Korean J Ophthalmol 2018;32(3):163-171

ht tps://doi.org/10.33 41/k jo.2017.0 075

pISSN: 1011-8942 eISSN: 2092-9382

Original Article

Comparison of Anterior, Posterior, and Total Corneal Astigmatism

Measured Using a Single Scheimpflug Camera in Healthy and
Keratoconus Eyes
Young Choi, Youngsub Eom, Jong Suk Song, Hyo Myung Kim

Department of Ophthalmology, Korea University College of Medicine, Seoul, Korea

Purpose: To compare the effect of posterior corneal astigmatism on the estimation of total corneal astigmatism
using anterior corneal measurements (simulated keratometry [K]) between eyes with keratoconus and healthy
eyes.
Methods: Thirty-three eyes of 33 patients with keratoconus of grade I or II and 33 eyes of 33 age- and sex-
matched healthy control subjects were enrolled. Anterior, posterior, and total corneal cylinder powers and flat
meridians measured by a single Scheimpflug camera were analyzed. The difference in corneal astigmatism
between the simulated K and total cornea was evaluated.
Results: The mean anterior, posterior, and total corneal cylinder powers of the keratoconus group (4.37 ± 1.73,
0.95 ± 0.39, and 4.36 ± 1.74 cylinder diopters [CD], respectively) were significantly greater than those of the
control group (1.10 ± 0.68, 0.39 ± 0.18, and 0.97 ± 0.63 CD, respectively). The cylinder power difference be-
tween the simulated K and total cornea was positively correlated with the posterior corneal cylinder power and
negatively correlated with the absolute flat meridian difference between the simulated K and total cornea in
both groups. The mean magnitude of the vector difference between the astigmatism of the simulated K and
total cornea of the keratoconus group (0.67 ± 0.67 CD) was significantly larger than that of the control group
(0.28 ± 0.12 CD).
Conclusions: Eyes with keratoconus had greater estimation errors of total corneal astigmatism based on an-
terior corneal measurement than did healthy eyes. Posterior corneal surface measurement should be more
emphasized to determine the total corneal astigmatism in eyes with keratoconus.

Key Words: Astigmatism, Cornea, Keratoconus, posterior corneal astigmatism, total corneal astigmatism

Keratoconus is a chronic, progressive, noninflammatory, myopia and irregular astigmatism [1]. The condition usual-
ectatic corneal disorder that deteriorates vision because of ly arrests in the third to fourth decades of life, although it
can commence later and progress at any age [1]. Currently,
a rigid gas-permeable contact lens, intrastromal corneal
Received: June 12, 2017 Accepted: October 15, 2017
ring segment implantation, corneal collagen cross-linking,
Corresponding Author: Youngsub Eom, MD, PhD. Department of Oph- photorefractive keratectomy, and a phakic intraocular lens
thalmology, Ansan Hospital, Korea University College of Medicine, #123
Jeokgeum-ro, Danwon-gu, Ansan 15355, Korea. Tel: 82-31-412-5160, Fax: (IOL) are the treatment options for keratoconus.
82-2-924-6820, E-mail: [email protected] Collagen cross-linking affects the progression of and can

© 2018 The Korean Ophthalmological Society

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses
/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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Korean J Ophthalmol Vol.32, No.3, 2018

