Atlas
12. Wavefront Basic Images 119

Roberto Pinelli
• Why this Simple and Emblematic Atlas? 119
Index 123
SECTION 1
The Project of Vision:
Hypothesis for a
Functional Structure
1. A New Winning Philosophy

Roberto Pinelli
2. Highlights on Statistics and Clinical Research

Roberto Pinelli
3. New Operative Tools to Improve the Structure

Elena Scaffidi
CHAPTER 1 Roberto Pinelli
A New Winning Philosophy
THE VISION INSTITUTE

Why do we describe ourselves as a ‘vision institute’ and not
a ‘refractive surgery center’ or a general ‘ophthalmology
institute’.?
We refer to our center [the Istituto Laser Microchirurgia
Oculare (Fig. 1)] as a ‘vision institute’: Refractive surgery
represents its core business, but there are many other
professionals involved who make their contribution to offer
an excellent service from multidisciplinary perspectives in
the vision field.
A vision institute is a health center entirely devoted to vision
in all its aspects. All types of visual defect are treated by means
of refractive surgery, employing a wide range of technology
and a multidisciplinary medical and nonmedical team.
In addition, ophthalmological diseases are treated
in accordance with the latest protocols. In this way, the
ophthalmic patient is followed in each phase of his/her life,
and can take the institute as a point of reference for ophthalmic
health throughout life. Let us consider for example, a patient,
35-year-old, with –15D sph., –2D cyl. in both eyes.
His myopia can be resolved by implanting a phakic IOL,
and the astigmatism can be subsequently dealt with by means
of LASIK or ASA.
When he turns 60, he might develop a cataract: The phakic
IOL can be removed at this point and substituted with an arti
ficial lens through phacoemulsification. Presbyopia could be
solved by the use of an accommodative IOL, or through corneal
surgery (CK or P-curve) subsequent to lens implantation. If
the patient presents any kind of problem with the health of his Fig. 1: Crystal palace, seat of the Istituto Laser Microchirurgia Oculare
4 The Project of Vision: Hypothesis for a Functional Structure
eyes (retina, glaucoma, etc.), the vision institute offers him a

state-of-the-art center at the forefront of research where he can
be confident of receiving treatment from specialists who are
continually updating their expertise.
Furthermore, the patient will be followed each step of the
way by the psychologist who will monitor his/her emotional
situation throughout, and will provide help in facing up to
the changes that refractive surgery or a medical therapy may
provoke not only without, but also within.
Thus, it is that vision in all its multifaceted meanings is to
be considered the true core business of the institute, above
and beyond ‘mere’ refractive surgery or ophthalmology.
SECTION
STRUCTURE OF THE NEW VISION

1
INSTITUTE Fig. 2: The entrance of the institute
The Medical Staff his name, offering a seat, a refreshing drink, and a choice of
The medical staff within a vision institute comprises a magazines (Fig. 2).
number of professionals with different roles. Duties should On the occasion of the first examination at the Institute,
be specifically allocated among each member of the medical for example, the patient is invited to answer some questions
staff in order that the different aspects of ophthalmology are relating to his personal details with the help of the FD staff,
covered. whose duty is also to administer a questionnaire called the
The main aim of the assistants in ophthalmology is to ‘Questionnaire of symptoms’ edited in collaboration with the
clarify all the possible doubts that can arise for patients Center for Functional Nutrition for Longevity.
concerning their visual situation, analyzing it through the The answers to the questionnaire allow the surgeon to gain
most innovative technologies. Furthermore, we believe that a better understanding of the relationship between the visual
it is of primary importance to establish a relationship based condition of the patient and his general state of health and to
on reliance with the patient, to make him feel at ease in each provide more appropriate and customized instructions.
moment of his/her transit through the institute. The FD staff is personally involved in the internal organiza
In conclusion, professionalism should always be accom tion of the Institute: It has to schedule the agendas in an
panied by strong interpersonal skills, and for this reason we optimum way, striving to reduce waiting times during agenda
firmly believe nonmedical staff members should be fully management, daily consultations and surgery. Only this way
trained in this area, stimulating the sense of belonging to a we can obtain efficient team work that enables the best results
team united in the same purpose. to be achieved. This implies not only a good knowledge of the
duties of the entire staff, but also the ability to anticipate the
outcome of a visit, thereby planning its duration allocated in
The Front Desk Staff the agenda (Fig. 3).
The first impression that patients have of the Institute is of In general the day comprises general and preoperative
paramount importance, since it initiates a complex series of examinations and check-ups (postoperative and others),
judgments that will ideally remain positive in nature. scheduled in the agenda on the basis of the surgery conducted.
As soon as the patient enters the Institute he evaluates Having set out the surgical calendar, the examination days
the setting, the courtesy of the staff, and their willingness to are planned. Normally no examinations are scheduled
help. He also immediately realizes who it is that he can refer during surgery day, in order that the whole staff (clinical
to, as the Front Desk (FD) and Patient Care (PC) staff wear and nonclinical), can devote themselves entirely to patient
a uniform providing a constant and unmistakable point of management. Even the day after surgery is organized so that
reference for the patient. the first part of the morning is reserved for those patients
It may sound trivial but the uniform is an essential aspect operated on the previous day.
of those staff members who are the first to come into direct Together with this procedure the FD staff has to be able
contact with the patient (such as Front Desk and Patient Care to manage all the incoming calls: Some of these may involve
staff). altering the day or time of a fixed appointment, but most
The FD staff must help the patient to feel comfortable and of them egard refractive surgery. The callers usually ask for
at ease, always welcoming him with a smile and remembering information regarding: Time needed to fix a consultation,
A New Winning Philosophy 5
CHAPTER
1
Fig. 3: The front desk with part of the staff Fig. 4: The external relations department
What to do before the consultation, Cost of the visit and the As far as a health company is concerned, marketing still
time required for surgery if it is deemed appropriate. remains an important expense, but some qualifications are
It is obvious that the more we communicate with our necessary. First of all, it must be clear what we are talking
callers the more open and honest will be the exchange of about. We are not discussing marketing in a public health
information. It is also important to underline that sometimes environment, such as a hospital or an emergency room for
aspiring patients, are not necessarily good candidates for example. What leads people towards these places is necessity
surgery—(see physical/clinical and motivational require or urgency (pain, a sudden health problem, or the need for
ments assessed by the clinical and patient care staff). special services that only large public services can offer). This
The role of the FD staff is to be helpful, informative, kind of health service cannot be compared to a private one, if
relaxed, and cheerful where appropriate, but most of all we consider dimensions and core business.
The topic that we want to analyze in this chapter is
they must possess a high degree of knowledge pertaining to
marketing in a private health company that offers those
of the specific subject and must transmit confidence: Only
services and practices that are not “urgent”, that are not
this way can one hope to gently persuade the patient to
geared towards saving a patient’s life. Of course, such health
make an appointment for a consultation, without imposing
centers offer clinical practices that undoubtedly greatly
any pressure so to do. FD staff must be able to discover, improve a patient’s quality of life, but they are not of primary
analyze and recognize patients emotional needs, state, fears, importance for the continuation of life.
frustrations and be able to play an active role in the patient’s In this specific case, we aim to analyze the distinctive
exploration of options regarding refractive surgery. It may qualities of the external relations department of a vision
seem trivial, but not only does the choice of words used play institute, which offers different services and technologies to
an important role, but also the voice of the person speaking restore patients’ vision. The external relations department
with the patient to establish communication. The importance must constantly maintain a fine balance between the need to
of establishing true communication is highlighted in the promote services offered by the institute and the necessity to
preoperative phase during the interview with the PC staff. abide by the dictates of the law in this delicate matter. We will
start by analyzing the Italian regulations for publicity in health.
The External Relations Department The ethical code of conduct in professional practice of
Between Information and Marketing 1999 sums up the main legal concepts regarding publicity in
health (which was the modification of a previous and more
Marketing is one of the most important elements in a private stringent law of 1992). It has been reported previously and
company, and a portion of the budget needs to be constantly gives us a clear idea of what the general trend of the law in
allocated to it. Italy is: The medical doctor, in this case the refractive surgeon,
A precise yearly plan regarding the use of the media to shall not promote the public or private heath structure where
market the company services and products is fundamental he/she professionally operates, through the most common
for attracting customers and ensuring that the company media (newspapers, magazines, television). Information
reaches, and stays in, the public eye (Fig. 4). in the health sector may not present any of the typical
‘Services Chart’ of his private company without needing any

permission to do so.
What is the most delicate issue in the external relations
department of an innovative center such as a full service
vision institute? The balance between scientific information
(characterized by specificity of terms, mathematical and
statistical analysis of data, and for this reason not really
attractive to the public) and marketing (characterized on
the contrary by a fresh and user-friendly language, colored
pictures, easy concepts). This balance is sometimes very hard
to find.
Concepts Vital to Every Marketing Initiative

SECTION
• Professionalism
1
• High quality standards in all services offered

• Innovative technologies
• Particular and significant attention to the patient
• The patient is the center and always remains at the center
• Particular attention to national and international research
• Constant attention to contact with other similar centers in
the world.
How can we Transmit all these Concepts

Attractively and yet Still Abide by the Law?
Newspapers and Magazines
Articles appearing in local and national reviews are an
excellent marketing tool that allow the surgeon and his
Fig. 5: Services information about the institute institute to become known in his geographical and historical
context. These articles must always be perfectly balanced in
the sense that they must be easy to read but full of information.
features of commercial publicity (Fig. 5). This is meant, of
They must attract the reader’s attention (through beautiful
course, to guarantee a professional health system to all the
pictures, for example, that do not bring the mind to ‘scary
citizens, avoiding the possibility that financial enterprise in
scenarios’ often seen in the news), and keep the attention
health services could mitigate against quality in these same
gained by providing useful and interesting information in a
services. It is, of course, correct to regulate the marketing and
the publicity in such a delicate area, considering that often fresh way. Language is of primary and absolute importance:
people’s lives depend on the quality of the services they get in Nowadays readers are usually quite well informed, so they
hospitals or in private health companies. need to read texts written in an appropriate manner. On the
As mentioned, the regulation in 1992 was even more other hand, the vocabulary used in the scientific reviews is
stringent: The only kind of publicity allowed was the often incomprehensible, and it would not fit a ‘softer’ contest
doorplate (with the name of the doctor and his/her academic such as a normal magazine (Fig. 6).
titles) and informative articles only in sector publications.
Television
Furthermore, even the doorplate had to be approved by the
Public Body and by the local Medical Board Association. Television (TV) represents a powerful tool in marketing.
In 1999 the law relaxed somewhat, additionally allowing There are many programs that concentrate on health, inviting
doctors to publicise in any general magazine, including those nationally well-known professionals to discuss different
publications that we usually find in bookshops. This made problems or new therapies or technologies in various fields
things easier for those companies that offered private health of medicine. Participation in these programs (usually greatly
services, who could now use the media in a different and appreciated by the public) is usually part of a planned
more profitable way. marketing strategy. In fact, it allows the institute to become
Of course, the doctor is not completely free of bias and very well known in a short time and over a large area. It is not
cannot say or write anything he likes in any newspaper or possible (because of the previously discussed regulations)
magazine, but now he has the possibility of publishing the to display the name of the vision center on air. This is why,
CHAPTER
1
Fig. 6: An article about the institute published on a local newspaper
before investing in TV presence, it is important to have a solid Confirmation of a patient’s suitability for surgery is
and sound reputation and to occupy a prominent position on therefore made via an appropriate assessment of his/her
the web in order to be found easily. motivation.
To evaluate the patient’s motivation for the surgery the
Breaking News: The Patient Care Staff Patient Care staff must pay attention to his behavior during
the consultation, assessing his expectations, doubts, desires
The patients themselves have often painted an eloquent and fears. To overcome fears of surgery for example, it is
picture when describing the PC staff, whose principal necessary to describe the procedure step by step to the
characteristic is to offer the recognized value of a point of patient, using appropriate terminology, method and tone
reference: A light at the end of the tunnel, a mountain guide, of voice. It can also prove valuable to refer to the fact that
and a tutor. some of the staff of the institute have also undergone eye
The PC staff plays an essential role in an Institute devoted surgery.
to the correction of visual defects. Its main aim is to provide
patients with accurate and comprehensive information
regarding surgery, often with a view to clearing up the
A MANAGEMENT HYPOTHESIS ON DAILY
confusion patients frequently have on the subject. BRIEFING: CONTACTS BETWEEN MEDICAL
One of the main prerogatives of the Institute is to assist the AND NONMEDICAL STAFF (ANALYZING
patient affected by a visual problem or defect right through
from the very first preoperative consultation to the last THE DAILY PATIENTS’ AGENDA)
postoperative examination. At the Istituto Laser Microchirurgia Oculare (ILMO) the day
The PC staff aims to help the patient to understand his begins with a ‘briefing’ concerning the patients scheduled
personal visual situation, his desires, his expectations and in the agenda (Fig. 7). All staff members must attend, even
must also satisfy his requests and answer any questions he those who do not normally come into direct contact with
may have concerning surgery. patients (for example the External Relations staff).The ILMO
Assuming the patient’s clinical suitability, could a patient is of the firm conviction that anything concerning the work of
nevertheless not reflect suitable ‘psychological parameters’ the Institute involves everyone who works for it.
and have expectations which are incompatible with the It is evident that people bringing different knowledge and
results that refractive surgery could offer? different professions working in the same center can represent
SECTION
1
Fig. 7: The staff gathered in

the meeting room
a wide gamut of important resources to meet patient’s needs

and can foster a co-operative working atmosphere.
This briefing allows the medical staff to enjoy a mutual
exchange of ideas with the nonmedical staff and to strive to
reach the optimal solution for each patient.
The FD (PC) staff knows much about the patient, not only
through what is written in his case history (taken when he first
came to the Institute) but also has an understanding of his
true needs and whether he has particular fears, expectations
or anxieties. Such elements can help the medical staff to
satisfy such needs.
What makes the relationship between the medical and
nonmedical staff relevant is that the FD staff is constantly
evaluating and streamlining the management of timing
during daily consultations with the consequence that patient
waiting times are reduced (Fig. 8).
The role of the FD staff is also to organize the movement of
the patients within the Institute and thereby avoid bottleneck
situations (often arising from high patient numbers) both in
the waiting rooms and other areas. When patients arrive they
are split into two waiting rooms and it is the task of the front
desk staff to make note of those present and direct them to the
appropriate examination rooms.
The logistics of patient management during surgery times
changes rhythm fundamentally with respect to examination
days. One of the two waiting rooms is dedicated to patients
awaiting surgery and their accompanying persons; the
other room is appropriately darkened to prevent any
intense external light entering (an immediate postoperative
requirement). This room is designed to receive the patient Fig. 8: Meetings take place to discuss the schedule of the day
after surgery, providing a reserved space which is calm somebody to talk to, and before speaking to the Patient
and relaxing, where some time can be spent with those Care staff (devoted to that very task) he can be sure that he
accompanying him, before they leave the Institute. is speaking to somebody who immediately understands him,
The medical staff has a great influence on the work of and when and what kind of surgery he had. We could even
the FD because it can provide key education and training to talk of an ‘art of listening’ that characterizes the FD (and
impart specific knowledge which will prove especially useful Patient Care staff). Not least because another vital aim is that
when talking to the patient regarding treatment following of being able to recognize, from a description of symptoms
the consultations or when managing patient needs in the on the phone, any potential complications (after surgery or
immediate postoperative phase. During this particular after therapy) and so be in a position to provide appropriate
phase, the patient needs to have a point of reference, medical advice.
CHAPTER
1
Highlights on Statistics
and Clinical Research
such ideas in the light of the institute’s own geographical,

EXTERNAL RELATIONS FOR SURGICAL cultural and social setting.
AND CLINICAL NEWS As we have seen, it is of primary importance to pay
A continuous updating regarding both the latest technology particular attention to the scientific publications for many
and the results of research being conducted in other eye reasons. Here are some practical suggestions to make the
surgery centers in the world is surely one of the key factors most of them:
contributing to the success of the vision institute. This is of • First of all, the office manager of the institute should make
primary importance for several reasons: sure that the institute subscribes to all the important, high-
• Being at the forefront in terms of the latest ophthalmology impact scientific journals. Some of these are strictly linked
treatments and state-of-the-art technology means that to scientific societies, and the subscription is automatic
the institute provides a point of reference for all patients, when the senior surgeon or a member of the staff joins
who over time appreciate that the institute is indeed a full the relevant society. Those journals whose subscriptions
service vision center that employs the latest technology are not contingent upon society membership can be
and treatment for any possible ophthalmic disease. readily subscribed to online or by contacting the publisher
• To maintain contact with other eye centers worldwide, it directly. Many journals are also available online, and
is essential to be updated in the different research fields anybody can subscribe to a newsletter service that will
in ophthalmology. Moreover, it is very useful to compare automatically send to the requestor a regular summary
one’s own results with those of colleagues, in order to of the main topics dealt with in each issue as and when it
improve one’s own services and ensure that the institute is published. In some cases it is possible to choose one’s
plays a significant role of at world level. favorite topics and receive articles on those very topics on
• Very often, in the scientific peer-reviewed journals in a regular basis by e-mail.
ophthalmology one can find interesting suggestions for • Once the journals are in the institute they should be
the internal organization of the center from the marketing systematically reviewed by a designated staff member.
and administrative point of view (Fig. 1). Sometimes, A practical suggestion could be for example to copy
expert administrators in the ophthalmic fields write or the most interesting articles and distribute them to the
edit dedicated sections in such publications, offering well appropriate department. In this way each member of
thought-out advice and describing existing exemplary the staff can be kept updated about the latest issues in
models of vision centers. It is therefore important to study ophthalmology with a particular emphasis on his or her
all the scientific publications carefully in order to draw own job. A knowledge of English is, of course, of primary
inspiration from those innovations that could improve importance, as all the international scientific journals are
the internal organization of the institute, reinterpreting published in English.
02.indd 10 29-03-2014 10:28:45

Highlights on Statistics and Clinical Research 11
CHAPTER
2
Fig. 1: Some of the most important journals about refractive surgery
• Furthermore, it is useful to devote a period in the weekly

or monthly schedule of the institute (depending on the
surgical and examination agendas) to a discussion of those
articles, in a ‘journal club’. Each member of the staff can
periodically choose a topic, collect the most interesting
articles and describe it to the colleagues from a critical
point of view. It offers the whole team a chance to discuss
and acquire knowledge about the colleague’s department,
and to gain a wider view of the topic as a result of studying
international contributions to research in the sector.
So far, we have only discussed the scientific periodical
publications in ophthalmology. Equal attention should
obviously be paid to books and other texts. The web offers
an incredible opportunity to become aware of the staggering
number of publications that exist in the world (Fig. 2). For
a vision institute it is also important to participate actively
in the publications in ophthalmology. Articles and chapters
in texts produced by our institute colleagues are important
elements in maintaining a high level and profile.
Clinical results and the scientific research conducted by
the senior surgeon and their team must be collected, analyzed
and processed by the statistics department and technical
writers. Articles and texts must be written in the correct style,
they should be evidence-based and graphs and tables should
be employed when presenting quantitative research data.
COOPERATION WITH NATIONAL AND

INTERNATIONAL SCIENTIFIC SOCIETIES
There are several international scientific societies in the Fig. 2: The most relevant scientific societies organize many
world dedicated to ophthalmology. The most important are: international congresses during the year
02.indd 11 29-03-2014 10:28:46

ASCRS, ESCRS, AAO, ISRS, APAO. In addition, there are the instructor or coinstructor requires thorough and efficient
local scientific societies, always of great importance: For Italy organization in advance. In fact, abstracts usually have to
there is the SOI (Società Oftalmologica Italiana, which organizes be presented months before the congress, in order to give
a national and an international symposium every year). the scientific committee the opportunity to evaluate them
All these scientific societies (Fig. 3) organize one or two all and choose the most significant. Sometimes the abstract
meetings every year (usually one), which represent occasions has to be written considering the clinical results that the
of fundamental importance whereby the surgeon and the institute will be able to collect in the following 4–6 months.
whole staff of the vision institute can come into direct contact The typical structure of the abstract can be summarized
with other situations, services and professionals existing as follows: Title—Objective/Purpose—Methods—Results
worldwide. This is of key importance because: —Conclusions. The important thing to keep in mind is
• The surgeon can present their clinical results, and also that each scientific society has its own rules for writing
their discoveries and ideas concerning refractive surgery an abstract (number of words, elements required…).
and ophthalmology in general to fellow colleagues at Handouts represent another important aspect to be taken
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international symposia (Fig. 4). This process of presenting care of in arranging one’s participation at a congress. They
a lecture, or of holding an instructional course as senior should be sent to the society some weeks in advance in
1
Fig. 3: Some important scientific societies related to refractive surgery
Fig. 4: A session of the 1st World Vision Surgery Symposium in June 2007
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Highlights on Statistics and Clinical Research 13
CHAPTER
2
Fig. 5: The preparation of the 1st World Vision Surgery Symposium
order to have them copied and distributed, before, during market all in once place, buying samples of them and
or after the course attended. finding innovative solutions for the institute at different
• During these occasions, the surgeon has the chance to levels (Fig. 5).
attend the colleagues’ courses and lectures, comparing • Furthermore, international congresses represent the
his/her results to theirs, with interesting observations. best occasion to meet people operating in the field of
• At such international events, many companies operating ophthalmology, leading to fruitful cooperation and forging
in the main branches of ophthalmology hire booths in beautiful friendships, in particular during the cocktails,
the convention centers. This represents an interesting lunches and dinners organized by the society itself for this
occasion to personally see the newest products on the very purpose.
02.indd 13 29-03-2014 10:28:47

CHAPTER 3 Elena Scaffidi
New Operative Tools to

Improve the Structure
PSYCHOLOGY OF VISION
Specificity of the Ophthalmic Setting
Is Psychology of Vision a Mere Branch of
Experimental Psychology?
It is often popularly believed that psychology of vision is
simply a branch of experimental psychology. This is partially
true, if we consider that over the last century vision has
attracted the interest of psychologists primarily in terms of
its functions and the search for correlations between eye and
brain.
The eye was at the time considered to be a simple optical
instrument, whose function was explicable in terms of
cerebral mechanisms (Fig. 1).
Sight is so familiar and apparently so easy that it only takes Fig. 1: Psychology of vision is not simply a branch of
a little imagination to realize that the eyes, insofar as the experimental psychology
visual processes is made possible, pose an extremely difficult
problem for the brain to solve.
A series of different paradigms have been proposed to of vision, there are nevertheless many other aspects of a
explain the fascinating phenomenon of vision, all ascribable psychological nature which cannot avoid being assessed and
to different theories of perception. The German Herman interpreted in a vision institute where a variety of persons
von Helmholtz (1821–1894), physiologist, physician and are seen on a daily basis. Along with a vision defect and the
psychologist, was the first to describe perceptions as desire to correct it, they also bring with them their social
‘unconscious inferences’ that link sensory data to external background, their culture, their (sometimes unshakeable)
reality. This concept introduces the possibility that a subjective certainties, their needs and their fears.
experience could play a significant role in perceiving one’s Not to take these aspects into account is tantamount
surroundings and that there could be different variables that to thinking of the patient as just a pair of eyes and not as a
influence how we think about our visual capacity. wholly unique individual whose motivations, expectations,
Besides the above huge body of research that has, and still and meaning embraced by his decisions within their wider
is, being conducted into the perceptual and sensory aspects life context may well differ enormously from those of any
03.indd 14 29-03-2014 10:30:26

New Operative Tools to Improve the Structure 15
other individual. In this case we have moved into the area of • Information (about his visual problem, about surgery,
vision psychology. about his own health conditions, about pre- and
postoperative phases, etc.).
What is the Relation between Psyche and Vision? • Prejudices, stereotypes (influenced by social culture,
academic culture, personal history, other people stories,
Vision and mind are strongly connected for different reasons: etc.).
• There is a great difference between an objective perception • Personal needs, visual needs, relationship needs
and a subjective perception. (important to investigate other aspects of his life to
• Different aspects of our daily life use vision to access the evaluate what he is looking for with surgery).
symbolic function of individuals to use representations: The above aspects must be examined from a multidis-
Memory, dreams, reading, thinking, hearing, music, etc. ciplinary perspective during the preoperative consultation
• Most people consider vision to be the most important by all the professionals who meet the patient (OD's, refractive
sense, which allows us to move in life and to distinguish surgeon, nurse). They are then reassessed and confirmed or
CHAPTER
persons, events, and behaviors. disconfirmed by the patient counselor during a subsequent
That is why when faced with a new patient it is mandatory interview which is specifically geared towards ensuring that
3
to proceed with the assessment of subjective dimensions, the health professionals are fully aware of these factors—
such as: which represent important parameters when assessing the
• Personality traits (e.g. the obsessive and/or compulsive, physiological suitability of the patient for surgery—and is
depressed, paranoid patient). also aimed at evaluating the patient’s level of information
• Cognitions (what he was told about his problem and its and ascertaining that he has been informed of all the facts
solutions—other people’s experiences, other doctors’ regarding his personal visual situation and fully understands
advice, etc.). the reason why LASIK is considered the best tool to solve his
• Cognitive mechanism (what is the process he most visual problem (Fig. 2).
frequently uses to process information and how emotions These skilled professionals have been trained to assess
are integrated with rationality). these variables by the vision psychologist who can play an
Fig. 2: Diagnostic area
03.indd 15 29-03-2014 10:30:27

active role in the process of assessment but, more frequently, The Assessment of Motivation, Expectations and
is to be considered an internal resource, a ‘coach’ of the
Level of Information
personnel.
It is also very important to remember that LASIK surgery Remember that the patient must be gently interviewed without
is not always mandatory. People can continue to live their giving him the impression of being under investigation. He
own lives wearing glasses or contact lenses. So the gravity must be offered the chance to speak openly and freely with
of the visual defect can be considered in some cases to an expert who is able to answer his questions and provide
demarcate the border line that will justify the patient’s asking information that will enable him to arrive at a conscious and
for surgery. mature decision regarding accessing LASIK surgery (Fig. 3).
It can be useful to have an internal checklist of aspects to
Does the patient need to undergo surgery? be verified during the interview with our patient:
• Visual impairment can be corrected only with surgery. • Motivations (why does the patient ask for surgery?).
• Limitation of subjective feeling of individual potential as a • Expectations (are they realistic? Does he imagine he will
SECTION
person (at work, within the family environment, with other develop ‘super-human vision’? What can he really get from
people, very much linked to self-esteem). surgery and what is beyond the limits of being realistically
1
• Patient feels justified in asking for surgery. possible?).

• Level of information (do not give up if the patients seems
Or does he ‘simply’ desire it? not to need any information; explain the nature of his
• How to match the realization of a desire with the feeling of vision defect and any differences from other cases/surgical
personal responsibility towards the difficult choice to have approaches).
surgery when it may not be necessary? • Myths and preconceptions (interview the patient about
• Social support (what do the patient’s relatives think about his family and friends experiences about vision, surgery;
surgery? Do they agree and advise the patient or are they lead him to talk about blindness, and try to understand
against it?). whether he is frightened or concerned, even if he does not
• Pros and cons evaluation (risks vs. benefits). openly talk about or express emotions).
• Is the surgery aimed at solving an aesthetic problem or a • Thoughts and emotions (remember that in human beings
functional problem? what we think is powerfully influenced by what we feel!).
Fig. 3: The first meeting with the patient care
03.indd 16 29-03-2014 10:30:27

What the Patient Fears and does not have the be necessary to make him aware of the rare, but sometimes
possible, inconveniences that can occur during surgery. We
Courage to Ask?
need to build a relationship based on mutual respect and
The above procedure is the first step towards obtaining trust. For the patient, to understand that his surgeon and
the patient’s informed consent. He knows very well that a the personnel of the institute he has chosen is always open
document will be given to him before surgery and sometimes to listen to him and ready to reply to his needs is the best
he does not exactly understand what it is for. Even though the guarantee to foster the patient's trust.
patient does not ask openly, I believe it is very important to
talk to the patient about what informed consent is and what
it is not, so that before leaving the ophthalmic center he fully
Introducing the Concept of Satisfaction
understands that it is a process which provides information as a Multidimensional Variable
and develops awareness in order that he may, of his own free
will, decide whether or not to undergo surgery. Furthermore, The Evaluation of Satisfaction: What is it for?
CHAPTER
he should understand that it is not a legal disclaimer merely
designed to protect the surgeon. Tell your patient that the Patient satisfaction and quality of life are both patient-
3
surgeon is always responsible for his professional decisions centered subjective endpoints. Quality of life depends on
and behaviors, and that any responsibility the surgeon may medical and psychological factors. Satisfaction with care
bear for malpractice would in no way be invalidated by relies on the different features of the health care received.
signing the informed consent document (Fig. 4). Whereas health care managers are long accustomed to
The innermost concern of any individual about to embark patient satisfaction assessment, clinicians are, by contrast,
upon ophthalmic surgery is that of permanently losing his more familiar with the subjective measure of quality of life.
sight. Only some of our patients are able to make this fear The former are especially concerned with ensuring the
explicit, whereas others are socially convinced that is neither competitiveness of the health care service, regarding patient
appropriate nor elegant to bombard the doctor with questions satisfaction data as a marketing tool. The latter are, on the
(after all, the doctor is supposed to be the expert) and also other hand, interested in evaluating the effectiveness of
may believe that a direct question could be judged as a therapies, supplementing this assessment with quality of life
psychological weakness on the part of the patient. The reality data (Fig. 5).
is that all have the same concern. So do not avoid touching Only recently in clinical research have surgeons also
on this point during patient counseling. In addition it will obtained valuable information from patient satisfaction
Fig. 4: The patient’s informed consent
03.indd 17 29-03-2014 10:30:28

SECTION
1
Fig. 5: The evaluation of clinical and patient satisfaction data
assessment. This variable may be viewed as a significant

determinant of quality of life.
Patient Satisfaction and Quality of Life Evaluation

Factors involved in patient perception of QoL
Medical = type and stage of disease, type of treatment
Psychosocial = coping mechanism, family support, socioeconomic
status
Factors involved in patient perception of satisfaction
Health care received = structure of care, process of care, outcomes
Satisfaction with Surgery = Good Quality of Vision?

In every medical setting exploring the association between
patient satisfaction and health-related quality of life is
complex. There is not necessarily a unidirectional causal
relationship between patient satisfaction and clinical out-
come. Patient satisfaction may also be seen as a consequence
of improved quality of life or health status.
To this extent, refractive surgery is quite a unique field
because it is almost universally acknowledged that a person
with a visual defect cannot be considered an ill patient. Also it
is no longer controversial that some individuals can perceive
themselves as highly damaged by their visual impairment
from a functional, aesthetic, behavioral and psychological
point of view (Fig. 6).
Thus it is that we find ourselves far more frequently
referring to nonpathological patients whose resolution or
amelioration of their visual defects can ease their own lives. Fig. 6: The laser room
03.indd 18 29-03-2014 10:30:29

In our comprehensive vision surgery institute we are Conceptual Questions Raised in the 3 Focus Groups
told on a daily basis of satisfaction for the care received as
• What does patient satisfaction mean?
reported by the patients. Nevertheless we have noticed that
some apparent incongruities are still present. For instance, • W
hat is the relationship between patients’ experience,
why does an individual with a postoperative outcome who expectations and satisfaction ratings?
has been assessed as an ‘8’ declare himself happier than • W
hat are the appropriate objects (components) for assessing
does a patient whose postoperative outcomes is rated ‘10’? satisfaction for refractive surgery?
This is clear proof that the variables contributing to patient • H
ow much patient comparison between preoperative visual
satisfaction personal perception are many and varied. acuity and postoperative outcomes is perceived by patients and
When refractive surgery developed in Italy about 10 years what factors can influence their self-perception?
ago, the initial idea was that LASIK was for people who were
not greatly affected by serious ophthalmic disease. In some
cases this led ophthalmologists to believe that such patients Overlapping Satisfactions: Feedback for the
CHAPTER
did not warrant being taken too seriously in their desire to Medical Staff and for the Ophthalmic Administrator
get their needs met together with their visual defects solved.
3
Many patient satisfaction surveys are now performed in
The Italian Refractive Surgery Society in cooperation with medical institutions, mainly in hospitals. Initially, collecting
the Istituto Laser Microchirurgia Oculare has developed this patient satisfaction data may alarm health care providers.
study with the aim of arriving at a better understanding of It may point out differences in their level of performance.
those variables which make a patient happy or otherwise and However, these surveys present strategic information for
of developing a questionnaire to be administered in different shaping the provision of health care and improving the
ophthalmic settings to investigate these dimensions (Fig. 7). attractiveness of the institution. As primary witnesses of
One of the purposes of the Italian Refractive Surgery care, patients may provide valuable perspectives on the
Society is to stress the importance among ophthalmologists performance of the health care institution.
of the doctor-patient relationship as an essential tool to The data they provide through surveys may elicit important
comprehend both the visual problem and the person as a suggestions, identify hidden problems and document the
whole and to better orientate the doctor’s decision-making impact of efforts made to improve the quality of care (Fig. 8).
concerning the surgery technique to be selected. For example, service quality in health care (waiting times,
Patients expectations and needs for health care and inconvenience) and in particular, interpersonal aspects of
also towards refractive surgery are many and varied. The the patient-clinician interactions (unanswered questions,
interactions between patients, health professionals, and unclear explanations) have been shown to deeply pervade
services are complex. The dependency, uncertainty and patients' experience of care.
anxiety involved in these interactions are likely to influence Care outcomes are affected by aspects such as uncertainty
patients’ judgement. It is thus difficult to propose a simple regarding the choice of the surgical technique and limited
definition of this concept and straightforward criteria for its consideration of the patient's overall concerns. Organization
assessment. managers may focus on these aspects for care improvement
In September 2005 a feasibility, prospective study started and resources allocation.
within the Istituto Laser Microchirurgia Oculare. In order In clinical practice, patient satisfaction assessment is
to define which domains needed to be considered in the being increasingly used in assessing consultations and
questionnaire, we organized three different focus groups patterns of communication. This evaluation may sensitize
led by a psychologist. Both patients who already had already clinicians to patient's concerns and allow them to better meet
undergone surgery and individuals willing to undergo surgery their needs. If shared in the consultation, these data facilitate
in the near future took part. more effective communication. They may lead to strategies
for helping patients to build up more reasonable expectations
of care and to promote adherence to, co-operation with
treatment by examining reasons for dissatisfaction.
EVALUATION OF PATIENT’S
SATISFACTION QUESTIONNAIRE
In December 2005, following the introduction of new
surgical technology and the strengthening of international
Fig. 7: Patient satisfaction in quality of care assessment in relationships, the Institute decided to embark upon a
ophthalmology procedure of surveying and assessing patient satisfaction.
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SECTION
1
Fig. 8: Clinical folders archive
The psychological aspect of satisfaction comprises a very Preliminary Phase: Investigation Objectives
important part of the evaluating the outcome of refractive
surgery, yet it is the most difficult aspect to evaluate in as As already indicated, the investigation arose from the require-
much as it is not based on measurable or verifiable factors. ment of the Institute to assess the level of satisfaction of its
The first step was that of setting out the research framework. patients not exclusively in terms of objective improvement
Planning a research project involves constructing an of visual capacity, but also (or indeed especially) taking the
overall outline of the investigation to be conducted, which more personal factors into consideration, which involved,
is known as the preliminary framework (Flow chart 1). It is in addition to surgical outcome, the entire process as
essential that when this planning is complete, the desired experienced by the patients during their period of contact
objectives be clearly set out, the variables of the investigation with the Institute.
are defined as precisely as possible, the reference population At the time of planning of the research project the Institute
is specified, the data collecting tools to be used are identified could already boast eight years of direct experience in the
and, if necessary a validation phase of these tools is provided field of refractive surgery; furthermore in 2004 the vision
for. The next step is to define a data collection plan, and then psychology unit was inaugurated, and since then it has been
process the information collected, calculating the appropriate dedicated to the exploration and study of all the ‘intangibles’
statistical indexes thereby arriving at a verification of the linked to the visual process, the approach to surgery and
hypotheses formulated in the preliminary phase. patient satisfaction with the outcome. These two elements
The analysis concludes with the validation of the tool and proved to be very useful in the problem analysis phase and in
the conceptual discussion of the results obtained. defining the objectives.
03.indd 20 29-03-2014 10:30:30

Flow chart 1: The research project
CHAPTER
3
As one may imagine, the analysis of psychological psychology unit, the institute decided to broaden its study to
characteristics is beset by a series of difficulties among include all of its patients. This choice undoubtedly called for
which are the definition of opinions, attitudes and subjective greater effort on the part of the institute in that the number
factors which contribute to such an evaluation. From a of persons involved in the survey was significantly increased
statistical point of view this implies the necessity to provide and different responses on the basis of the different possible
a set of indicators that enable one to evaluate not only situations had to be provided for, but at the end of the survey
extrinsic aspects but also those belonging to the subjective this proved to be an optimal situation since it enabled the
sphere which are of an intrinsic and relational nature. institute to possess a complete overview of the opinions of its
Whereas various models of analysis have been proposed patients, providing the possibility to examine the satisfaction
for customer satisfaction, a much-discussed topic in the of patients who had undergone different techniques.
literature, there has as yet been little discussion regarding
patient satisfaction—a decidedly more delicate topic in that Choice of Tools and their Definition
it is inherent to health.
Following a long-period of study and reflection on the Having determined the study population, it is necessary to
topic, the Institute identified five aspects for investigation define the investigation tools. Some of the factors influencing
which were considered as offering a good representation of their choice were:
patient satisfaction. • The need to request direct opinions regarding institute
staff
• Time required to conduct the investigation (period
Executive Plan following the operation and differing according to the type
of operation)
Population Choice
• Administration of a high number of persons
Initially the investigation was to be conduced only on • The need to leave an appropriate period of time for the
those patients who were to undergo surgery via the P-curve patient to respond without pressure, yet at the same time,
technique. At the request of the medical area and the vision attempting to avoid distractions.
03.indd 21 29-03-2014 10:30:30

Taking all these factors into consideration, the vision is associated with p latent variables, using the sum of the m
psychology service, together with the biostatistics unit simple indicators.
favored the use of the self-administered questionnaire, which m
was handed to every patient at the conclusion of their check- x = f(q) = S a q with weightings a ' = (a , a , ..., a
j=1
j j f j1 j2 jp)
up examination.
A fundamental role is carried out by the patient care staff It is important to remember that the synthesis carried
in that they have to present the survey to the patient, explain out via compound indicators is not equivalent to the latent
its objectives and how to complete it, and, having handed it variable but represents only the empirical and operational
to the patient, being available should any clarifications or version, that is to say an estimate whose reliability should
explanations be needed. be evaluated on a case by case basis with the available data.
As indicated, since the questionnaire had to be calibrated The employment of a relatively large number of simple
against different surgical techniques, the fact that these indicators can at least in part reduce the problems deriving
techniques required differing postoperative adjustment from the fact that subjects have a tendency to give replies
SECTION
periods had to be taken into consideration. For this reason it which suffer from a certain margin of inaccuracy. This may
was necessary to allow different timing pathways on the basis also be desirable should the questions happen to touch on
1
of each postoperative procedure. At the same time as the first topics of a somewhat delicate nature. The weightings to be
check-up the full questionnaire was administered containing assigned at the indicator construction phase are estimated
questions regarding personal data, reasons behind the choice by means of appropriate statistical procedures together with
to undergo the operation, in which institute and using which considerations regarding methodology and robustness of
technique, satisfaction with treatment, and any pain felt results.
during or after the operation. Subsequently, at the 3, 6 and With reference to the properties of the q simple indicators
12 months check-up the patient again went through just the constructed on the basis of observed responses on ordinal
series of items related to assessment of visual adjustment and scales, it is necessary that every item and the related response
satisfaction with the outcome of the intervention. scale be interpreted in a basically analogous manner by
the subjects; this assumption requires that the phrasing
of questions be simple and clear. Even if the condition of
Statistical Methods homogeneity is met, the ordinal nature of the responses
We have already indicated that, satisfaction being a latent however, does not permit the property of linearity of variables
variable, we needed to find subjective indicators which, to be attributed a priori: in other words one cannot assume
appropriately combined, would enable us to arrive at the that numbers 1, 2, … (representative of response categories)
variable which was the object of the investigation. are equidistant. For this reason, when ordinal variables are
These subjective indicators were created with the ultimate available it is good practice to employ models that do not
aim of supplying valid and reliable measures which could assume linearity of ordinal variables a priori and to then
then be used in models of varying complexity for the verify whether such a restriction is plausible for the data one
verification of our theoretical hypotheses. has available.
The following two phases may be distinguished: For the patient satisfaction study the Institute decided
1. The determination of a group of m > p simple indicators to adopt the algorithmic model of ‘Non-linear Principal
q’ = (q1, q2, …, qm ), which are assumed to be in relation Component Analysis’ (NLPCA), which enables one to
with the latent variables. distinguish between subjects as clearly as possible. The model
2. The adoption of an f(q) procedure which enables a enables the determination of the combination of weights
p-dimensional compound indicator x’ = (x1, x2, …, xp ) to that maximizes such separation; from a statistical point of
be constructed to be used as a scale for measuring latent view this means choosing the weights aj that, if the simple
variables. indicators q are fixed, enable one to obtain the maximum
In phase 1 the data were collected by inserting into variance for each of the p components of x.
the questionnaire numerous questions assumed to be in
some way connected with the constructs of interest; the Four Macroareas of the Investigation
replies to such questions were inserted into scales with
ordered categories which expressed the level of agreement,
and the Definition of the Single Item
for example from ‘not at all satisfied’ to ‘very satisfied’. In the light of all the observations made, the Institute decided
With a view to statistical analysis these categories were to divide the questionnaire into four sections:
represented by means of a numerical code (from 1 to 5 or 7); 1. Personal section
the quantification of each observed variable represented a 2. General information
simple indicator of the latent variables. In phase 2 it is 3. Intervention and recovery
common practice to construct a compound indicator, which 4. Satisfaction.
03.indd 22 29-03-2014 10:30:30