suppress keratoconus [2]. A previous study demonstrated the Declaration of Helsinki and was approved by the insti-
that combined collagen cross-linking and toric phakic IOL tutional review board of Korea University Ansan Hospital
implantation was associated with good clinical outcomes (AS14068). According to the institutional review board
for correcting myopic astigmatism for mild to moderate standard operating procedures on retrospective single cen-
progressive keratoconus [3]. The cylinder power of a toric ter clinical study, ethics committee of the Korea University
phakic IOL is determined by ocular astigmatism, not by Ansan Hospital ruled that subject consent was not required
corneal astigmatism. In comparison, when cataract surgery for this study. Retrospective reviews were performed on all
with toric IOL implantation is considered, the cylinder patients diagnosed with keratoconus at our institution be-
power of toric IOL is determined by corneal astigmatism, tween May 8, 2009 and May 31, 2017. We included patients
because the lenticular astigmatism disappears [4]. who underwent a single Scheimpflug camera examination
Recently, the importance of posterior corneal astigma- (Oculus, Wetzler, Germany) at our institution [7]. All pa-
tism has been recognized when toric IOL is considered, tients also underwent measurement of refractive error us-
because selecting toric IOL based on anterior corneal mea- ing an autorefractometer (KR-8100; Topcon, Tokyo, Japan).
surements and neglecting posterior corneal astigmatism Keratoconus was defined as exhibiting at least one typi-
could lead to an incorrect estimation of total corneal astig- cal keratoconus sign (i.e., anterior bulging of the cornea,
matism [5,6]. Unlike the anterior corneal surface, most stromal thinning, Fleischer ring, Vogt striae, or Descemet’s
eyes had against-the-rule (ATR) astigmatism on the poste- breaks) on slit-lamp examination and topographic findings
rior corneal surface. Thus, estimating the total corneal (i.e., asymmetric bow-tie pattern with or without skewed
astigmatism using anterior corneal measurements (simu- axes and central or paracentral steepening of the cornea)
lated keratometry [K]) could lead to overcorrection in eyes [13]. Eyes with grade I or II keratoconus according to the
with with-the-rule (WTR) astigmatism and undercorrec- Amsler-Krumeich classification (keratometric astigmatism
tion in eyes with ATR astigmatism [5,7,8]. This phenome- <8.00 diopters [D], mean central K reading <53.00 D, ab-
non might be more pronounced in patients with keratoco- sence of corneal scarring, or minimum corneal thickness
nus, because keratoconus involves a high degree of corneal > 400 μm) and no history of treatment for keratoconus were
astigmatism [9-11]. included [14,15]. Because corneal opacity precludes accu-
Eyes with keratoconus cannot avoid cataract develop- rate corneal topography measurement, patients with corne-
ment, and cataract surgery with toric IOL implantation can al opacity such as subepithelial fibrosis or anterior stromal
be considered for progression of cataracts. Alio et al. [12] scarring were excluded.
reported that cataract surgery with toric IOL implantation The patients were matched for age (±3 years), sex, and
is a safe and effective procedure in eyes with cataracts and laterality at a ratio of 1 : 1 to a normal control group who
stable keratoconus. Thus, the aim of this study was to underwent a single Scheimpf lug camera examination at
compare the anterior, posterior, and total corneal powers our institution during the same study period. The normal
and astigmatisms of keratoconus with those of healthy control group was selected by reviewing charts and the
eyes and to evaluate the effect of posterior corneal astig- single Scheimpflug examination results. We excluded con-
matism on the estimation of total corneal astigmatism us- trols with abnormal findings on both the slit-lamp exam-
ing anterior corneal measurements in eyes with keratoco- ination and the single Scheimpflug examination.
nus using a single Scheimpflug camera.
Main outcome measures

Materials and Methods For each subject, we measured anterior, posterior, and
total mean corneal power; cylinder power; flat meridian;
Study population and central corneal thickness using a single Scheimpflug
camera. The refractive indices used in the Scheimpf lug
This retrospective cross-sectional study was conducted camera were 1 for air, 1.376 for cornea, and 1.336 for aque-
at the department of ophthalmology in the Korea Universi- ous humor. Anterior corneal power, or simulated K, was
ty College of Medicine. The study adhered to the tenets of calculated using a single value for the keratometric index

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 Y Choi, et al. Corneal Astigmatism in Keratoconus Eyes

(n k = 1.3375). The total corneal power, or true net power, formed to compare the mean magnitudes of the vector
was calculated using the Gaussian total corneal power with differences of the astigmatism and the mean absolute cor-
the Gullstrand eye model without regard for corneal thick- neal power and the flat meridian differences between the
ness in the 4.0-mm zone [16]. Anterior, posterior, and total simulated K and total cornea between keratoconus and
corneal powers were calculated in a single Scheimpf lug healthy eyes. Linear regression and Pearson’s correlation
camera based on the following equations: analyses were performed to evaluate correlations between
corneal power, cylinder power, and flat meridian among
Anterior corneal power= 1.3375-1 ×1,000 anterior and posterior corneal surfaces and the total cor-
r ant
nea. Chi-square tests were performed to compare the pro-
Posterior corneal power= 1.336-1.376 ×1,000 portions of anterior and posterior corneal astigmatism ac-
r post
cording to the flat meridian between eyes with keratoconus
Total corneal power= 1.376-1 ×1,000+1.336-1.376 ×1,000 and healthy eyes. Results were considered statistically sig-
r ant r post nificant at a p-value <0.05.