The entire Institute staff was involved in defining the For example:
single items. Each staff member was requested to identify
certain aspects which in their opinion were fundamental for 1. Please state your level of Very Very
assessing the patient in their particular field. For example, satisfaction regarding dissatisfied satisfied
the medical area was assigned the task of determining the Technical and professional quality
scales for evaluation of long and near visual capacity. Once
• T he manner in which 1 2 3 4 5 6 7
the questionnaire had been created a training session was
diagnostic examinations
organized in which the staff underwent the final version of were conducted
the questionnaire, during which they were able to discuss
• Competence of doctors 1 2 3 4 5 6 7
further the formulation of certain questions and the method
of administering the questionnaire to patients. • C
ompetence of assistants 1 2 3 4 5 6 7
(orthoptist, optician,
Personal section: The questionnaire is not anonymous operating theater technician
CHAPTER
since it is necessary for the Institute to be able to compare,
at the results analysis stage, patient satisfaction and patient
3
Another aspect to be studied concerned the patient’s
perception of outcome with the medical data contained in the perception of quality of life following the intervention.
patient medical record. Quality of life being difficult to define in as much as it is a
latent construct, several simple indicators were determined,
General information: The questions in this section serve among which were degree of worry regarding visual deficit,
to highlight the sources of information regarding refractive the necessity to ask others for help, and how this aspect was
surgery, why the patient decided to undergo the operation, influenced by the surgery.
the patient’s visual defect, and the main reason for which the
patient opted for the technique that was performed.
Validation
Intervention and recovery: This section is in fact divided At this point, it was necessary to validate the questionnaire
into two: The intervention itself and post-intervention. we had created for the survey. In fact, independently of the
Regarding the former, the patient is asked to provide their measuring scale used or the characteristic being measured
opinion regarding the information given him by the surgeon it is necessary to demonstrate that the tool being used for
and surgical staff concerning the operation and everything research is valid, i.e. it effectively measures the variable. The
associated with it. The patient is then asked to evaluate his concept of validity of psychological measurements often
visual capacity before the intervention, the level he hoped to depends on the theory underlying the construction of the
reach after surgery, and his current visual capacity. The second tool: if the theory is not completely shared, the tests one uses
part is designed to find out whether the patient experienced may be differently valid or differ in certain aspects.
any problems after surgery, whether he felt any discomfort or In addition to being valid, the tool must also be reliable:
pain, and the time taken for his vision to stabilize after surgery. The measurement that we take today regarding a certain
In addition he is asked if he needed a second operation in one characteristic should, all conditions being equal, be
or both eyes in order to perfect the results obtained in the substantially analogous to that which we take at a later time.
first operation and whether he considers that the outcome of Summarizing, a psychometric tool should therefore be:
the operation corresponds with the information he received • Objective
during the preoperative examination. • Sensitive and discriminating
• Reliable and consistent
Satisfaction: This is obviously the central part of the • Valid.
questionnaire in which the patient is asked, more or less By validity of content is meant the capacity to accurately
directly, to express various opinions concerning his degree of represent the whole gamut of possible behaviors linked to the
satisfaction with different aspects. psychological characteristic one intends to measure; usually
The composite indicators determined refer to: this is based on the opinion of experts and does not need
• Technical and professional quality statistical concepts. When one refers to conceptual validity
• Interpersonal relations and communicative abilities one must demonstrate the extent to which the performance
• Internal organization of the Institute of the test in relation to the construct one wishes to measure,
• Surroundings. using for example factorial analysis, multivariate analysis of
For each of these, several simple indicators were variance and multiple regression.
determined (from 3 to 8 per composite), on which the patient To verify our tool we provided for its validation phase,
had to express an opinion ranging from 1–very dissatisfied to inserting a battery of questions at the end of the questionnaire
7–very satisfied. aimed precisely at the above-mentioned aspects and at
03.indd 23 29-03-2014 10:30:30

highlighting any problems or difficulties the patient might

have encountered in the compilation phase (Fig. 9).
The assessment section is repeated at the end of each
compilation so as to evaluate the tool during the process of its
administration.
Execution
Data Collection
As mentioned earlier, it is the patient care team that occupies
the main role in this phase, and administers the questionnaire
directly to the patient. The manner in which the patient deals
SECTION
with the survey the consequent quality of their responses

may also depend on the way in which they are involved in
1
it. It is therefore essential that there be someone present

who will explain the objectives of the survey to them and
who will make themselves available to answer any queries
and, if necessary, encourage the patient to complete the
questionnaire accurately and fully.
Data Processing
In order to analyze the data a database was created to meet
the needs determined at the questionnaire preparation and
statistical model decision making phase.
The initial phase of data collection lasted three months,
at the end of which we started to process the information
obtained from the patients.
The number of questionnaires from the initial adminis-
tering (those handed out to the patients at their first
postoperative check-up) was such as to enable a complete
analysis to be undertaken along with a first revision of the
questionnaire. The number of questionnaires returned from Fig. 9: Verification of the comprehension and
the second administering was, on the other hand, insufficient adequacy questionnaire
to proceed (the first time limit before readministration was in
fact three months). surprising. For example the overall average satisfaction was
The first step was that of conducting a clean-up operation equivalent to 8 (1 = not at all satisfied, scale 1 and 10 = very
of the data itself and verifying the data coherence. Usually this satisfied).
is a somewhat delicate process in that the database must be At the end of the data processing period, the questionnaire
handled directly to manage any input errors or those arising validation procedure was carried out. This took into
from any lack of understanding (albeit involuntary) on the account the problems encountered during the clean-up
part of the respondent. It is at this point that a decision must and coherence verification phase, the results obtained from
be taken concerning how to handle missing data. The first processing and the information contained in that part of the
thing we noticed was that the percentage of missing data questionnaire dedicated to its own validation. Essentially,
was indeed very low, i.e. almost all patients answered all the two problems were found: one concerning the question
questions completely. This was probably because the patients regarding the patient’s perception of pain, and the other
felt involved in the survey and understood the reasons for it regarding the length of the questionnaire itself. Regarding
when it was presented to them by the patient care staff. the first, it was noticed that a considerable percentage of
Once the data clean-up operation had been carried out, patients who underwent a particular technique reported
data analysis was conducted, the results being differentiated slight pain/discomfort during and immediately after the
according to the surgical technique of reference. First all, operation. This came as a surprise to many, since in the
descriptive analyzes were performed referring to the reference experience of the Institute a characteristic of the technique
population (sex, age and profession), represented by means is that that it does not cause the patient pain. After a brief
of simple histograms. The statistical model was then applied meeting with the medical area and vision psychology staff, it
(Non-linear Principal Component Analysis). The results were was concluded that the respondents could have been misled
03.indd 24 29-03-2014 10:30:30

by the fact that the question asks “Did you feel sensations of
discomfort or pain?”, and does not differentiate between pain
BIBLIOGRAPHY
and discomfort which are in fact two substantially different 1. Baker R. Development of a questionnaire to assess patients’
aspects. It is very important, in fact, to know if a respondent satisfaction with consultations in general practice. British
has simply felt slight discomfort (obviously due to the fact that Journal of General Practice. 1990;40(341):487-90.
they have undergone an eye operation), or if they have really 2. Bernhart MH, Wiadnyana IGP, Wihardjo H, et al. Patient
felt actual pain. To resolve this question, steps were taken to satisfaction in developing countries. Social Science and
Medicine. 1999;48:989-96.
distinguish between the two aspects in the questionnaire,
3. Calnan M, Katsouyiannoupoulos V, Ovcharov VK, Proshorskas
asking first of all if the patient felt discomfort and then asking R, Ramic H, Williams S. Major determinants of consumer
if they had felt pain. satisfaction with primary care in different health systems.
Concerning the fact that some considered the number of Family Practice. 1994;11:468-78.
questions to be too high, we asked ourselves whether all the 4. Gasquet I. Satisfaction des patients et performance hospitalière.
questions included were relevant in terms of the aims of the La Presse Médicale. 1999;28:1610-16.
CHAPTER
investigation. However the statistical model employed used 5. Gregory RL. Eye and Brain. Raffaello Cortina Editore, 1998.
all the variables included, attributing a significant importance 6. Rubin HR, Ware JE, Nelson EC, et al. The Patient Judgement
3
of Hospital Quality (PJHQ) questionnaire. Medical Care.
to each one. This, plus the fact that despite commenting on
1990;28:S17-S18.
the excessive length of the questionnaire, practically all the 7. Sitzia J, Wood N. Patient satisfaction: A review of issues and
patients completed it carefully and in full, led us to decide not concepts. Social Science and Medicine. 1997;45:1829-43.
to change it. It might, however, be useful to let the patients 8. Ware JE, Snyder MK, Wright WR, et al. Defining and measuring
know right from the start how much time is needed to patient satisfaction with medical care. Evaluation and Program
complete the questionnaire. Planning. 1983;6:247-63.
03.indd 25 29-03-2014 10:30:31

SECTION 2
Overview
4. Eye Aberrations: Overview

5. An Approach to the Wavefront Technology: Aberrometry Basis

Jesús Andrés Rosas Apráez, Juan Pablo Castañeda Borrero, Luís Antonio Ruiz
6. Wavefront Aberrations from A to Z

Yazan A Zahran
7. Basic Wavefront Optics and Ocular Aberrations

Vance Thompson
04.indd 27 29-03-2014 10:31:38

04.indd 28 29-03-2014 10:31:38
CHAPTER 4 Tangwa Martin Neville
Eye Aberrations: Overview
eventual scars from surgery, trauma and disease. Aberrations

CLINICAL CONTROLLER—ISTITUTO however change and increase with age.9-24 Of great clinical
LASER MICROCHIRURGIA OCULARE importance is the pupil diameter, it has been estimated that
When a light point or source emanates light, it travels in rays the best functional diameter would be 3–3.2 mm; the wider
in different directions1,31-34—Parallel rays travelling in a given the pupil the more disturbing the aberrations are, while
direction may hit a surface and are either reflected absorbed smaller pupils lead to diffraction which also disturbs image
or transmitted. When the surface is an optical surface it will quality.
either converge the rays to form an image or diverge the same Eye aberrations are classified into low and higher order
to a second plain to form a virtual image. Geometrical optics and are generally studied at the pupil area.8-20 They have
describes this behavior in a series of laws.7-11 been graded mathematically using the Zernike polynomial
Optical systems produce images emanating from sources, expansions, which can describe an infinite number of
objects, light points and the visual world by converging or aberrations and of the 60 sorted out thus far, eye scientists
diverging the rays to focal points. A wavefront is a surface over use the first 15 as it is understood that these can completely
which an optical disturbance forms, and is in constant phase describe the visual scenery. In the Zernike polynomials the
and normal to the light rays.16-18 superscript describes the angular frequency; the number
The eye is an optical system that conveys the visual world of times the wavefront repeats itself while the subscript
to the retina. Thus, light coming from a point source or object describes the order.16-19 On this basis and with this name a
will be conveyed to the retina through the pupil and the triangle of aberrations and list of modes have been designed
refracting surfaces; the main being the cornea and crystalline (Figs 1A and B).
lens.2-16 Others include the aqueous humor, vitreous humor The low order aberrations which form 80–90% of the total,
and the tear film. The complexity of the system is quite clear. start off at the zero aberration or piston which is the reference
It is well-known that the eye is not a perfect optical system. point. It is flat, the first order aberration tilt or prism is also of
In a perfect or emmetropic eye the resulting wavefront would no clinical importance.7
be a flat wavefront, i.e. without impurities or aberrations. Very familiar to the ophthalmologists are the second order
This flat wavefront is known as the piston or reference. In aberrations—defocus or visual defects myopia, hyperopia,
the eye the rays converge at different image points from this presbyopia and symmetrical astigmatism. These are the daily
ideal, and the distance measured in microns is the wavefront refractive defects corrected with spectacle glasses, contact
aberration.2-10 lenses and more often today with refractive surgery. They
Principally, the aberrations in the eye are determined by cause visual blurring, loss of visual lines and management has
the disalignment of it's main optical elements the cornea and thus far been efficient safe and of great patient appreciation.
the crystalline lens with the visual axis.2-13 Other elements Higher order aberrations make up 10–17% of the total
are the state of the tear film the vitreous and aqueous humor aberrations. These have more complex geomertical forms,
04.indd 29 29-03-2014 10:31:38

30 Overview
SECTION
2
A B
Figs 1A and B: (A) Zernike images; (B) Zernike classification
cause difficulties like haloes, glare, ghost images starburst problems. Higher order aberrations are useful in as much as
patterns and diplopia especially in low lighting conditions they are capable and responsible for countering chromatic
and during night driving, third order aberrations are aberrations.22,23 In the era of refractive surgery it is believed
Coma and trefoil. Trefoil is an aberration of little clinical and to some extent some of these aberrations are already
significance.28 being treated.through customized ablations.
Coma is present in keratoconus, decentered corneal
grafts, intraocular lenses and laser ablations; as well as in
REFERENCES
asymmetric astigmatism.8-11 It has a comet graphic shape,
is highly influenced by pupil diameter, causes reduction in 1. Applegate RA, Thibos LN, Hilmantel G. Optics of aberroscopy
visual lines, ghost images haze polydiplopia. and supervision. Journal of Cataract and Refractive Surgery.
Fourth order aberrations are secondary astigmatism, 2001;27(7):1093-107.
2. Artal P, Guirao A. Contributions of the cornea and the lens to the
quadrafoils of little clinical significance20 and spherical
aberrations of the human eye. Optic Letters. 1998;23:1713-5.
aberration. This aberration is spherical in shape with the 3. Artal P, Berrio E, Guirao A, Piers P. Contribution of the cornea
graphic form of a Mexican hat the sombrero. It causes loss of and internal surfaces to the change of oculare aberrations with
contrast sensitivity, haloes and night myopia, could increase age. J Opt Am A. 2002:137-43.
after myopic lasik.12-30 Most wave aberration depends 4. Atchison D, Collins M, Wildsoet C, Christensen J, Waterworth
on second order aberrations which have a square radius M. Measurement of monochromatic aberrations of human eyes
dependency, such that the increase in overall wave aberration as a function of accomodation by the Howland aberroscope
with pupil size is reported to increase approximately by the technique. Vis Res. 1995;35:313-23.
second power of the pupil diameter. The normal human 5. Atchinson D, Smith G. Schematic eyes. In: Atchinson D Smith
G (Eds). Optics of the Human Eye. London Butterworth-
eye has some amount of spherical aberration, which is
Heinemann; 2000: Appendix 3.
positive for about one diopter in mydriasis. It is dependent
6. Barbero S, Marcos S, Merayo-Lloves JM. Total and corneal
on pupil diameter and the wavelength of incident light. The aberrations in an unilateral aphakic subject. J cat Refract Surg.
longitudinal spherical aberration is positive for the cornea 2002;28:1594-1600.
and negative for the crystalline and young accommodating 7. Born M, Wolf E. Principles of optics (6th edn) Pergamon Press,
lens.15-30 While in the positive aberration-undercorrected, the Oxford 1993.
marginal rays go to focus before the axial and paraxial rays, 8. Buhren J, Kuhne C, Kohnen T. Defining subclinical keratoconus
in the negative, hypercorrected, which is of the crystalline using corneal first-surface higher-order aberrations. Am J
lens the axial and paraxial rays are first in focus. The energy opthalmol. 2007;143:3424-32.
distribution to the photoreceptors scales down from the 9. Castejon-Mochon FJ, Lopez-Gil N, Benito A, Artal P. Oculare
wave-front aberration statistics in a normal young population.
peripheral rays to the central so that the eye downgrades the
Vis Res. 2002;42:926-36.
images formed, by high lighting those conveyed by the axial 10. Charman WN, Jennings JAM. Objective measurments of the
and paraxial rays. The same holds for the directionality of longitudinal chromatic aberration of the human eye. Vis Res.
retinal receptors and the Stiles-Crawford phenomenon. 1976;16:999-1005.
The pentafoils, secondary trefoils, coma are other higher 11. Charman WN. The optics of the eye. In: Bass M (Ed). Handbook
order aberrations which do not cause clinically significant of optics (2nd edn) Mcgraw-Hill, New York (NY) 1995.
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Eye Aberrations: Overview 31
12. Collins MJ, Wildsoet CF, Atchinson DA. Monochromatic 24. Mclellan J, Marcos S, Burns S. Age related changes in
aberrations and myopia. Vis Res. 1995;35:1157-63. monochromatic wave aberrations in human eyes. Invest
13. Guirao A, Artal P. Off-axis monochromatic aberrations Ophalmol Vis Sci. 2001;42:1390-5.
estimated from double pass easurements in the human eye. 25. Navarro R, Artal R, Williams DR. Modulation transfer of the
Vis Res. 199;39:207-17. human eye as a function of retinal eccentricity. J Opt Soc Am A.
14. He JC, Marcos S, Webb RH, Burns SA. Measurement of the 1993;10:201-12.
wave-front aberration of the eye by a fast psychophysical 26. Navarro R, Moreno E, Dorronsoro C. Monochromatic
procedure. J Opt Soc Am A. 1998;15:2449-54. aberrations and point spread functions of the human eye
15. He JC, Burns SA, Marcos S. Monochromatic aberrations in the across the visual field. J Opt Soc Am A. 1998;15:2522-9.
accomodated human eye. Vis Res. 2000;200:41-8. 27. Porter J, Guirao A, Cox I, Williams D. Monochromatic
16. Hofer H, Artal P, singer B, Aragon J, Williams D. Dynamics of aberrations of the human eye in a large population. J opt Soc
the human eye wave aberration. J Opt Soc Am A. 2001;18:497- Am A. 2001;18:1793-1803.
506. 28. Rapuano Christopher J. American Academy of Ophthalmology,
17. Jennings JAM, Charman WN. Off-axis image quality in the Basic and clinical science course section 13: refractive surgery.
2011.
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human eye. Vis Res. 1981:21:445-55.
29. Rynders MC, Lidkea BA, Chisholm WJ, Thibos LN, Haggerty
18. Lombardo M, Lombardo G. Wave aberration of human eyes
KM. Distribution of pupil centers with respect to the visual axis.
4
and new descriptors of image optical quality and visual
Optometry and vision science. 1993;70:157-8.
performance. Journal of cataract and refractive surgery.
30. Rynders MC, Navarro R, Losada MA. Objective measurment
2010;36(2):313-31.
of the off-axis longitudinal chromatic aberration in the human
19. Myron Yanoff, Jay S Duker. Opthalmology (3rd edn) Mosby eye. Vis Res. 1998;38:513-22.
Elsevier. 2009. 31. Seiler T, Kaemmerer M, Mierdel P, Krinke HE. Ocular optical
20. Mahajan VN. Zernike circle polynomials and optical aberra aberrations after refractive keratectomy for myopia and myopic
tions of systems with circular pupil. Appl Opt. 1994;38:8121-4. astigmatism. Arch Opthalmol. 2000;11817-21.
21. Marcos S, Burns SA. On the symmetry between eyes of 32. Simonet P, Campbell MCW. The optical transvers chromatic
wavefront aberration and cone directionality. Vis Res. 2000;40: aberration on the fovea of the human eye. Vis Res. 1990;30:187-
2437-47. 206.
22. Marcos S, Burns SA, Moreno-Barriuso E, Navarro R. A new 33. Thibos LN, Bradley A, Still DL, Zhang X, Howarth PA. Theory
approach to the study of ocular chromatic aberrations. Vis Res. and measurement of ocular chromatic aberration. Vis Res.
1999;39:4309-23. 1990;30:33-49.
23. Mclellan JS, Marcos S, Prieto PM, Burns SA. Imperfect Optics 34. Wang L, Santella RM, Booth M, Kock DD. Higher order
may be the eye's defence against chromatic blur. Nature. 2002; aberrations from the internal optics of the eye. J cataract
17:696-9. Refract. Surg. 2005;1512-9.
04.indd 31 29-03-2014 10:31:39

CHAPTER 5 Jesús Andrés Rosas Apráez, Juan Pablo
Castañeda Borrero, Luis Antonio Ruiz
An Approach to the Wavefront

Technology: Aberrometry Basis
the detail of what really could be captured by these optical

OVERVIEW AND HISTORY elements. Using a technology called adaptive optics which
A new trend breaks in the field of refractive surgery and the is based on systems of deformable or mobile mirrors,
study of visual quality: the study of wavefront or aberrometry, astrophysical scientists attain to correct the distorted images
a science very new for us, eye care professionals, but since of celestial bodies and determine the details of any form
mid-seventies it sat his important start from the astrophysical however diffuse it looks1,2 (Figs 1 and 2).
scientific concerns about improving the images of celestial Joseff Bille, PhD, professor and physicist at the University
objects captured by their telescopes. The atmosphere, gaseous of Heidelberg in Germany, is considered by many as the
layer surrounding our planet, is composed of different gases ‘father’ of wavefront technology applied to the research
densities. When the image of a celestial object crosses from in the visual sciences. In this moment Dr Bille currently
vacuum of space different densities of atmospheric gases, serves as the Director of the Institute of Applied Physics at
the image captured by telescopes deforms and distorts in the University of Heidelberg. In 1982 he registered the first
A B
Figs 1A and B: (A) Keck I and II telescopes located on Mauna Kea (Hawaii); (B) Panel of hexagonal mirrors comprising
the adaptive optics system compared to the size of a person (center of the figure)
An Approach to the Wavefront Technology: Aberrometry Basis 33
CHAPTER
5
A B
Figs 2A and B: Image of NGC 7469 galaxy view with and without adaptive optics
Fig. 3: From left to right: The author, Luis Antonio Ruiz MD, PhD and Professor Bille Joseff
patent about the applications of this technology in the field focusing internal place that would be the equivalent to the
of visual sciences which was granted in 1986 by the German macula in a biological eye, and if we could somehow analyze
government. In 1997 becomes one of the cofounders of the this output wavefront of the same optical system we would
20/10 Club of Perfect Vision1-3 (Fig. 3). realize that this wavefront has not suffered any distortion and
It is important here to analyze what is the basic principle therefore the output beams are also parallel in the same way
of the application of wavefront in the ocular optical system. as they entered without undergoing any change.3,4
Worth expressing in advance that there is no ideal optical When analyzing an optical system in which aberrations
system, but for purposes of study consider a perfect artificial exist, as could be an eye with some type of refractive error,
eye such as the ‘Indiana Eye’ which is a mathematical scheme irregularity or lack of transparent refractive media, we find
free from any kind of optical aberration and can be considered that the light beams outgoing lose their parallelism and
that its only optical limitation is the diffraction generated at some of them are advanced with respect to the reference
the expense of the edge of the diaphragm (pupil). When in this plane or delayed with respect to there. This is which we call
perfect eye, parallel beams of object-image coming from the deformity in wavefront or, etymologically, optical aberration
optical infinity refract, we can see that they all reach a same (Figs 4A and B).
34 Overview
SECTION
2
A B
Figs 4A and B: (A) Perfect eye without aberrations; (B) Eye with aberrated wavefront
Each component of the optical system (optical train) pays ZERNIKE POLYNOMIALS
a percentage of the wavefront distortion and this percentage
depends directly on the relationship between the refracting The Optical Society of America (OSA) recommended in the
surfaces (tear film, cornea, aqueous humor, lens and vitreous early interpreting wave front maps to adopt the expansion
humor) and its refractive index. of Zernike polynomials as the standard method to describe
From this point of view we can say that the tear film and the error in the wavefront of an optical system. Zernike
the cornea are the refracting elements where the impact of polynomials are considered as the basic blocks of description
the optical aberrations affects more on visual quality. or construction of any wavefront how complex it may be. Are
known as optical basic functions.
The tear film is where the biggest refractive index change
Each of these basic functions is the product of other two
occurs of all the optical train: from an index 1 corresponding
functions, one of which depends only on the radio and the
to air to 1,336 corresponding to the corneal stroma, so the
other on the meridian, this gives to the polynomials the
tear film has a key role and also dichotomous over the impact
mutual orthogonality characteristic, which means some are
on visual quality: normal tear film has a constant thickness
independent of other mathematically.
and has no optical effect in the perception of images and a
Another desirable feature of these polynomials is that,
tear film incomplete or poor in quality (dry eye) degrades the except for the first term, all have a zero mean and are scaled
perceived image quality, because in this first interface, as said, to have a variance corresponding to the unit. This puts all the
occurs the highest index change of all refractive optical train. terms in a common basis so that their relative magnitudes
Being the cornea a powerful refractive element (2/3 parts can be compared easily.7-9
of total optical power of the eye) also is governed by a mathe- The basic functions of Zernike or ‘polynomials’ as is often
matical ratio regarding its contribution to the wavefront know are systematically arranged in a ‘periodic table’ with the
deformation: this ratio was described by Dr. Allain Telandro shape of a pyramid.
in Cannes (France) as ‘the ratio 3 to 1’ in which Dr. Telandro Each row of the pyramid corresponds to a given order
concludes that 3 microns of distortion in cornea generates 1 of the polynomial component of the function and each
micron distortion in the wavefront.3-5 column corresponds to a different meridional frequency,
These deformities in the wavefront can be as complex as by convention, the harmonics in cosine phase corresponds
aberrated is the system that owns them. Depending on what to positive frequencies and those in sine phase to negative
the optical problem is based, certain types of alterations frequencies. There is also a simpler way of placing each of
(aberrations) prevail on others, so that it is more or less these polynomial functions inside the pyramid and is giving
deductible the aberration type to be found depending on it a simple ordinal number or even a double name with
the case being analyzed, by example myopic LASIK (positive subscript and superscript indicating the exact position within
spherical aberration), hyperopic LASIK (negative spherical the pyramid8-10 (Fig. 5).
aberration), keratoconus (coma and trefoil), dry eye (other of It is important to know that depending on the position of
high order combined).4-6 the aberration within the pyramid, this tends to deteriorate
CHAPTER
5
Fig. 5: Organization of Zernike polynomials in the pyramid Fig. 6: Constant aberration tilt type
more or less the quality of the analyzed image. Thus it is high that if you take it into account within the aberrometric
considered that the more above the pyramid is placed an calculation it would overshadow the detail and extent of the
aberration and more centrally is located to the axis thereof, other distortions7-10 (Fig. 6).
will have greater impact on the quality of patient’s vision.
As an example we then say that a pentafoil (peripheral
LOW ORDER ABERRATIONS
aberration) of the same quantitative micron magnitude than
a comma (central aberration) never distort the same way the Also known as second-order aberrations are the aberrations
quality of the vision of the analyzed system. we know in our diagnostic and therapeutic reality daily.
The wave front resulting in the quantitative analysis of the They are three expressions that occupy this second
visual quality of a patient is the result of the mathematical sum order: two components of astigmatism and a spherical blur
of each of the polynomial expressions of Zernike pyramid, i.e. component or defocus. These are the aberrations that we are
constant aberrations (Piston and Tilt), low-order aberrations used to measure, correct and deal with glasses, contact lenses
(sphere and cylinder) and high-order aberrations (spherical or conventional refractive surgery.
aberration, coma, trefoil and other high-order ones). It is important to understand at this point that low-order
The pyramid of polynomials then provides six different aberrations aberrometrically represent the amount of vision
orders starting with zero order and can be considered divided or quantification of the sphero cylindrical defect.
into three main groups: constant aberrations, low-order Astigmatism has two expressions used to determine its
aberrations and high-order ones.7-10 magnitude and its axis as follows: from the sum of the first
term and the second, we obtain the magnitude of astigmatism
as we know it and of the percentage respect to one another is
CONSTANT ABERRATIONS determined its axis. Regarding defocus or spherical blur we
Orders zero and one of the pyramid contain 3 aberrations mention that aberrometrically represents the error of the
that are considered constant in all optical systems and central rays of a wave front respect to the peripherals and
these are: the piston, horizontal tilt (Tilt) and the vertical this in turn can be positive or negative (if this is a myopic or
tilt (Tip). The first one, the piston can be considered in its hyperopic error).
simplest form as the movement of internal focal plane in To better understand the dimensions of a low-aberration
the attempt of the aberrometer optical system to conjugate order is necessary to note that these aberrometrical maps are
with the retinal plane to capture the perceived image. The built based on advanced or delayed microns with respect to a
horizontal and vertical tilt aberrations are also constant, if we zero reference plane. By convention as a similar way to construct
consider that our complex optical system is a symmetrically corneal elevation maps, the representation of the referential
asymmetric system as the pupil has a certain asymmetry and aberrometrical plane is given by variations in color tone, in the
is not in the mathematical center of the eye, like asymmetry green range is shown a zero level of measure in microns, the
characteristics of the cornea, of the lens, and the difference of ‘hot’ colors in the range of yellows, oranges and reds with their
the visual axis with the anatomical axis of the structures. various tones representing the wave front advancing in microns
Considering these aberrations as constants in all or that is considered faster with respect to the zero reference
optical systems we not generally take into account the total plane, and in turn ‘cool’ colors show the slow or delayed wave
calculation of the aberrometry since its magnitude is so front in microns respect to the ideal plane.
36 Overview
In this way, if we represent bidimensionally an aberro- carrying to not previously thought limits the vision quality
metrical map of astigmatism this would have the shape of our patients, as well as understanding new concepts of
of a curved plane alternately towards and forth. Its three- our limited knowledge of the objective visual quality. It
dimensional representation would be a figure described by is considered that in a normal eye, low-order aberrations
some as the ‘saddle’ where a fast front alternates with a slow constitute 80–85 percent of deteriorating Visual Quantity and
one (Figs 7A to C). that high-order aberrations constitute only 15% of the total
The two-dimensional representation of a myopic spherical error (Visual Quality).9,10
defect would show a wavefront fast in the periphery, that is Despite the significant difference in these variables
progressively slowing as it approaches the center of the optical percentage these high-order aberrations are those that limit
axis of the system. The three-dimensional representation of the vision of a healthy eye below the retinal limit and can be
this front will display a figure that has been described as a said that they are not susceptible to correct with conventional
‘bowl’ shape. The reason for this is that in the myopic patient, methods.11
rays that go through the axial center of the system must go Trefoil is the first of these aberrations, also known by
SECTION
a distance much longer than the rays of the periphery and some as triangular astigmatism, represents bidimensionally
therefore these leave long before the eye and reach prior the the alternation forward-backward of three fixed points
2
aberrometer sensor than those that are located in the central which define a steepening of the plane at the expense of
part of the pupil. Similar but opposite is the case of hyperopia the periphery. Its three-dimensional image represents an
in which we can consider its three-dimensional wavefront advancing wave front that delays and alternate on 3 occasions
as a ‘bowl’ but seen by the base, in which we have a fast at the expense of periphery (Figs 8A and B).
wavefront at the center to be progressively slowing towards The Coma is considered perhaps one of the most fearsome
the periphery7-10 (Figs 7A to C). aberrations within the spectrum of high-order aberrations
due to the significant visual quality deterioration that its
finding represents, when induced by a surgical or therapeutic
HIGHER-ORDER ABERRATIONS
procedure. Moderate natural coma however, seems to be
From the third order we find a number that is progressively related with good visual acuities as in the case of emmetropic
expanding the length of the pyramid and in fact this expansion airline pilots with excellent visual acuity in which is found
may become infinite, but for practical purposes of the human that this was the most frequent aberration (Figs 8A and B).
optical analysis is only considered important to the sixth Throughout his speech the comma represents the offset
order and even some researchers claim that the analysis of of the elements constituting an optical system, hence its
the expressions only to the fourth order is sufficient when it importance as contributing to the deterioration of visual
comes to optical measurements of visual quality. The sum of quality. This aberration is an important finding in patients
the high-order aberrations quantifies irregular astigmatism with diseases such as asymmetric keratoconus, where
in an optical system, which is directly related to the objective becomes a sensitive marker of its presence. Or in patients
visual quality. with offset refractive treatments or inclined intraocular lenses
Irregular astigmatism or so-called High Order aberrations or out of position.14-16
are the Visual Function part that we are not used to measure Bidimensionally coma displays from the periphery to the
or to treat and that now with wavefront technology and center a split wavefront alternating horizontally or vertically
customized ablations we try to measure and correct for (depending on the type of coma), in planes that move or are
A B C
Figs 7A to C: Low order aberrations: three-dimensional representation of hyperopic, myopic and astigmatic defect
CHAPTER
5
A B
Figs 8A and B: High order aberrations: (A) Trefoil; (B) Coma
delayed abruptly. In a three-dimensional representation, this of its front and back face as well as the refractive index differ-
wave front reveals a sharp breaking with deep undulations ence between the central area and periphery.4,11,12
alternating forward—backward from the center to the Aberrometrically the bidimensional analysis of this type
periphery. of optical distortion shows an image with cool colors on the
The Tetrafoil or quadratic astigmatism, is located in the periphery of wavefront which increases gradually towards the
fourth order and has two expressions for the angular fre- center, its three-dimensional classical shape describes it as a
quency of sine and cosine respectively, in a similar way ‘Mexican hat’.
and progressive as trefoil, is the peripheral aberration that It is important to know that this aberration as others
represents the symmetry of four fixed points at the expense of described above are related directly to their quantitative
periphery and in its two and three dimensional form represents impact on visual quality factors depending on the size of the
a wave front advancing and is delayed in four opportunities on pupil, so large pupils contribute with a higher percentage
the periphery of the analyzed area (Figs 9A and B). of aberrations in optical systems than systems with small
Spherical aberration is located inside the pyramid in the pupils.18-21
fourth radial order with angular frequency zero. Spherical Typically is described that conventional techniques of
aberration is a symmetric aberration and is defined as the LASIK can increase the presence of this kind of aberration
focal distance between the center points and the periphery of due to micro offsets of treatments or due to the size of the
a wave front, if the center and periphery of a system become optical zone22 (Figs 9A and B).
more curved, spherical aberration becomes greater. Insofar as we descend progressively in the analysis of
The human eye handles positive spherical aberration the aberrations in the pyramid, each of these aberrations
naturally and has different elements that are optically evolved presents its secondary component, which is a variation in
to control or minimize the impact of this aberration in visual shape of the primary. Also can be located in sine or cosine
quality, in fact mechanisms to be mentioned reduce to one phase (except for the zero symmetry aberrations—center of
third the amount of spherical aberration of an optical system the pyramid) and be negative or positive. This would give
when doing analysis in a young healthy eye. An important for each of the majority of aberrations 4 possible terms with
mechanism of control is the ‘Aspheric’ shape in the cornea, which could be described its position, nature and symmetry
the flattening of the radius of curvature of the cornea from the through combinations thereof.13 For example:
center towards the periphery, enables both beams, central
Zero symmetry aberration: Primary spherical aberration,
and peripheral to occupy the same position in the macular
secondary spherical aberration, positive spherical aberration,
focal plane improving the quantity of useful light (irradiance)
negative spherical aberration.
for the formation of the image.
The other mechanism of spherical aberration compensa- Asymmetric aberrations: Primary coma, secondary coma,
tion comes at the expense of the lens by virtue of the curvature coma in sine phase coma in cosine phase.
38 Overview
SECTION
2
A B
Figs 9A and B: High order aberrations: (A) Tetrafoil; (B) Spherical aberration
wave front for a pupil diameter we arbitrary have chosen. This

OBJECTIVE VISUAL QUALITY MEASURES feature may be selected for example in visual quality studies
Although this type of objective measure of visual quality (e.g. refractive surgery results, performance of intraocular
through aberrometric tests provides different numerical data lenses, etc.).
as information, we will make special mention of some terms
Root mean square—average square error (RMS): A term
considered important and representative of a wavefront
that could be considered complicated in its definition is just
analysis.3,5,6,8
the average mathematical quantification of the error in the
The objective visual quality measures can be quantified
wavefront.
numerically at pupil or retinal level.
Represents the square sum of each of the polynomial
terms in the Zernique pyramid being studied and the square
Pupil Level root expression of this summation. Its value is absolute and
Pupil as a dynamic diaphragm that allows passage of light is it is considered that the RMS is the numerical representation
considered of vital importance in quantifying the objective of the amount of error of an ideal wave front respect to the
visual quality. patient studied. The RMS of an ideal optical system is zero,
Pupils with sizes greater than 6 mm in diameter are but as said earlier this ideal system does not exist.
considered large from the refractive and aberrometric point The RMS is considered an objective quantitative measure-
of view, this means that the optical systems that have these ment of visual quality at pupillary plane level.
large pupils may be mostly subject to the impact of the The RMS can be analyzed from the context of sum of all
objective visual quality deterioration in terms of maximum aberrations of a system and is called total RMS or from the
dilation (e.g. mesopic or scotopic condition in myopic), point of analysis of single high-order aberrations where RMS
instead patients with small pupils less than 3 mm have a low is described as RMSHO (higher order or irregular astigmatism
impact on visual. RMS).
quality at the expense of the aberrations, but are subject to The total RMS of a human emmetropic optical system is
the limitation by the diffraction generated by the pupillary considered equal to unity (1) measured in microns, if less
margin per se. than one can say that this eye sees beyond the one hundred
There is a pupil size of ‘balance’ between the limited size percent and if it is greater than unity indicates a deterioration
by aberrations and diffraction limited size and this is equal to of the quality of patient’s vision.
4 mm diameter. Total RMS Visual acuity
An important condition for taking an aberrometric test is 1.5 microns 20/80
total absence of natural or artificial ambient light. This allows
1.0 microns 20/20
the examination to be made on the condition of maximum
natural pupillary dilation, the aberrometric test result always 0.5 microns 20/15
expresses measurement results based on the higher obtained Moreover, the RMS can be analyzed individually or in
pupil under this minimal luminous condition, but it is also subgroups depending on the detail of the clinical-optical
important to know that any aberrometer can recalculate the analysis being performed.
The high-order RMS or RMS HO only quantifies high Retinal Level

order aberrations, in other words, irregular astigmatism and
therefore becomes an important objective measure of visual
quality, multiple studies confirm that in normal populations Point Spread Function (PSF)
the cutoff of this type RMS is 0.4 microns, this means that The spread function of a point, is an objective measure
patients with RMS HO with values below 0.4 microns can of the visual quality quantification at retinal plane level.
be considered with a normal or low irregular astigmatism Considering the PSF as the measure of the dispersion of an
and therefore with a normal or high visual quality. Whereas object-image with the shape of a point at the plane of focus
patients with RMS HO greater than 0.4 microns may have on the retina. Optical system without aberrations is able
some alteration of optical components which impairs the to perceive a luminous point as a point, while an aberrated
visual quality. These patients should undergo careful clinical optical system induce significant changes in the perception
analysis to determine the cause of impairment in the objective of this point.
visual quality.11,13
CHAPTER
A suitable PSF should consider features such as its high
I had just spoken of the “single qualitative weight” of each contrast and compact form. The compact form (volume) is
aberration: and we can say that even when two individual
5
directly related with the quality of the image that is forming in
aberrations have the same numerical magnitude of RMS in the retina of the optical system examined: the more compact
microns, they will not have the same impact on the visual the better the quality of the vision of this system. The high
quality of the individual. contrast defines the amount of light energy (irradiance) that
The individual RMS of each aberration separately is is transmitted to the retina or macular attachment point
considered maximum to 0.18 microns, this means that in (Fig. 10)
the individual analysis of each aberration. In polynomials
Zernique pyramid, there should not be a value greater than
this for every single term, for example, spherical aberration Optical Transfer Function (OTF)
greater than 0.18 microns could be related to a prior refractive
procedure, vertical coma greater than 0.18 micras could be The efficiency of transfer of images through an optical system
related to the early presence of keratoconus.11 should be evaluated in two ways: the transfer process itself
Fig. 10: Point spread function horizontal line—volume and vertical line: irradiance or energy that reaches the retina
40 Overview
and the quality of images transferred through the system in This so, an important limitation of the aberrometry can be
question. This is accomplished by analyzing the ability to converted in the future in a valuable technique to understand
transfer different images with sinusoidal characteristics and changes in visual quality related to dry eye (Fig. 11).
with different spatial frequencies.
Pupil Size
Phase Transfer Function (PTF) The contour or an aberrometric map and the aberrations there
found can change significantly depending on with pupil size
Represents a simple lateral displacement of a sinusoidal measurement is made, since a small change in millimeters of
image of specific spatial frequency, observed through an pupillar diameter may represent huge variations in terms of
aberrated system. square area of its circular shape. Also worth bearing in mind
the diffractive effect that the edge of the pupil exerts on light
Modulated Transfer Function (MTF) beams that constitute the aberrometer measurement and
SECTION
limit the quality of the aberrometrical acquisition in very small

It is defined as the quantified ability to transfer a specific pupils or distort data in very large pupils or pharmacologically
2
image through an optical system with a specific resolution dilated. That is why perhaps most aberrometrical systems
and contrast. In other words the amount of image transmitted manufacturers, with the exception of a few, suggests that an
from the observed object through an aberrated optical system ideal aberroscopic measurement should be made in scotopic
(refracting elements of the eye) to the photoreceptor (retina). conditions without action of drugs that dilate the pupil
(Figs 12A and B).
Aberrometry Limitations Chromatic Aberration

As far wavefront measurement is a science of new application Aberrometric technology with which we currently use, mostly
in our ophthalmologic field, is important to know the reality uses coherent and monochromatic wavelengths based on the
of the historic moment we are living with this brand new principle and application of laser wavelengths, typically in
technology and though this development promises offer the infrared range.
significant advances in terms of study and understanding of These laser beams to measure the distortion of the
the role of visual quality and also personalized treatments wavefront have a single wavelength, which is constant and
with refractive surgery, it is considered that this is a science does not change in its entry or exit path. It is important to note
developing in their ocular applications and therefore should here that the many wavelengths of a multicolor world occupy
be at aware of the limitations that wavefront measures can different focusing places in the thickness of the retina, so the
have at some point.22-25 lengths of short wavelengths in the blue spectrum are focused
on the anterior part of the retina, the medium wavelength in
Tear Film the yellow and orange spectrum focus on the middle part of
the retina and finally long wavelengths corresponding to the
The tear film is considered the first refracting surface of range of colors in the red spectrum focus more on the retina
eye with all known importance because it is the area which after. Aberrations and RMS tend to increase to the extent that
holds the most drastic change in terms of refractive indices the wavelength also increases.
(refractive index of air = 1, refractive index of the tear Unfortunately not exist at the time an aberrometer to
film = 1.336). be able to measure all the spectrum of visible light and its
It is well-known by everyone in our daily clinical practice single drive in a human optic system. Aberrometers spatially
the important subjective annoyance that patients manifest resolved, experimental type, after complex measures have
with some degree of dry eye and constant complaint of succeeded in giving information to 6 various different
fluctuating vision or loss of visual quality.17 wavelengths, but this is not possible with technology that is
In this same way, a wavefront measure in an eye with currently available in the market.
poor tear film can dramatically affect the outcome of an
aberrometry and induce multiple high-order distortions that
Aberrometer Sensors Resolution
should constitute an irregular astigmatism induced by micro
differences in the thickness of the tear film and consequent This is an inherent characteristic of construction, principle
loss of the homogeneity of the surface of corneal epithelium. and density of the sensors with which is constituted the
Considering the quality of the tear film as a major aberrometer, it is important to know that the greater number
constraint of aberrometrical measurement is also true that of sensors better the measuring at the expense of one more
the aberrometers with which the market has are sensitive detailed description of what the wavefront can be and the
enough to monitor and quantify optical changes associated specific quantification of each Zernike polynomials that
with the disruption of the tear. constituent.
CHAPTER
5
Fig. 11: Images: backlight centroids of Shack-Hartmann system and map of densities in the same patient after 40 seconds without blinking
A B
Figs 12A and B: Aberrometric test results with different pupil size
The aberrometric measurement principles can be for aberrometric calculation from high-resolution corneal
classified for practical purposes from the point of view topography.24-32
of the place where the machine captures the image to be • Internal process (ingoing process)
analyzed, according to this are called: of internal process – Tscherning
(ingoing process) or of external process (outgoing process); – Ray tracing
in the first group of aberrometers image capturing is done • External process (outgoing process)
at the retinal plane and in the second at the output level of – Hartman-Shack
the pupil. In a separate group we found the schiascopic • Schiascopic
aberrometers, the spatially resolved (experimental) and – Dynamic retinoscopy
42 Overview
• Spatially resolved: It is considered the only subjective 12. Marine Gobbe, Michel Guillon, Cecile Maissa. Measurement
aberrometer, experimental use repeatability of corneal aberrations. J Refract Surg. 2002;18:
• Corneal aberrometers: Based on high-resolution corneal S567-71.
13. Andrew B Watson, Albert J Ahumada. Predicting visual acuity
topography (not real aberrometers)
from wavefront aberrations. J of Vision. 2008;8(4);17:1-19.
The density of the number of sensors also speaks of the 14. Jorge L Alió, Mohamed H Shabayek. Corneal higher order
richness of the information with which to build aberrometrical aberrations a method to grade keratoconus. J Refract Surg.
data. One way to express is as from the measure of the 2006;22:539-45.
aberrometer resolution, which is expressed in microns and 15. Batool Jafri, Xiaohui Li, Huiying Yang, Yaron S Rabinowitz.
tells us that with a fewer resolution in microns image quality Higher order wavefront aberrations and topography in early
measured is better. and suspected keratoconus. J Refract Surg. 2007;23:774-81.
16. Ramkumar Sabesan. Visual performance after correcting
HOAs in keratoconic eyes. J of Vision. 2009;9(5);6:1-10.
CONCLUSION 17. Lung-Kun Yeh, Cheng-Jen Chiu, Chieh-Fang Fong, I-Jong
Wang, Wei-Li Chen, Chuhsing Kate Hsiao, Samuel CM Huang,
SECTION
The aberrometry, new diagnostic trend, heritage of

Yung-Feng Shih, Fung-Rong Hu, Luke LK Lin. The genetic
astrophysics, has aroused curiosity and loathing in effect on refractive error and anterior corneal aberration twin
2
ophthalmology colleagues, many of them interested in this eye study. J Refract Surg. 2007;23:257-65.
new science as another way to analyze the visual function, 18. Sabong Srivannaboon, Dan Z Reinstein, Timothy J Archer.
others are not at all interested for the difficult terminology of Diurnal variation of higher order aberrations in human eyes.
their slang or by complex mathematical concepts underlying. J Refract Surg. 2007;23:442-6.
With the advent of multiple aberrometric systems in the 19. Ioannis G Pallikaris, Sophia I Panagopoulou, Charalambos
diagnosis and therapeutic arsenal in refractive surgery, it is S Siganos, Vasilys V Molebny. Objective measurement of
wavefront aberrations with and without accommodation.
important to know in detail the principle and the foundations
J Refract Surg. 2001;17:S602-7.
of this new branch of knowledge of visual quality. We believe 20. Hang Cheng, Raymond Applegate. A population study on
that venture into this new world with solid basic knowledge changes in wave aberrations with accommodation. J of Vision.
and easily explained, help to understand more easily a 2004;4:272-80.
fascinating universe of optical functions. 21. Krisztina Hagyó, Béla Csákány, Zsolt Lang, János Németh.
Variability of higher order wavefront aberrations after blinks.
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22. Susana Marcos. Aberrations and visual performance following
1. Howard C Howland. The history and methods of ophthalmic standard laser vision correction. J Refract Surg. 2001;17:S596-
wavefront sensing. J Refract Surg. 2000;16:S552-3. S601.
2. Aberraciones que es eso de lo que habla todo el mundo?: 23. Alejandro Cerviño, Sarah L Hosking, Robert Montes-Mico,
Manual Básico de Supervivencia., Pablo Artal, Comunicado Keith Bates. Clinical ocular wavefront analyzers. J Refract Surg.
Ver y Oír, Marzo de 2002. 2007;23:603-16.
3. Benjamin F Boyd. Wavefront Analysis: Aberrómetros y 24. Michael Mrochen. Revealing company secrets—please tell the
Topografía Corneal. Highlights of Ophthalmology Inter- truth and nothing but the truth! J Refract Surg. 2000;16:S654-9.
national, Primera edicion en español, 2003. 25. Pablo Rodríguez, Rafael Navarro, Justo Arines, Salvador Bará.
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J Refract Surg. 2007;23:505-14. J Refract Surg. 2006;22:275-84.
5. Susana Marcos, Stephen A Burns, Esther Moreno-Barriusop, 26. Stephen A Burns. The spatially resolved refractometer. J Refract
Rafael Navarro. A new approach to the study of ocular Surg. 2000;16:S566-9.
chromatic aberrations. Vision Research. 1999; 39:4309-23. 27. Michael Mrochen, Maik Kaemmerer, Peter Mierdel, Hans-
6. Heidi Hofer, Pablo Artal, Ben Singer, Juan Luis Aragón, David R. Eberhard Krinke, Theo Seiler. Principles of Tscherning
Williams. Dynamics of the eye’s wave aberration. J Opt Soc Am. aberrometry. J Refract Surg. 2000;16:S570-1.
2001;18(3):497-506. 28. Vasyl V Molebny, Sophia I Panagopoulou, Sergiy V Molebny,
7. Larry N Thibos, Raymond A Applegate, James T Schwiegerling, Youssef S Wakil, Ioannis G Pallikaris. Principles of ray tracing
Robert Webb. Report from the VSIA taskforce on standards aberrometry. J Refract Surg. 2000;16:S572-5.
for reporting optical aberrations of the eye. J Refract Surg. 29. Paul D Pulaski, James T Roller, Daniel R Neal, Keith Ratte.
2000;16:S654-5. Measurement of aberrations with microlenses using a Shack-
8. Guang-ming Dai. Comparison of wavefront reconstructions Hartmann wavefront sensor. J Optal Soc America. 1980;70(8).
with zernike polynomials and fourier transforms. J Refract 30. Larry N Thibos. Principles of Hartmann-Shack aberrometry.
Surg. 2006;22:943-8. J Refract Surg. 2000;16:S565-3.
9. Larry N Thibos, Raymond A Applegate, James T Schwiegerling, 31. Ahmet Z Burakgazi, Bernard Tinio, Alejandro Bababyan,
Robert Webb. Standards for reporting the optical aberrations of Kevin Kevork Niksarli, Penny Asbell. Higher order aberrations
eyes. J Refract Surg. 2002;18:S652-60. in normal eyes measured with three different aberrometers.
10. Larry N Thibos. Wavefront Data Reporting and Terminology. J Refract Surg. 2006;22:898-903.
J Refract Surg. 2001;17:S578-83. 32. Alejandro Cervino, Sarah L Hosking, Gurjeet K Rai, Shezhad
11. Raymond A Applegate, Edwin J Sarver, Vic Khemsara. Are all A Naroo, Bernard Gilmartin. Wavefront analyzers induce
aberrations equal? J Refract Surg. 2002;18:S556-62. instrument myopia. J Refract Surg. 2006;22:795-803.
CHAPTER 6 Yazan A Zahran
Wavefront Aberrations from A to Z
INTRODUCTION
Before we start talking about wavefront we should mention
that to understand wavefront aberrations, we should change
our thinking about light, light is expressed differently in
geometrical and physical optics. The rays from a point source
of light radiates out in all directions in geometrical optics. In
physical optics, conversely light is considered as a wave and
the light wave spreads in all directions as a spherical wave.
The wavefront is the shape of the light waves that are all in-
phase. Although light coming from infinity is considered to
be linear bundles of light rays. It also expressed as a plane
wavefront (wavefront is a continuous surface that propagates
perpendicular to the direction of the lights rays) (Fig. 1).
FACTORS AFFECT THE OPTICAL QUALITY

OF THE RETINAL IMAGE
• Diffraction Fig. 1: Linear rays
• Whole eye wavefront error (wavefront aberration) that will
be discussed in this chapter
• Scatter From a clinical perspective, one of the most useful ways to
• Chromatic aberration. interpret the wavefront aberration function is the differences in
the optical path length (OPL) traveled by rays as they pass from
object to image, OPL is a measurement of the number of oscil
Wavefront Basics lations of a light wave that propagates from point to another.
So the main question is what do we mean by wavefront A propagating wavefront of light is defined by a collection
aberrations? To define the concept of wavefront aberration, of points in space that are found at the same OPL of a common
it is necessary to define the wavefront of a point light source, light source to define the aberration of an optical system, the
and before that the concepts of optical path length (OPL) and OPL of a ray that passes through any point (x, y) of the pupil
the optical path difference (OPD). plane can be compared to a main ray, which passes through
06.indd 43 29-03-2014 10:32:41

44 Overview
the center of the pupil (0, 0) as this light ray is not deviated nor inclination of the various optical components of the eye and
distorted along its path. The result is the OPD. each component’s relationship to the others (Fig. 3).
In a perfect optical system, the OPL will be the same for So to sum up wavefront aberration is defined as the optical
all light rays that travel from a point on an object to a point path difference (OPD) between the ideal and the actual
on the image, so the OPD is 0 for all positions (x, y) on the (aberrated) wavefront (Figs 4A and B).
pupil. THese rays will have the same phase and will therefore
aggregate constructively to produce the perfect image for an Classification of Aberrations
eye focused on infinity, the ideal wavefront exiting from an
aberration-free eye is flat and circular (Fig. 2). We can classify wavefront aberration into:
On the other hand, light that passes through different • Low order aberrations (0-2 radial order) include refractive
points on the pupil will arrive at the destination in different defects that can be corrected with spectacles or standard
phases. Consequently, the system is aberrated and the quality contact lenses.
of the image will be distorted. So if we consider aberrations • High order aberrations (more than second radial order)
SECTION
as being the difference in OPL it stands to reason that the include spherical aberrations, coma and all aberrations
aberrations could derive from the qualitative and quantitative that are classed under the heading of irregular astigmatism
2
anomalies of the lacrimal film, the cornea, the aqueous or defects that cannot be corrected with commercially
humor, the crystalline lens, the vitreous body, decentering or available spectacles or lenses.
We can classify the aberration further into monochromatic
or polychromatic:
• Monochromatic aberrations are associated with a specific
wavelength.
• Polychromatic aberrations is caused by the dispersion of
light in various media it crosses and the light will spilt into
various colors of the visible spectrum.
Fig. 2: The relationship between the wavefront and the light rays.
The light rays travel perpendicular to the wavefront at all points
Figs 4A and B: The emerging light in these two images neither

Fig. 3: The wavefront aberrations, illustrated in gray, is the difference converges to a point nor does it form a parallel beam, resulting in
between the ideal wavefront and aberrated wavefront irregular-shaped wavefront
06.indd 44 29-03-2014 10:32:41

Wavefront Aberrations from A to Z 45
We can classify aberrations according the site of origin of systematically grouped on a pyramid-shaped periodic table.
the aberrations which include: Each line of the pyramid corresponds to a given order of the
• Corneal aberrations polynomial of the function and each column corresponds to the
• Internal optics aberrations different Azimuthal frequency. By convention the harmonics
• Total ocular aberrations which include the sum of the in the cosine phase are identified with plus sign while those
corneal and the internal optics aberrations (Fig. 5). in the sine phase are identified with minus sign. The unit of
measurement for every Zernike coefficient is the micron.
Representing Wavefront Aberrations Polynomials can be expanded up to any arbitrary order
if sufficient numbers of measurements for calculations are
For wavefront measurement to be useful in the analysis of made.
vision, aberration must be represented by terms that can
be understood by ophthalmologist here comes the role of
Measurement of Wavefront Aberrations
the Zernike and Fourier series polynomials and in simple
CHAPTER
words both Zernike and Fourier describe complex three- Wavefront sensing techniques can be categorized by whether
dimensional surfaces in mathematical terms, making it the measurement is based on subjective or objective methods.
6
possible to design customized corneal ablation. It is difficult to measure the wavefront aberrations accurately
The Zernike polynomials are the most widely adopted tool using subjective methods due to prolonged measurement
to describe wavefront aberration, this mathematical method period and its dependence on the subject’s judgment.
considers every map as the adjusted sum of fundamental Wavefront sensors usually use ray-tracing methods to
shapes or the basic functions as shown in the figure below. reconstruct the wavefront and are classified into the following
These group of mathematical expressions are the product three types:
of two functions-one of which depends solely on the R radius 1. Outgoing wavefront aberrometry is used in the Hartmann-
of a point on the pupil, and the other depends solely on the Shack sensor.
θ meridian of a point on the pupil plane. THe first function is 2. Ingoing retinal imaging aberrometry is used in the cross
a simple polynomial of the nth degree and the second is the cylinder aberroscope, the Tscherning aberroscope and the
harmonic of a sinusoid or co-sinusoid. sequential ray tracing method.
The double index model Z(r, f) where the index r describes 3. The ingoing feedback aberrometer is used in the spatially
the higher power (order) of the radial polynomials and the resolved refractometer (SRR). THe optical path difference
index f described the Azimuthal frequency of the sinusoidal method (OPD) (slit retinoscopy or skiascopy) is a variant
component. The basic Zernike functions or modes or terms are of this method.
Fig. 5: Wavefront total results
06.indd 45 29-03-2014 10:32:42

46 Overview
Table 1: Zernike polynomials up to the forth order

Term Polar representation Monomial representation Meaning
Z0(x,y) 1 1 Constant term
Z1(x,y) rsenq x Tilt on x direction
Z2(x,y) rconsq y Tilt on y direction
Z3(x,y) r2sen(2q) 2xy Astigmatism with axis at ±45°
Z4(x,y) 2r2 – 1 –1 + 2y2 + 2x2 Focal aberration (myopia or hyperopia)
Z5(x,y) r2cos(2q) y2 – x2 Astigmatism with axis at ±90°
Z6(x,y) r3sen(3q) 3xy2 – x3
Z7(x,y) (3r3 – 2p)senq –2x + 3xy2 + 3x3 Coma of 3rd order at x axis
SECTION
Z8(x,y) (3r3 – 2p)cosq –2y + 3y3 + 3x2y Coma of 3rd order at y axis
2
Z9(x,y) r3cos(3q) y3 – 3x2y

Z10(x,y) r4sen(4q) 4y3x – 4x3y
Z11(x,y) (4r4 – 3r2)sen(2q) –6xy + 8y3x + 8x3y
Z12(x,y) 6r4 – 6r2 + 1 1 – 6y2 – 6x2 + 6y4 + 12x2y2 – 6x4 Spherical aberration of 3rd order
Z13(x,y) (4r4 – 3r2) + cos(2q) –3y2 + 3x2 + 4y4 – 4x2y2 – 4x4
Z14(x,y) r4cos(4q) y4 – 6x2y2 + x4
We will discuss the Hartman-Shack aberrometer because

it is the most popular instrument used in the clinical practice.
The concept of H-S that a narrow beam from monochromatic
light source (the laser diode) was collimated and delivered
to the eye which projects a light spot on the retina, part of
the light is reflected back from the point source. Because
the shape of an aberrated wavefront surface changes as it
propagates, the exit pupil of the eye is imaged to the lenslet
array of the CCD camera by a set of relay lenses. The wavefront
aberrations at the exit pupil of the eye are then measured as
shown in the following image.
In perfect eye, the reflected plane wave will be focused
into images with each point locating on the optical axis of
the corresponding lenslet, otherwise the aberrated wavefront Fig. 6: Zernike pupil related
shows a distorted grid pattern. By measuring the displacement
of each point from its corresponding lenslet axis, the slope
of aberrated wavefront when it entered the lenslet can be
calculated. After mathematical integration of the slope, the
final aberration map will be obtained then the measured
wavefront aberrations can be described and analyzed with
the earlier introduced Zernike polynomials (Figs 6 to 8).
Metrics to Define Image Quality
Root Mean Square Aberration

It is a measure of the magnitude of the wave aberrations.
In another words, the root mean square aberration (RMS)
is the standard deviation of total wavefront with respect to
ideal. The RMS calculated as the square root of the sum of
the square of the Zernike coefficients. The following equation
shows such a calculation: Fig. 7: Zernike index
06.indd 46 29-03-2014 10:32:42

CHAPTER
6
Fig. 9: Point patterns
Fig. 8: Zernike images In another words, the Strehl ratio is the ratio between the
peak heights of the PSF over the peak height for the same
optical system if it were diffraction limited (dl) (Fig. 13).
RMS = Z–22 + Z02 + Z22 + Z–33 + ...
RMS error has limited utility as an ideal single metric for
Modulation Transfer Function
visual performance because it does not show how a given The modulation transfer function (MTF) indicates the ability
aberration affects visual performance. of an optical system to reproduce (transfer) various levels of
detail (spatial frequencies) from the object to the image. Its
Point Spread Function units are the ratio of image contrast over the object contrast
as a function of spatial frequency.
Objects are made up of an infinite number of points. The A person, for example is composed of many spatial
point spread function (PSF) of the eye describes how each frequencies from low (torso, arms, legs) to high (facial
object point is imaged on the retina. Consequently the PSF features, hair, etc.). We all know that fine detail or high spatial
is one of the fundamental methods for describing the optical frequencies are the first to be get lost when you degrade an
quality of an imaging system such as the eye. So in a perfect image. When you are out of focus, you can still make out a
optical system, the PSF should look like a point or a distant person (low spatial frequencies), but you may not identify his
star (Figs 9 to 12). or her fine facial features (high spatial frequencies).
Strehl Ratio Phase Transfer Function

Before we talk about this ratio, we must clarify what do we When spatial frequencies get transferred to the image plane,
mean by DIFFRACTION. Diffraction is defined as deviation of the location of the bright and dark bars, called the PHASE of
the light rays from rectilinear path that cannot be interpreted the reduced–contrast grating may also be shifted. In another
as reflection or refraction. Diffraction effects are pupil size words, it is the phase difference between the object image
dependent. The diffraction effects induced by the pupil and retinal image.
diameter are easily viewed by observing how increasing
pupil diameter decrease diameter of the PSF in a perfect eye
(no wavefront aberrations—such an optical system is often
Optical Transfer Function
referred to as diffraction limited). The MTF and the phase transfer function (PTF) combine to
The Strehl ratio is measurement correlated for PSF. form the optical transfer function (OTF). Like the PSF, the
It expresses the relationship between the real luminous OTF is an entirely adequate and complete way to present how
intensity of the object-image and the maximum intensity of a an image is formed by the optical system. In the simple words,
focal point limited by diffraction alone. in a healthy visual system, the improvement in the quality of
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48 Overview
SECTION
2
A B
C D
Figs 10A to D: Process from perfect to aberrated wavefront
Fig. 11: PSF for increasing pupil sizes in perfect eye, the small pupil size Fig. 12: PSF of increasing pupil sizes in a typical human eye, the effect
as 1 mm. The image-point is large due to diffraction not aberrations of aberrations as the pupil size increase is very obvious
06.indd 48 29-03-2014 10:32:43

CHAPTER
6
Fig. 13: Pictorial definition of Strehl ratio. The maximum value of Strehl
ratio is 1, which occurs when the optical system is diffraction limited
the retinal image is translated into greater contrast (with an

increase in the MTF) and sharper definition (with reduction
in PTF) (Fig. 14).
Relationships Between Wavefront Aberrations,

Point Spread Function and Optical Transfer
Function
The wavefront aberration, the PSF, and the OTF are all
intimately related. Once the wave aberration is known the
PSF and OTF can be calculated. The relationships between
the three are typically through the Fourier transform (Fourier Fig. 14: Pictorial demonstration of the calculation of the MTF and the
transform is mathematical operation has allowed various PTF. The first row shows the object, which are 100% contrast vertical
measures of optical quality to be linked and allows the sinusoidal gratings with low, medium, and high spatial frequencies.
computation of the expected retinal image for any visual After passing through the imaging system, the gratings have less
object). From wave aberration to PSF, one takes the Fourier contrast and the peak locations (phase) are shifted. The MTF plots the
change in contrast relative to the original object. The PTF plots the
transform of the complex pupil function. The OTF is the
change in phase of the same grating. This procedure may be different
Fourier transform of the PSF. for each orientation of the gratings. The OTF is the combination of the
MTF and the PTF for all grating orientations
Factors Affecting Wavefront Aberrations
in the Human Eye
1. Pupil size: In smaller pupil size (less than 2.0 mm), 3. Age: The normal aging process affects all ocular tissues
diffraction affects the image quality more than aberrations. and causes changes to both neural and optical parameters
A larger pupil will allow the light rays to enter the eye of the human eye. Increase in the wavefront aberrations
through the periphery which may cause an increase of have been found in aged eyes and these changes in the
wavefront aberrations. As the pupil size increases, the ocular aberrations may be contributed by the age-related
effect of aberrations on image quality increases and changes of two major optical components, the cornea and
become more dominant in the larger pupil. the crystalline lens.
2. Accommodation: Accommodation-induced changes of 4. Refractive error: There is conflicting results of the impact
aberrations including changes of defocus, astigmatism, of refractive errors on the optical structure and the higher
and high order aberrations especially the spherical order aberrations of the eye.
aberrations which change in direction to negative with 5. Ocular disease especially keratoconus: Significant
increase accommodation. amount of corneal and ocular HOAs are induced by the
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50 Overview
SECTION
2
Fig. 15: Wavefront aberration, PSF and MTF for three different wave aberrations. The relation between them: when aberrations are present, the
PSF broadens and becomes more irregular. The MTF shows that with aberrations, contrast drops quickly and in nonuniform manner for all high
spatial frequencies
distortion of cornea in keratoconus compared to normal visual quality. It is necessary to diagnose visual symp
eyes. Coma, trefoil and spherical aberration were found to toms related to aberrations such as diplopia, halos,
be the most dominant HOAs in both corneal and ocular glare as this can help determine the best treatment.
aberrations in keratoconus eyes. • Intraocular lens design: The use of aspheric IOLs to
6. Corneal refractive procedures: There is induction of reduce preoperative normal corneal positive spherical
HOAs in many refractive procedures like PRK and LASIK. aberration has been shown to increase the contrast
sensitivity in mesopic conditions. Customization of
Application of Wavefront Technology the selection of an IOL is a new concept that goes
further than achieving emmetropia after cataract
1. Wavefront-guided ablation: The use of wavefront
surgery. The objective is to estimate the optimum
aberrometry to guide an excimer laser ablation is based
amount of spherical aberration within the eye and the
on the notable theoretical advantage of correcting not
only spherocylindrical errors but also the HOAs while IOL to optimize optical quality. The corneal HOAs are
minimizing the induction of aberrations by the laser measured and help determine the best IOL according
ablation. to the expected induction in spherical aberration.
2. Diagnostic and intraocular lens design applications: Appropriate IOL selection is becoming more important
The applications of wavefront sensing go far beyond as more patients with prior refractive surgery are now
wavefront-guided ablations. in need of cataract extraction.
• Diagnostic: Wavefront technology as a diagnostic tool 3. Expanding the depth of focus by modifying higher–
has been important in understanding the relationship order aberrations: Although HOAs degrade the quality
between anatomical structures, optics, and subjective of vision in most circumstances, in some instances they
06.indd 50 29-03-2014 10:32:44

may have a beneficial effect. In the case of presbyopia, the every ophthalmologist must have a good insight about this
induction of specific HOAs may expand the depth of focus subject.
without significantly compromising the quality of vision
and this will improve the near vision with compromising
BIBLIOGRAPHY
the distant vision (Fig. 15).
1. Borish’s clinical refraction, 2nd edn. Chapter 19 (wavefront
refraction).
CONCLUSION 2. Mello GR, Rocha KM, Santhiago MR, et al. Applications of
wavefront technology. J Cataract Refract Surg. 2012;38:1671-83.
Wavefront technology is a new tool that will have a 3. Wavefront customized visual correction. The Quest for
widespread application in the field of ophthalmology so Supervision 2 Slack Incorporated. 2004.
CHAPTER
6
06.indd 51 29-03-2014 10:32:44

CHAPTER 7 Vance Thompson
Basic Wavefront Optics and

Ocular Aberrations
these aberrations so that these more accurate measurements

INTRODUCTION could be used to develop treatment plans that would drive
The surgical treatment of refractive error involves precision the excimer laser for ablation patterns that addressed low
preoperative measurements. For decades, the phoropter has order aberrations in smaller increments that was ever before
been a critical tool for measuring refractive error. A traditional possible plus describe and treat for the first time ever, the
phoropter or loose lens refraction will measure spherical and patients high order aberrations.5
regular astigmatism refractive error only. For many patients,
this is enough for quality vision but for some it may not be. WAVEFRONT TECHNOLOGY IN
For any doctor that has diligently performed a manifest
refraction for an otherwise healthy patient with a seemingly CLINICAL PRACTICE
healthy ocular system, it can be frustrating when the patient In wavefront terminology low order aberrations (LOAs) refer
feels that even though they can read the 20/20 line the letters to myopia, hyperopia, and astigmatism. In an otherwise
look ‘fuzzy’ or have a ‘ghost image’. Prior to this century, healthy eye, LOAs make the vast majority of refractive error
even though we knew that internal high order aberrations and high order aberrations (HOAs) make up a much smaller
were often the culprit blurring retinal image quality, we had portion or the total error. Wavefront technology allows the
no technology to document this. We called refractive error examiner to learn much more about the optical state of a
that we could not correct with a refraction, for lack of a better patient’s eye (Fig. 1). If there is pathology such as corneal
term, irregular astigmatism. trauma, previous corneal surgery (refractive or therapeutic),
Wavefront technology allowed us, for the first time in significant dry eye, corneal edema, or anything else besides
history, to diagnostically measure beyond regular sphere and a normal cornea the amount of HOAs can become large
cylinder, which allowed us to clinically understand the low enough to be a significant cause of visual blur or frustration6-9
and high order aberration state of an eye and thus start to (Figs 2 and 3). Reduced image quality, glare, and halos from
define much more specifically these high order terms, we had elevated HOAs can be measured, quantified, and potentially
been calling irregular astigmatism.1-3 In a short period of time, treated. It is also important to realize that HOAs can be very
wavefront testing of eyes has revolutionized the definition of normal and be present in eyes with very good vision (Figs 4A
refractive error.4 Wavefront measuring devices, also known and B). HOA patterns can also share certain characteristics in
as aberrometers, have allowed us the ability to measure and certain disease states like keratoconus.10 Wavefront analysis
subsequently both quantify and mathematically describe can tell us vital information in laser vision correction patients
07.indd 52 29-03-2014 10:33:17

Basic Wavefront Optics and Ocular Aberrations 53
CHAPTER
7
Fig. 1: Wavefront analysis provides much more data than manifest refraction. This 55-year-old preoperative wavefront shows HOAs of 5.4% and
a detailed analysis of both a wavefront derived LOA refraction and breakdown and magnitude of HOAs
with a near plano result but still not satisfied with their image variety of aberrations with names such as coma, trefoil, and
quality (Figs 5A and B). This data can then be used to develop spherical aberration.
vision changing treatment plans that can help these frustrated
patients achieve a quality visual result. Finally, wavefront
changes occur naturally with aging, such as an increase in WAVEFRONT MEASURING DEVICES:
spherical aberration due to lenticular changes with time, and ABERROMETERS
it is important to take these changes into consideration when
analyzing aberration maps11,12 (Figs 6 and 7). That is why, it There are many more HOAs and the measurement of
is important to learn wavefront technology and apply it to the them with what is called an aberrometer requires more
overall clinical situation when trying to decide whether HOAs sophisticated techniques such as Shack-Hartmann sensing
need to be addressed surgically, optically, or not. can provide data from which the wave aberrations of the
In the world of wavefront terminology, myopia and hyper- human eye can be accurately and reliably quantified (Fig. 9).
opia are referred to as defocus. Defocus and astigmatism are Clinical aberrometers provide very detailed measurements
called 2nd order aberrations (Fig. 8). Measuring defocus of the eye's wavefront aberration state and have become
and astigmatism is most commonly done with a phoropter very important in modern day eyecare both diagnostically
or autorefractor. High order aberrations (HOAs) comprise a and for optical and surgical treatment planning. The total
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54 Overview
SECTION
2
Fig. 2A: Dry eye can significantly impact a wavefront due to tear film irregularities inducting high order aberrations
as shown in on the left in this 32-year-old preoperative LASIK with newly diagnosed dry eye
wavefront error and the individual contribution of each As stated previously a common aberrometer used in clinical
higher-order aberration in the individual eye can now be practice is the Hartmann-Shack aberrometer. This technology
accurately determined and quantified by these aberrometers. works by projected a highly collimated light source onto the
An aberrometer is basically a wavefront sensing device retina which then reflects off the retina, comes back through
which measures the wavefront as it exits the eye. They can the lens, through the pupil, and exits the eye through the
only analyze data that comes through the pupil so typically cornea. This wavefront is then focused by individual lenses
having a dilated pupil for the examination is helpful, but not called lenslets. This array of lenslets in the aberrometer each
always necessary, to assess pupillary areas used in low light have the same focal length. Each is focused onto a photosensor
situations. Accommodation should be controlled for, ideally (typically CCD). In this way, a very detailed analysis across
with cylcoplegia. Any dry eye should be treated also since an the entire wavefront occurs with the final result being a quite
irregular tear film can cause unpredictable changes in the accurate (but not perfect) reconstruction of the patient’s total
wavefront and make the measurement less accurate.6-8 (LOAs and HOAs) optical data. There are other wavefront
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CHAPTER
7
Fig. 2B: With 4 weeks of dry eye therapy, this same dry eye patient the wavefront is much improved with lower
HOAs and a better quality wavefront
analyzers used clinically also. The construction of a wavefront to describe these measured LOAs and HOAs is Zernike or
map utilizes sophisticated mathematics called polynomials Fourier polynomials.3,17,18 They share many similarities but
to describe it in details that allow it to be clinically useful also differences that are beyond the goals of this chapter. The
and put into color maps that share similarities with corneal main purpose in this discussion is to understand that after
topography for helpful viewing.3,13 a clinical wavefront sensing device captures wavefront data
exiting an eye these mathematical polynomial equations are
used to describe the wavefront numerically or graphically.
ANALYSIS OF THE WAVEFRONT DATA
This data is able to describe both wavefront aberrations and
As mentioned above, the shape of a wavefront is corneal surfaces and thus be used diagnostically to assess
mathematically described complex equations called the overall optical quality of an eye plus design customized
polynomials.13-16 A common mathematical method used corneal ablations for PRK or LASIK.19,20
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56 Overview
SECTION
2
Fig. 3A: Point spread function (PSF) of the same 32-year-old preoperative LASIK patient in
Figure 2 on the left in this with newly diagnosed dry eye
A common clinically useful way to describe the wavefront us understand the optical quality of an eye. The higher the
shape uses a single number to describe the amount the RMS value the greater the number of aberrations. Typically,
wavefront deviates from a plane wave called the root mean patients who have fewer total aberrations (lower RMS value)
square (RMS) error.3,21 Mathematically, it represents the tend to have better contrast sensitivity and low light image
standard deviation of the wavefront from a plane wave and quality. A perfect example of this is comparing Figure 4
is often used to describe the overall optical quality of the eye. where the 22-year-old patient has quality vision and an HOA-
The RMS can be calculated for the total aberration or for the RMS value of 0.18 while the 27-year-old with glare and halos
individual higher-order aberrations (HOAs). It is important in Figure 5 has an RMS value of 0.94.
to remember that the RMS value is a number that indicates Wavefront analysis gives other important parameters
the magnitude of the aberration but not its unique shape. A helpful in analyzing a patient’s image quality, namely, point
perfect optical system would have a flat wavefront and an spread function (PSF) and modulation transfer function
RMS of zero. Evaluating root mean square (RMS) values helps (MTF).19 The PSF image is formed by light from a point source
07.indd 56 29-03-2014 10:33:18

CHAPTER
7
Fig. 3B: With 4 weeks of dry eye therapy, this same dry eye patient the point spread function is much improved
with lower HOAs and a better quality wavefront
traveling through an optical system. The PSF is small and highly Besides looking at the low and high order aberration state
focused in an eye with minimal aberrations (Fig. 4). The PSF of an eye, it can be very helpful clinically to routinely assess
is large, irregular, and highly defocused in an eye with a lot of these useful parameters such as RMS, PSF, and MTF.
aberrations and poor image quality (Fig. 5). The MTF measures
the loss of contrast with increasing spatial frequency when an
CONCLUSION
image travels through an aberrated optical system. Spatial
frequency refers to the number of pairs of bars imaged within Understanding the total optics of the eye is critically important
a given distance on the retina and is defined by the number of diagnostically and in developing surgical plans. Custom
cycles (line pairs) per unit distance. It is known that high spatial laser vision correction addressing both low and high order
frequencies (fine details, closely spaced alternation black and aberrations was made possible by wavefront technology.
white fine lines) are the first to be affected when the quality of Wavefront technology has forever revolutionized, how we
an optical system is degraded. MTF quantifies this loss. analyze the optical state of the eye.
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58 Overview
SECTION
2
A B
Figs 4A and B: (A) High order aberrations are present also in eyes with quality vision and no glare or halos. This is a 22-year-old patient happy
with their image quality. Note HOA of 7.4%, Coma of 0.116, and spherical aberration of 0.07. (B) Point spread function of the same patient
A B
Figs 5A and B: (A) A 27-year-old post-LASIK patient who has had previous conventional treatment of myopia and sphere who suffers from glare
and halos due to induced high order aberrations. Their wavefront quantifies their high and low order aberrations to aid in treatment planning.
(B) Point spread function, if the same patient on the right
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CHAPTER
7
Fig. 6A: Wavefront changes normally with age. Note spherical aberration in this 22-year-old patient with
20/20 best corrected vision (BCVA) and no complaints
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60 Overview
SECTION
2
Fig. 6B: Wavefront changes normally with age. Note spherical aberration for this 53-year-old patient with 20/20 BCVA and no complaints
07.indd 60 29-03-2014 10:33:20

CHAPTER
7
A B
Figs 7A and B: Same patients as in Figure 6 showing how point spread function changes normally with age also. (A) Note point spread function
in this 22-year-old patient with 20/20 best corrected vision (BCVA) and no complaints. (B) Note point spread function for this 53-year-old patient
with 20/20 BCVA and no complaints
Fig. 8: Zernike polynomials
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62 Overview
SECTION
2
Fig. 9: The VISX WaveScan Wavefront System is an example of a common clinically used Hartmann-Shack Aberrometer. The WaveScan
wavefront system uses the same Hartmann-Shack technology used in the Hubble space telescope
REFERENCES 6. Deschamps N, Ricaud X, Rabut G, Labbé A, Baudouin

C, Denoyer A. The impact of dry eye disease on visual
1. Huelle JO, Katz T, Draeger J, Pahlitzsch M, Druchkiv V, Steinberg performance while driving. Am J Ophthalmol. 2013;156(1):
J, Richard G, Linke SJ. Accuracy of wavefront aberrometer 184-9.
refraction vs manifest refraction in cataract patients: impact 7. Himebaugh NL, Nam J, Bradley A, Liu H, Thibos LN, Begley CG.
of age, ametropia and visual function. Graefes Arch Clin Exp Scale and spatial distribution of aberrations associated with
Ophthalmol. 2013;251(4):1163-73. tear breakup. Optom Vis Sci. 2012;89(11):1590-600.
2. López-Miguel A, Martínez-Almeida L, González-García MJ, 8. Denoyer A, Rabut G, Baudouin C. Tear film aberration dyna-
Coco-Martín MB, Sobrado-Calvo P, Maldonado MJ. Precision mics and vision-related quality of life in patients with dry eye
of higher-order aberration measurements with a new placido- disease. Ophthalmology. 2012;119(9):1811-8.
disk topographer and Hartmann-Shack wavefront sensor. 9. Oliveira CM, Ferreira A, Franco S. Wavefront analysis and
J Cataract Refract Surg. 2013;39(2):242-9. Zernike polynomial decomposition for evaluation of corneal
3. Mello GR, Rocha KM, Santhiago MR, Smadja D, Krueger RR. optical quality. J Cataract Refract Surg. 2012;38(2):343-56.
Applications of wavefront technology. J Cataract Refract Surg. 10. Saad A, Gatinel D. Evaluation of total and corneal wavefront
2012;38(9):1671-83. high order aberrations for the detection of forme fruste
4. López-Miguel A, Maldonado MJ, Belzunce A, Barrio-Barrio J, keratoconus. Invest Ophthalmol Vis Sci. 2012;53(6):2978-92.
Coco-Martín MB, Nieto JC. Precision of a commercial Hartmann- 11. Oshika T, Klyce SD, Applegate RA, Howland HC. Changes in
Shack aberrometer: limits of total wavefront laser vision corneal wavefront aberrations with aging. Invest Ophthalmol
correction. Am J Ophthalmol. 2012;154(5):799-807. Vis Sci. 1999;40(7):1351-5.
5. Liyanage SE, Allan BD. Multiple regression analysis in myopic 12. Wang L, Dai E, Koch DD, Nathoo A. Optical aberrations of the
wavefront laser in situ keratomileusis nomogram development. human anterior cornea. J Cataract Refract Surg. 2003;29(8):
J Cataract Refract Surg. 2012;38(7):1232-9. 1514-21.
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13. Dai GM, Mahajan VN. Orthonormal polynomials in wavefront 18. Maeda N. Clinical applications of wavefront aberrometry: a
analysis: error analysis. Appl Opt. 2008;47(19):3433-45. review. Clin Exp Ophthalmol. 2009;37:118-29.
14. Smolek MK, Klyce SD. Goodness-of-prediction of Zernike 19. Zhou C, Chai X, Yuan L, He Y, Jin M, Ren Q. Corneal higher-
polynomial fitting to corneal surfaces. J Cataract Refract Surg. order aberrations after customized aspheric ablation and
2005;31(12):2350-5. conventional ablation for myopic correction. Curr Eye Res.
15. Klyce SD, Karon MD, Smolek MK. Advantages and disadvan- 2007;32(5):431-8.
tages of the Zernike expansion for representing wave aberration 20. Wang Y, Zhao KX, He JC, Jin Y, Zuo T. Ocular higher-order
of the normal and aberrated eye. J Refract Surg. 2004;20(5):
aberrations features analysis after corneal refractive surgery.
S537-41.
Chin Med J. 2007;120(4):269-73.
16. Smolek MK, Klyce SD. Zernike polynomial fitting fails to
represent all visually significant corneal aberrations. Invest 21. Thibos, L, Applegate RA, Schweigerling JT, Webb R. VSIA
Ophthalmol Vis Sci. 2003;44(11):4676-81. Standards Taskforce Members, “Standards for Reporting
17. Roorda A. A review of basic wavefront optics. In: Krueger the Optical Aberrations of Eyes,’’ OSA Trends in Optics and
RR, Applegate RA, MacRae SM (Eds). Wavefront Customized Photonics, Vision Science and its Applications, Lakshmi-
CHAPTER
Visual Correction; the Quest for Super Vision II. Thorofare, NJ, narayanan, V (Ed). Optical Society of America, Washington
Slack. 2004;pp.9-18. DC. 2000;35:232-44.
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SECTION 3
Clinical Cases
8. Corneal Aberrometry Changes Following Intracorneal Ring Segment

Implantation
Jorge L Alio, Alfredo Vega-Estrada, Pablo Peña-García
9. Monocular Diplopia
José Luis Güell
10. Wavefront Analysis and Scheimpflug Imagery in Diagnosis of

Anterior Lenticonus
Peter S Hersch, Yinfei Xu, David S Chu
11. P-curve Clinical Cases

Roberto Pinelli
CHAPTER 8 Jorge L Alio, Alfredo Vega Estrada,
Pablo Peña-García
Corneal Aberrometry Changes

Following Intracorneal Ring Segment
Implantation
Regarding the aberrometric changes after ICRS surgery,

INTRODUCTION results are also variable and depend on factors such as,
The idea of using intracorneal ring segments (ICRS) for preoperative refractive error, location of the ectasia, and
the correction of ametropías was developed by JI Barraquer preoperative values of lower and higher order aberrations.
in the early 50’s.1 This technique-based on the thickness The current nomograms select the number of segments
law of the same author,2 states that the addition of tissue in depending on the location of the ectasia. The length and
the peripheral cornea or the removal in the center induces thickness of the segments is determined according to the
a flattening of the cornea. In addition, the postulates of manifest refraction of the patient. Due to the great variability
Blavatskaya2 and Barraquer, states also, that the compensation in refraction, symmetries of the cone and biomechanical
of the ametropia is directly proportional to the thickness of behavior of each case, the aberrometric changes are quite
the segment and inversely proportional to their length. variable as mentioned.
Although, the physical basis that explains the ICRS The main problem of the refractive compensation in
performance were known, they were not used in keratoconus keratoconic eyes is the irregular astigmatism. Therefore,
patients until the year 2000 when Colin et al.3 used them the goal of this surgery is not only to reduce the mean
for this purpose. They reported a significant flattening keratometry but also to regularize the corneal shape. The
of the central cornea and a reduction of the topographic most desirable situation is produced when the steepest
astigmatism, resulting in a more regular shape. They also meridian is flattened and the flattest meridian is incurved, or
found a statistically significant reduction in the refractive when both are flattened but with higher dioptric reduction
error, congruent with the topographical effect described. in the steepest meridian.14 When this happens, the corneal
Subsequent studies reported similar results, and evaluated the cylinder diminishes and the root mean square (RMS) of the
efficacy and safety of this surgical procedure in keratoconus primary astigmatic aberration (corresponding to the Z(2, 2)
patients.4-10 The previous studies showed gain of lines of and Z(2, –2) Zernike coefficients) is also reduced.
corrected vision by the patients, in mean terms, however Regarding the high order aberrations (HOA), the spherical-
the unpredictability of this treatment has been reported.11,12 like and coma-like aberrations have been described to have a
Taking into account the grading system for keratoconus great influence in the visual function in keratoconic patients.
developed by our investigational group, mainly based on The ocular spherical aberration is affected by the optics of
the visual status of the patient,13 it was shown that ICRS the cornea and the crystalline lens. Beiko et al15 reported a
implantation can result in a loss of lines of corrected vision mean of +0.27 microns for the spherical aberration induced
in initial grades of keratoconus.11,12 However, in advanced by the cornea in the normal healthy population. This positive
grades of the illness, results are good enough to consider value is compensated by the optics of the crystalline in young
ICRS implantation as an excellent alternative to prevent, or at patients as reported by Artal et al.16 However, the ability
least delay, corneal graft. for the compensation of this aberration declines with age,
68 Clinical Cases
because the spherical aberration induced by the crystalline Both implants showed to reduce significantly the spherical
lens in older eyes is more positive. equivalent, however, a more limited compensation of the
Of course, the changes in the asphericity of the cornea astigmatism was found in the eyes implanted with INTACS.
after the implantation of ICRS play an important role in the This fact is congruent with a statistically significant higher
change of the spherical aberration induced by the cornea and reduction of the astigmatism RMS in the group of eyes
therefore in the ocular spherical aberration. The segments implanted with Keraring. The reason for this different
are designed to induce a larger flattening in eyes with higher behavior seems to be related with the different length of these
keratometric values. Normally, the higher the myopia, the two types of segments, shorter in the case of Keraring.
higher the flattening and therefore, a more positive spherical Both implants provided a mean reduction on the primary
aberration is induced. coma and coma-like aberrations 6 months after the surgery
Therefore, the effect of the segments regarding ocular although, this improvement was not statistically significant. In
spherical aberration, depends on the preoperative a previous study, it was found statistical significant reduction
keratometry, corneal asphericity and age of the patient. Since of the primary coma in those patients with preoperative
SECTION
the spherical aberration has been referred as an important values coma RMS values higher than 3.0.19
source of visual disturbance, the newest designs of some Regarding spherical aberration, this study found a
3
commercial marks (like the Ferrara segments) have started to significant negativization of the primary spherical aberration
consider the corneal asphericity as a parameter to take into in the eyes implanted with INTACS. This effect was not found
account for the selection of the implants. in the eyes implanted with Kerarring.
A mean reduction of the primary coma after the Another kind of implant, called Myoring, was also
implantation of segments has been reported by most of the evaluated in a pilot study by our group.20 The Myoring is a 360°
authors. The reduction of this aberration, obviously is positive arc length implant, and showed to produce a very powerful
for the visual acuity of the patient, however several studies flattening of the central cornea, with a mean decrease of
have investigated this without obtaining a clear conclusion 8.00D. Evidently, this behavior has an important impact on
about the preoperative aspects that leads to a reduction of the spherical aberration. Although, the sample evaluated
this aberration.12 Moreover, although in mean terms, the was not large (12 eyes), a very significant increment in the
implantation of segments produces a slight reduction of the corneal primary spherical aberration was noted (p = 0.001)
coma and coma-like aberrations, this reduction could be not one month after the surgery. However, a significant reduction
statistically significant, at least for all grades.17 in the high order aberrations was detected 3 to 6 months after
The type of segments used for the surgery have also the surgery (p = 0.027).
influence on the aberrometric changes that happens after Finally, the technique used for the implantation of the
the implantation. This issue was studied by our group.17 segments has also been referred as an influent factor on the
Seventeen eyes implanted with INTACS and 20 eyes implan aberrometric outcomes. In 2009, Alió et al.21 reported the
ted with Keraring were compared. All the patients included results of the comparison of mechanical versus femtosecond
in this study were graded as low-to-moderate keratoconus laser assisted procedures. Although, both techniques
under the Alió-Shabayeck classification.18 This classification achieved similar visual and refractive results, a worse aberro
is mainly based on the aberrometric status of the patients and metric correction was found in the case of the manual
confers special importance to the coma-like aberrations. procedure.
Corneal Aberrometry Changes Following Intracorneal Ring Segment Implantation 69
CLINICAL CASES
CASE 1
This case corresponds to a 21 years old female patient with a
longstanding history of keratoconus who wear contact lenses
during the last seven years. During the last six months she
referred intolerance to contact lens on her right eye and she
notice that her visual acuity has decrease over the last few
months.
Ophthalmological Evaluation
CHAPTER
8
Uncorrected visual acuity (UCVA)
Right eye (RE): 0.050.
Left eye (LE): 0.200.
Corrected visual acuity (CDVA)

Right eye (RE): 0.800. Fig. 1: Keratokonus preoperative
Left eye (LE): 1.00.
Refraction Postoperative Evaluation

RE: Sph –3.00 cyl –3.00@140°. Ophthalmological evaluation six months after the procedure
LE: Sph –2.50 cyl –2.00@30. showed the following findings:
Biomicroscopy UCVA
RE: Transparent cornea, peripheral nerve thickening. Right eye (RE): 0.300.
LE: Unremarkable. Spectacle CDVA (RE): 0.840.
Contact lens CDVA (RE): 1.000.
Fundus evaluation Refraction: Sph –1.50 cyl –2.50@140°.
Unremarkable.
Postoperative Corneal Topography and
Corneal pachymetry
RE: 458 microns. Aberrometry (Figs 3 and 4)
LE: 480 microns. K1: 46.74D.
K2: 51.39D.
Preoperative Corneal Topography (Fig. 1) RMS total aberrations: 7.53 microns.
RMS coma aberration: 1.24 microns.
RE: Central oval pattern with flattest keratometry (K1):
47.82 D and steepest keratometry (K2): 52.03D.
LE: Normal. Summary
This case correspond to a mild keratoconus case taking into
Preoperative Corneal Aberrometry (Fig. 2) account the level of anterior corneal aberrations and the
degree of visual limitation. After implantation of two ICRS
RE around the central zone of the cornea which correspond to
RMS total: 9.50 microns. the focal steepening in the corneal topography, we found a
RMS coma: 2.41 microns. central flattening of the area that leads to a reduction in the
RMS spherical aberration: 1.66 microns. spherical equivalent of the patient. We also observed an
Surgical planning: We decided to perform an implantation important reduction of more than 1 micron in the root mean
of two intracorneal ring segments (ICRS) on the right eye square of the coma aberration that certainly will increase the
following the guidelines of the manufacturer´s nomogram. optical quality of the patient.
70 Clinical Cases
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3
Fig. 2: Preoperative
Fig. 3: Postoperative
CHAPTER
8
72 Clinical Cases
CASE 2
This case corresponds to a 26 years old female patient with
a longstanding history of keratoconus who has a poor
motivation to contact lens wearing.
UCVA
RE: 0.100.
LE: 0.100.
CDVA
SECTION
RE: 0.600.
3
LE: 0.800.
Refraction Fig. 5: Keratokonus preoperative

RE: Sph +1.50 cyl –4.25@80°.
LE: Sph cyl –2.00@110. Postoperative Evaluation
Biomicroscopy Ophthalmological evaluation six months after the procedure
RE: Corneal thinning, Fleischer ring. showed the following findings:
LE: Unremarkable.
UCVA
Fundus evaluation Right eye (RE): 0.500.
CDVA (RE): 0.800.
Unremarkable.
Refraction
Corneal pachymetry
Sph 0.00 cyl –2.50@110°.
RE: 419 microns.
LE: 472 microns.
Postoperative Corneal Topography and
Preoperative Corneal Topography (Fig. 5) Aberrometry (Figs 7 and 8)
RE: Inferior steepening and asymmetric bowtie pattern. K1: 51.75D.
K1: 52.18D. K2: 55.13D.
K2: 58.37D. RMS total aberrations: 16.06 micorns.
RMS coma aberration: 1.36 microns.
Preoperative Corneal Aberrometry (Fig. 6)
Summary
RE This case corresponds to a moderate keratoconus case taking
RMS total: 40.00 microns. into account the level of anterior corneal aberrations and the
RMS coma: 3.70 microns. degree of visual limitation. Inferiorly implantation of one
RMS spherical aberration: –0.58 microns. ICRS leads to a “push up” of the inferior steepening towards
Surgical planning: We decided to perform an implantation the center of the cornea which induces a more regular anterior
of one ICRS inferiorly on the right eye as suggested by the corneal surface with the consequent reduction of more than 2
guidelines of the manufacturer´s nomogram. microns in the asymmetric (coma) aberration.
CHAPTER
8
74 Clinical Cases
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3
CASE 3
The last case corresponds to a 25 years old male patient with
a longstanding history of keratoconus who underwent a
penetrating keratoplasty procedure 3 years ago on the right
eye. He is referred to our center to evaluate the possibility of
performing a deep anterior lamellar keratoplasty (DALK) on
the left eye.
UCVA
CHAPTER
RE: 0.500.
LE: Counting fingers at 3 meters.
8
CDVA
RE: 0.900. Fig. 9: Keratokonus preoperative
LE: 0.320.
Refraction Postoperative Evaluation

RE: Sph –1.00 cyl –2.00@10°. Ophthalmological evaluation six months after the procedure
LE: Sph –7.50 cyl –4.00@60. showed the following findings:
Biomicroscopy UCVA
RE: Transparent corneal graft. LE: 0.300.
LE: Central corneal thinning, Vogt striae, transparent cornea
without central leucoma. Spectacle CDVA
LE: 0.500.
Fundus evaluation
Contact lens CDVA
Unremarkable.
LE: 0.700.
Corneal pachymetry
Refraction
RE: 570 microns.
Sph –3.00 cyl –2.25@140°.
LE: 361 microns.
Preoperative Corneal Topography (Fig. 9) Postoperative Corneal Topography and

Aberrometry (Figs 11 and 12)
LE: Central oval pattern with a severe central steepening.
K1: 53.67D. K1: 53.85D.
K2: 60.29D. K2: 56.62D.
RMS total aberrations: 7.46.
Preoperative Corneal Aberrometry (Fig. 10) RMS coma aberration: 1.69 microns.
LE Summary
• RMS total: 29.01 microns.
This case correspond to a severe keratoconus case taking into
• RMS coma: 4.94 microns.
account the level of anterior corneal aberrations and the degree
• RMS spherical aberration: 0.91 microns. of visual limitation. We found that after ICRS implantation
Surgical planning: Even though the visual acuity and the there is a flattening of the central cornea and a major reduction
prognosis of this case was very poor we discuss the different of the coma aberration that improves the visual function and
therapeutic alternative with the patient and decided to offer the refraction of the patient. The modeling effect of the corneal
him ICRS implantation leaving the DALK procedure for the stroma observed after implantation of the segments allow us
future in case that ICRS implantation failed. We decided to in this case not just to achieved an important reduction of
perform an implantation of two ICRS following the guidelines the anterior corneal aberrations but to delay or even avoid a
of the manufacturer's nomogram. keratoplasty procedure in a young patient.
76 Clinical Cases
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CHAPTER
8
segments; preliminary results. Ophthalmology. 2003;110:

REFERENCES 516-24.
1. Barraquer JI. Queratoplastia refractiva, estudios e 7. Kymionis GD, Siganos CS, Kounis G, Astyrakakis N, Kalyvianaki
informaciones oftalmológicas. 1949;2:10-30. MI, Pallikaris IG. Management of post-LASIK corneal ectasia
2. Barraquer JI. Cirugía Refractiva de la Córnea. Instituto with Intacs inserts; one-year results. Arch Ophthalmol.
Barraquer de América- Bogotá, Tomo I, 1989. 2003;121:322-6.
3. Colin J, Cochener B, Savary G, Malet F. Correcting keratoconus 8. Barbara A, Shehadeh-Masha’our R, Zvi R, Garzozi HJ.
with intracorneal rings. J Cataract Refract Surg. 2000;26: Management of pellucid marginal degeneration with
1117-22. intracorneal ring segments. J Refract Surg. 2005;21:296-8.
4. Alió JL, Salem TF, Artola A, Osman AA. Intracorneal rings to 9. Alió JL, Shabayek MH, Artola A. Intracorneal ring segments
correct corneal ectasia after laser in situ keratomileusis. J for keratoconus correction: long-term follow-up. J Cataract
Cataract Refract Surg. 2002;28:1568-74. Refract Surg. 2006;32:978-85.
5. Siganos CS, Kymionis GD, Kartakis N, Theodorakis MA, 10. Shabayek MH, Alió JL. Intrastromal corneal ring segment
Astyrakakis N, Pallikaris IG. Management of keratoconus with implantation by femtosecond laser for keratoconus correction.
Intacs. Am J Ophthalmol. 2003;135:64-70. Ophthalmology. 2007;114:1643-52.
6. Ruckhofer J, Stoiber J, Twa MD, Grabner G. Correction of 11. Vega-Estrada A, Alio JL, Brenner LF, Javaloy J, Plaza Puche
astigmatism with short arc-length intrastromal corneal ring AB, Barraquer RI, Teus MA, Murta J, Henriques J, Uceda-
78 Clinical Cases
Montanes A. Outcome analysis of intracorneal ring segments 16. Artal P, Berrio E, Guirao A, Piers P. Contribution of the cornea
for the treatment of keratoconus based on visual, refractive, and internal surfaces to the change of ocular aberrations with
and aberrometric impairment. Am J Ophthalmol. 2013;155(3): age. J Opt Soc Am A Opt Image Sci Vis. 2002;19(1):137-43.
575-84. 17. Piñero DP, Alió JL, El Kady B, Pascual I. Corneal aberrometric
12. Peña-García P, Vega-Estrada A, Barraquer RI, Burguera- and refractive performance of 2 intrastromal corneal ring
Giménez N, Alio JL. Intracorneal ring segment in keratoconus: segment models in early and moderate ectatic disease. J
a model to predict visual changes induced by the surgery. Cataract Refract Surg. 2010;36(1):102-9.
Invest Ophthalmol Vis Sci. 2012;53(13):8447-57. 18. Alió JL, Shabayek MH. Corneal higher order aberrations:
13. Alió JL, Piñero DP, Alesón A, Teus MA, Barraquer RI, Murta a method to grade keratoconus. J Refract Surg. 2006;22(6):
J, Maldonado MJ, Castro de Luna G, Gutiérrez R, Villa C, 539-45.
Uceda-Montanes A. Keratoconus-integrated characterization 19. Shabayek MH, Alió JL. Intrastromal corneal ring segment
considering anterior corneal aberrations, internal implantation by femtosecond laser for keratoconus correction.
SECTION
astigmatism, and corneal biomechanics. J Cataract Refract Ophthalmology. 2007;114:1643-52.

3
Surg. 2011;37(3):552-68. 20. Alio JL, Piñero DP, Daxer A. Clinical outcomes after complete
14. Albertazzi R. Tratamiento del queratocono con segmentos ring implantation in corneal ectasia using the femtosecond
intracorneales. Editor: Albertazzi R. Queratocono: pautas technology: a pilot study. Ophthalmology. 2011;118(7):
para su diagnostico y tratamiento. Buenos Aires. Ediciones 1282-90.
Científicas Argentinas para la Keratoconus Society. 2010:205-67. 21. Piñero DP, Alio JL, El Kady B, Coskunseven E, Morbelli H, Uceda-
15. Beiko GH, Haigis W, Steinmueller A. Distribution of corneal Montanes A, Maldonado MJ, Cuevas D, Pascual I. Refractive
spherical aberration in a comprehensive ophthalmology and aberrometric outcomes of intracorneal ring segments for
practice and whether keratometry can predict aberration keratoconus: mechanical versus femtosecond-assisted
values. J Cataract Refract Surg. 2007;33(5):848-58. procedures. Ophthalmology. 2009;116(9):1675-87.
CHAPTER 9 José Luis Güell
Monocular Diplopia
EXAMPLE OF TOPO-GUIDED ABLATION

Here you will find some examples of post-LASIK significant astigmatism was treated with CIPTA Software (topo-guided
visual complains such as monocular diplopia. The irregular ablation): symptoms were reduced and UCVA improved.
09.indd 79 29-03-2014 10:34:25

80 Clinical Cases
Case 1
SECTION
3
50°-1.00 + 2.00 VA 0.2 + “ghost image”
10°-2.00 + 1.50 VA 0.63
09.indd 80 29-03-2014 10:34:26

Monocular Diplopia 81
Case 2
CHAPTER
9
UCVA 0.25 (120°-1.00 + 2.00) 0.4 + monocular diplopia
UCVA 0.4 – (120°-0.50 + 1.50) 0.6 + no monocular diplopia
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82 Clinical Cases
Case 3
SECTION
3
UCVA 0.2 (70°-3.00 + 2.25) 0.5 – pinhole 0.8 – monocular diplopia UCVA 0.6 (55º-0.75 + 0.50) 0.8 – no monocular diplopia
09.indd 82 29-03-2014 10:34:28

Monocular Diplopia 83
Case 4
UCVA 0.2- (25º-4.00 + 0.50) 0.3-blurred UCVA 0.4 (110º-2.00 + 1.25) 0.6-clear
CHAPTER
9
09.indd 83 29-03-2014 10:34:28

CHAPTER 10 Peter S Hersh, Yinfei Xu, David S Chu
Wavefront Analysis and Scheimpflug

Imagery in Diagnosis of
Anterior Lenticonus
Abstract
We present the case of an Alport syndrome patient whose anterior lenticonus was detected by wavefront analysis and Scheimpflug imaging
technology. Patient’s lenticular abnormalities were too subtle to be detected by the initial slit-lamp examination. However, normal corneal
topography and elevation maps with high total eye aberrations pointed to internal optics as the source of aberrations. More specifically,
predominant negative spherical aberrations suggested anterior lenticonus, a diagnosis further confirmed by Scheimpflug images showing
central bulging of the anterior lens surface. Following diagnosis, patient underwent successful phacoemulsification and intraocular lens (IOL)
implantation. We recommend wavefront analysis and Scheimpflug imaging technology as effective tools in the detection of lens disorders,
especially those that are too subtle to be observed by other examination methods.
INTRODUCTION change in lens contour is often very subtle, AL can remain

undetected throughout ocular examinations. New imaging
Anterior lenticonus (AL) is a rare condition in which a portion technology, such as wavefront sensing and Schiempflug
of the crystalline lens capsule and underlying cortex bulge imaging, can help in the early diagnosis of such optical
anteriorly. The conical protrusion results from a genetic defect disorders.
in synthesis of type IV collagen, a major component of the To demonstrate these technologies as important tools in
lenticular basement membrane.1 AL develops progressively diagnosing anterior lenticonus and other optical disorders, we
and bilaterally, possibly manifesting as severe myopia and present an Alport syndrome patient whose subtle lenticular
lenticular irregular astigmatism.2 Although sometimes abnormalities were first detected by wavefront analysis and
isolated, AL may also present as a pathognomonic feature then confirmed by Scheimpflug quantitative imaging.
of Alport syndrome, a hereditary nephritis accompanied
by sensorineural hearing loss as well as other ocular
abnormalities.3 AL occurs in approximately 25% of patients
CASE REPORT AND METHODS
with X-linked Alport syndrome.4 Posterior lenticonus is not A 44-year-old male with Alport syndrome was referred to
usually associated with a systematic disease.5 our clinic to be considered for refractive surgery. His chief
Several literatures have reported success in treatment of complaint was a progressive reduction of vision in both
AL. Liu et al5 recommend phacoemulsification with foldable eyes and he sought the procedure in hopes of improving
IOL implantation as a safe and efficient procedure. However, his vision. Ocular symptoms were managed by wearing
the disorder must be diagnosed before it can be treated, a prescription glasses but best corrected visual acuity (BCVA)
process that may sometimes prove difficult. Because the remained unsatisfactory. Past ocular histories were otherwise
Wavefront Analysis and Scheimpflug Imagery in Diagnosis of Anterior Lenticonus 85
unremarkable. Patient had a history of renal failure and kidney that predominant spherical aberrations were suggestive of
transplant twenty-one years previously. His medications anterior lenticonus (AL).6
included prednisone, cyclosporine, magox, soriatune, The OCULUS Pentacam is also able to define the anterior
nexium, norvasc, atorvastatin calcium, warfarin sodium, curvature of the lens. Rotating Scheimpflug imaging with the
colchicines, niferex, atenolol, doxercalciferol, fenofibrate, Pentacam captures twenty-five image slices from the anterior
folic acid, duloxetine hydrochloride, foltx, allopurinol, and surface of the cornea to the posterior surface of the lens.5
digoxin. These images detailed the contour of the protrusion in our
On examination, uncorrected visual acuity was 20/50–1 OD patient’s dilated lens over a 360-degree circle. Scheimpflug
and 20/70 OS. BCVA and subjective manifest refraction was images in Figures 3A to C display the anterior lenticonus in
20/30–1 OD with –6.25 –1.00 × 155 and 20/40–2 OS with –7.25 our patient against that of a normal lens.
–2.50 × 170. Slit-lamp biomicroscopy revealed a clear and To characterize this Scheimpflug image of lenticonus
compact cornea with normal intraocular pressure and fundi. and compare it to the normal population, measurements
No significant cataract or other obvious anomalies of the lens were taken from the apex of the bulge to a 4 mm chord
CHAPTER
and anterior segment were observed. length for fifteen refractive surgery candidates with normal
10
Corneal topographic and elevation maps were normal as lenses. Variability was minimized by including only dilated
computed by the OCULUS Pentacam software (OCULUS, lenses and candidates within 6 years of age from our patient.
Lynnwood WA, USA). Sagittal curvature and elevation maps Measurements yielded a 400 μm protrusion in the lenticonus
of the patient’s cornea front are shown in Figure 1. eye reported herein compared to a mean of 256.7 μm with
Wavefront analysis was performed with the Alcon 27.2 μm standard deviation for those without lenticular
LADARWave aberrometer (Alcon Labs, Fort Worth, Texas, abnormalities (Figs 3A to C).
USA). The device utilizes Hartmann-Shack principles to Since ocular symptoms were most severe in the left eye,
detect, measure, and display higher order aberrations of cataract extraction and IOL implantation were selected to be
the eye. Total-eye wavefront analysis revealed high negative performed first on the left eye. Following lens removal through
spherical aberration in both eyes with RMS values of –1.08 μm phacoemulsification, an ACRYSOF® IOL, manufactured by
and –1.43 μm for right and left eyes, respectively. Preoperative Alcon Labs, Fort Worth, Texas, was inserted into the eye.
wavefront maps with Zernike modes and aberration values
are shown in Figures 2A to C. Given normal corneal maps
DISCUSSION
and abnormal total-eye wavefront analysis, the internal
optics of the eye, thus, was likely the main source of vision This case highlights the role of wavefront analysis and
deficits. More specifically, previous literature indicated Scheimpflug imaging technology in detecting lenticular
Fig. 1: Normal left eye corneal front topographic maps of sagittal curvature and elevation
86 Clinical Cases
SECTION
3
A B
Figs 2A to C: Preoperative wavefront maps of (A) right and (B) left eyes reveal dominant spherical aberrations in both eyes, represented by a
highly negative center with positive ring; (C) Zernike modes, including coma and spherical, with patient’s total-eye aberration values are shown
below wavefront maps
abnormalities that first went undetected by other ophthalmic Wavefront maps define the deviation of an aberrated
examinations, including anterior segment slit-lamp. Eye wavefront from the ideal reference wavefront. The reference
aberrations can result from both lenticular and corneal shape used for comparison is a flat, circular plane which
imperfections since the cornea and lens contribute represents an emmetropic, or theoretically perfect, eye.
approximately two-thirds and one-third of the total focusing RMS values correspond to decreases in optical quality
power of the eye, respectively. The subtlety of the lenticular and are represented by deviations from the emmetropic
abnormality made it difficult to detect and was only observed plane as cooler or warmer colors. Evaluation of higher-
after wavefront analysis first pointed to it as a contributing order aberrations in our patient revealed predominant
factor in the patient’s vision loss. spherical aberration in both eyes (Figs 2A to C), suggesting
CHAPTER
10
A B
Figs 3A to C: Scheimpflug images distinguishing the dilated lens contour of anterior lenticonus (A) and that of a normal lens (B).
(C) 4 mm chord and lens protrusion values are indicated
that reflection patterns were produced by an anterior lens diagnosis with quantitative results. Lenticular protrusion at
surface bulge. In a study evaluating irregular astigmatism, 400 μm from a 4 mm chord was more than three standard
Ninomoya and associates6 found that astigmatism induced deviations away from the mean of fifteen normal patients
by anterior lenticonus produced such spherical-like at 256.7 μm. Given the patient’s medical history of Alport
aberrations. On the other hand, predominance of coma- syndrome and wavefront analysis results, Scheimpflug
like aberrations would have indicated keratoconus-induced imaging was sufficient to confirm the diagnosis.
irregular astigmatism. After cataract extraction and IOL implantation, total-
Further examination with the Scheimpflug camera eye aberrations were reduced from 2.64 μm to 1.38 μm. The
captured a complete picture of the anterior segment and improvements in optical quality are reflected in the post-
provided visual confirmation of AL. Measurements and operative wavefront map and aberration values (Figs 4A
calculations performed on the images supported the to C), which show a much greater resemblance to a flat,
88 Clinical Cases
SECTION
3
A B
C
Figs 4A to C: Postoperative wavefront maps (A and B) and Zernike modes (C) of left eye showing significant reduction of spherical and
other aberrations, resulting in a greater resemblance to the emmetropic eye
circular plane, representing the emmetropic eye. As most of Since optical disorders may be of various origins, such
the aberrations were due to lenticonus, surgical treatment as lenticular, corneal, retinal and/or neurological, a long
dramatically restored the patient’s left eye vision from 20/40–2 differential process of elimination may be required. However,
to a BCVA of 20/25. wavefront analysis can assist the diagnostic process by
Advanced imaging technologies are useful for diagnosing identifying subtle abnormalities through characteristic
a variety of optical disorders, including anterior lenticonus. clues such as spherical and coma aberrations. Finally, when
correlated with medical history and wavefront analysis, the treatment of a patient with bilateral anterior lenticonus due
Scheimpflug imaging can provide visual confirmation of to Alport syndrome. J Int Med Res. 2008;36:1440-4.
treatable pathology. 3. Lagona E, Tsartsali L, Kostaridou S, Skiathitou A, Georgaki E,
Sotsiou F. Skin biopsy for the diagnosis of Alport Syndrome.
Hippokratia. 2008;12:116-8.
REFERENCES 4. Amiraslanzadeh G. Is anterior lenticonus the most common
ocular finding in Alport syndrome? J Cataract Refract Surg.
1. Blaise P, Delanaye P, Martalo O, Pierard GE, Rorive G, Galand 2008;34:5.
A. Anterior lenticonus: diagnostic aid in Alport syndrome. J Fr 5. Grewal DS, Jain R, Brar GS, Grewal SP. Scheimpflug imaging
of pediatric posterior capsule rupture. Indian J Ophthalmol.
Ophtalmol. 2003;26:1075-82.
2009;57:236-8.
2. Liu YB, Tan SJ, Sun ZY, Li X, Huang BY, Hu QM. Clear 6. Ninomoya S, Maeda N, Kuroda T. Evaluation of lenticular
lens phacoemulsification with continuous curvilinear irregular astigmatism using wavefront analysis in patients with
capsulorhexis and foldable intraocular lens implantation for lenticonus. Arch Ophthalmol. 2002;120:1388-93.
CHAPTER
10
P-curve Clinical Cases
P-curveTM is an algorithm patented for correcting presbyopia Do not forget that, in any human being eye, accommodat-
through LASIK. ing, the negative spherical aberrations are growing in terms of
The cases show aberrations changes after P-curve number.
ablations. All the cases show presbyopia correction with J1 This means a simple thing negative spherical aberration is
OU in all the patients. a key for presbyopia correction in a presbyopic patient.
A short analysis of aberrations changes shows negative Enjoy those clinical cases and think about the negative
spherical aberrations augmentation in ALL cases. spherical aberration rule!
This probably means that negative spherical aberrations
have a rule in presbyopia correction.
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P-curve Clinical Cases 91
CASE 1: Female, 51 years old
Preoperative UCVA for Far

RE: 20/50 nat
LE: 20/50 nat
Preoperative UCVA for Near

RE: J6 nat
LE: J6 nat
CHAPTER
Preoperative BCVA for Far
11
RE: 20/20 sph. +1.00
LE: 20/20 sph. + 0.75 cyl + 0.50 ax 85°
Preoperative BCVA for Near

J1 add. + 1.50 OU
Postoperative UCVA for Far (12 Months)

RE: 20/20
LE: 20/20
Autorefractometry Postoperative
RE: sph 0.00 cyl –0.50 ax 150°
LE: sph 0.00 cyl –0.75 ax 22°
Postoperative UCVA for Near

J1 OU.
RE = Right Eye; LE = Left Eye; UCVA = Uncorrected Visual Acuity;

BCVA = Best-corrected Visual Acuity
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92 Clinical Cases
Right Eye Preoperative Aberrations Map

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3
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Right Eye Postoperative Aberrations Map
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94 Clinical Cases
Left Eye Preoperative Aberrations Map

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3
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Left Eye Postoperative Aberrations Map
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11
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96 Clinical Cases

RE: 20/40 nat
LE: 20/40 nat

RE: J7 nat
LE: J7 nat

SECTION
RE: 20/20 sph. +0.50 Cyl 0.50 ax 90°

3
LE: 20/20 sph. +0.50 cyl +1.00 ax 80°

J1 add. +1.75 OU

RE: 20/20
LE: 20/20
RE: sph 0.00 cyl –0.25 ax 65°
LE: sph +0.50 cyl +0.50 ax 15°

J1 OU.
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98 Clinical Cases

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100 Clinical Cases

SECTION
3
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RE: 20/32 nat
LE: 20/32 nat

RE: J6 nat
LE: J6 nat
CHAPTER
RE: 20/20 sph. + 0.00 cyl + 1.00 ax 90°
11
LE: 20/20 sph. + 0.00 cyl + 0.50 ax 90°

J1 add. +1.25 OU

RE: 20/20
LE: 20/20
RE: sph + 0.50 cyl –0.75 ax 30°
LE: sph –0.25 cyl –0.50 ax 160°

J1 OU.
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102 Clinical Cases

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104 Clinical Cases

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3
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106 Clinical Cases
CASE 4: Male, 53 years old

RE: 20/40 nat
LE: 20/40 nat

RE: J6 nat
LE: J6 nat

SECTION
RE: 20/20 sph. + 0.75 Cyl /

3
LE: 20/20 sph. +1.00 Cyl /

J1 add. + 1.50 OU

RE: 20/20
LE: 20/20
RE: sph + 0.00 cyl –0.75 ax 40°
LE: sph + 0.25 cyl –0.75 ax 160°

J1 OU.
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108 Clinical Cases

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CHAPTER
11
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110 Clinical Cases

SECTION
3
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CASE 5: Male, 56 years old

RE: 20/50 nat
LE: 20/50 nat

RE: J7 nat
LE: J7 nat
CHAPTER
RE: 20/20 sph. + 0.50 cyl + 0.75 ax 90°
11
LE: 20/20 sph. + 0.25 cyl + 0.75 ax 85°

J1 add. +1.50 OU

RE: 20/20
LE: 20/20
RE: sph –0.75 cyl –0.25 ax 50°
LE: sph –0.50 cyl –0.50 ax 50°

J1 OU.
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112 Clinical Cases

SECTION
3
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CHAPTER
11
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114 Clinical Cases

SECTION
3
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CHAPTER
11
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SECTION 4
Atlas
12. Wavefront Basic Images

Roberto Pinelli
12.indd 117 29-03-2014 10:35:58

12.indd 118 29-03-2014 10:35:58
Wavefront Basic Images
WHY THIS SIMPLE AND EMBLEMATIC

images. See also the power of those pure designs and think
ATLAS? with your own knowledge and mind to the symbolic message
Lots of images are everyday running on our screens and of those. And do not forget, when, if we use them, we always
diagnostic machines but some “clear” and “pure” images of create a compromise. This small and primordial Atlas is an
aberrations, uncontaminated, will be more useful compared invitation/suggestion/intimidation to think that we are
to a classic list. See the peculiarities of those “primordial” playing with great concepts.
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120 Atlas
SECTION
4
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Wavefront Basic Images 121
CHAPTER
12
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122 Atlas
SECTION
4
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Index
Page numbers followed by f refer to figure
A F N
Aberrometer 53 Ferrara segments 68 Negative spherical aberration 37
sensors resolution 40
Aberrometric test 41f
Aberrometry limitations 40
Alió-Shabayeck classification 68 G O
Alport syndrome 84 Ghost image 80 Ocular disease 49
Application of Glaucoma 4 Ophthalmological
wavefront technology 50 evaluation 69, 72, 75
Asymmetric aberrations 37 Optical
Autorefractometry postoperative 91, 96, 101, basic functions 34
106, 111 H path
Hartmann-Shack difference method 45
aberrometer 46, 62f length 43
B technology 62f Society of America 34
High order aberrations 36-38, 52, 53, 67 transfer function 39, 49, 47
Basic wavefront optics Organization of Zernike polynomials in
and ocular aberrations 52 pyramid 35f
Biomicroscopy 69, 72, 75
I
Internal optics aberrations 45 P
C Intracorneal ring segment 67, 69
implantation 67 Peripheral
Chromatic aberration 40, 43 Intraocular lens design 50 aberration 35
Classification of nerve thickening 69
aberrations 44 Phase transfer function 40, 47
Constant aberrations 35 Point spread function 39, 47, 56
Contact lens CDVA 69, 75 K Positive spherical aberration 37
Cooperation with National and Postoperative
International Scientific Societies 11 Keratokonus preoperative 69f, 72f, 75f corneal topography and
Corneal aberrometry 69, 72, 75
aberrations 45 evaluation 69, 72, 75
aberrometers 42 L Preoperative corneal
pachymetry 69, 72, 75 aberrometry 69, 72, 75
refractive procedures 50 Left eye Primary spherical aberration 37
postoperative aberrations map 95, 100, Project of vision 1
105, 110, 115 Psychology of vision 14
Pupil size 40, 49
D preoperative aberrations map 94, 99,
104, 109, 114
Deep anterior lamellar keratoplasty 75 Low order aberrations 35, 36f, 52
Diffraction 43 R
M Refraction 69, 72, 75
Refractive
E error 49
Modulation transfer function 47, 56
Eye aberrations 29 Monocular diplopia 79, 81, 82 surgery 11f
124 Wavefront: A Text and Atlas
Representing wavefront Spectacle CDVA 69, 75

aberrations 45 Spherical aberration 37, 38f
w
Retina 4 Strehl ratio 47 Wavefront
Right eye Structure of new vision institute 4 aberrations 43, 44f, 45, 49, 50f
postoperative aberrations map 93, 98, basic images 119
103, 108, 113 guided ablation 50
preoperative aberrations map 92, 97, T measuring devices 53
102, 107, 112 technology 52
Root mean square 38, 56, 67 Total ocular aberrations 69
aberration 46 Transparent cornea 69
coma 69, 75
aberration 69, 72, 75
error 56
Z
spherical aberration 69, 72, 75 U
Zernike
total aberrations 69, 72, 75 Uncorrected visual acuity (UCVA) 69, 72, classification 30f
75, 81-83 coefficients 45-67
images 30f, 47f
S index 46f
polynomials 34, 61f
Secondary spherical aberration 37 v Zero symmetry
Shack-Hartmann system 41f
Single qualitative weight 39 Visx wavescan wavefront system 62f aberration 37

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WAVEFRONT

A Text and Atlas

JAYPEE B ROTH ERS M EDI CAL PUBL I SHERS ( P) L T D

© 2014, Jaypee Brothers Medical Publishers

Inquiries for bulk sales may be solicited at: jaypee@jaypeebrothers.com

Wavefront: A Text and Atlas

First Edition: 2014

Alfredo Vega Estrada MD Luis Antonio Ruiz MD

Tangwa Martin Neville MD

Section 1 the Project of Vision: Hypothesis for a Functional Structure

1. A New Winning Philosophy 3

2. Highlights on Statistics and Clinical Research 10

3. New Operative Tools to Improve the Structure 14

4. Eye Aberrations: Overview 29

5. An Approach to the Wavefront Technology: Aberrometry Basis 32

6. Wavefront Aberrations from A to Z 43

7. Basic Wavefront Optics and Ocular Aberrations 52

Section 3 Clinical Cases

8. Corneal Aberrometry Changes Following Intracorneal Ring Segment Implantation 67

10. Wavefront Analysis and Scheimpflug Imagery in Diagnosis of Anterior Lenticonus 84

11. P-curve Clinical Cases 90

12. Wavefront Basic Images 119

1. A New Winning Philosophy

2. Highlights on Statistics and Clinical Research

3. New Operative Tools to Improve the Structure

A New Winning Philosophy

THE VISION INSTITUTE

eyes (retina, glaucoma, etc.), the vision institute offers him a

STRUCTURE OF THE NEW VISION

INSTITUTE Fig. 2: The entrance of the institute

‘Services Chart’ of his private company without needing any

Concepts Vital to Every Marketing Initiative

• High quality standards in all services offered

How can we Transmit all these Concepts

Fig. 7: The staff gathered in

a wide gamut of important resources to meet patient’s needs

such ideas in the light of the institute’s own geographical,

02.indd 10 29-03-2014 10:28:45

• Furthermore, it is useful to devote a period in the weekly

COOPERATION WITH NATIONAL AND

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Fig. 3: Some important scientific societies related to refractive surgery

02.indd 12 29-03-2014 10:28:46

02.indd 13 29-03-2014 10:28:47

New Operative Tools to

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Fig. 2: Diagnostic area

03.indd 15 29-03-2014 10:30:27

• Patient feels justified in asking for surgery. possible?).

Fig. 3: The first meeting with the patient care

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Fig. 4: The patient’s informed consent

03.indd 17 29-03-2014 10:30:28

Fig. 5: The evaluation of clinical and patient satisfaction data

assessment. This variable may be viewed as a significant

Patient Satisfaction and Quality of Life Evaluation

Satisfaction with Surgery = Good Quality of Vision?

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03.indd 19 29-03-2014 10:30:29

Fig. 8: Clinical folders archive