where rant is the radius of the anterior corneal surface, and

r post is the radius of the posterior corneal surface. Results
Correlations among the anterior, posterior, and total cor-
neal measurements were evaluated. The cylinder power Sixty-six eyes of 66 subjects were enrolled in this study
difference between the simulated K and total cornea was (33 eyes of 33 patients with keratoconus and 33 eyes of 33
defined as the difference in cylinder power between the controls). The mean age (±standard deviation, SD) of all
simulated K and total cornea (cylinder power difference subjects was 28.4 ± 9.2 years. There were 22 females
between the simulated K and total cornea = anterior corne- (66.7%) and 18 left eyes (54.5%) in each group. The mean
al cylinder power – total corneal cylinder power) [6]. The anterior, posterior, and total corneal powers (±SD) of the
mean absolute corneal power difference between the simu- keratoconus group (46.99 ± 2.83, -6.92 ± 0.54, and 45.92 ±
lated K and total cornea was defined as the mean absolute 2.94 D, respectively) were greater than those of the control
value of the difference between the corneal power of the group (42.98 ± 1.42, -6.30 ± 0.24, and 42.00 ± 1.38 D, re-
simulated K and total cornea. To compare the astigmatism spectively). The mean total corneal power was significant-
of the simulated K and total cornea, the vector difference ly smaller than the mean anterior corneal power in both
between the astigmatism of the simulated K and total cor- groups ( p < 0.001 and p < 0.001, respectively). The mean
nea was calculated using vector analysis, and double-angle anterior, posterior, and total corneal cylinder powers (±SD)
plots were drawn [5,6,17]. The mean absolute flat meridian of the keratoconus group (4.37 ± 1.73, 0.95 ± 0.39, and 4.36
difference between the simulated K and the total cornea ± 1.74 cylinder diopters [CD], respectively) were also great-
was defined as the mean absolute value of the difference er than those of the control group (1.10 ± 0.68, 0.39 ± 0.18,
between the anterior and total corneal flat meridian. and 0.97 ± 0.63 CD, respectively). The mean central corne-
WTR astigmatism was defined as a flat meridian of the al thickness (±SD) of the keratoconus group (509.8 ± 37.5
anterior or posterior corneal surface of 180 ± 30 degrees, μm) was significantly smaller than that of the control
ATR astigmatism as 90 ± 30 degrees, and the rest were group (567.8 ± 30.2 μm) (Table 1).
defined as oblique astigmatism. All correlation coefficients of corneal power and cylin-
der power showed significant correlations among anterior
Statistical analysis and posterior corneal surfaces and with the total cornea in
the keratoconus and control groups (Table 2). According to
Descriptive statistics for all patient data were calculated linear regression analysis, the correlation between the an-
using IBM SPSS ver. 21.0 (IBM Corp., Armonk, NY, terior and total corneal cylinder powers was more promi-
USA). Student’s t-tests were performed to compare anteri- nent in both groups than between the anterior and posteri-
or, posterior, and total mean corneal powers; cylinder pow- or corneal cylinder powers (Fig. 1, 2).
ers; and f lat meridians. Student’s t-tests were also per- The cylinder power difference between the simulated K

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Table 1. Baseline clinical characteristics of participants and their eyes

Parameter Keratoconus (n = 33) Control (n = 33) p-value*
Mean age (yr) 28.1 ± 9.3 28.7 ± 9.3 0.792
Sex >0.999†
Male 22 (66.7) 22 (66.7)
Female 11 (33.3) 11 (33.3)
Laterality >0.999†
Right eye 15 (45.5) 15 (45.5)
Left eye 18 (54.5) 18 (54.5)
Refractive errors (D)
Spherical -4.23 ± 4.26 -1.60 ± 2.31 0.003
Cylindrical -4.29 ± 1.68 -0.77 ± 0.69 <0.001
Spherical equivalent -6.37 ± 4.28 -1.99 ± 2.42 <0.001
Mean anterior corneal power (D) 46.99 ± 2.83 42.98 ± 1.42 <0.001
Mean anterior corneal cylinder power (CD) 4.37 ± 1.73 1.10 ± 0.68 <0.001
Mean posterior corneal power (D) -6.92 ± 0.54 -6.30 ± 0.24 <0.001
Mean posterior corneal cylinder power (CD) 0.95 ± 0.39 0.39 ± 0.18 <0.001
‡
Mean total corneal power (D) 45.92 ± 2.94 42.00 ± 1.38 <0.001
‡
Mean total corneal cylinder power (D) 4.36 ± 1.74 0.97 ± 0.63 <0.001
Mean central corneal thickness (μm) 509.8 ± 37.5 567.8 ± 30.2 <0.001
Values are presented as mean ± standard deviation or number (%).
D = diopters; CD = cylinder diopters.
*
Student’s t-test; †Fisher’s exact test; ‡True net power in the 4.0-mm zone, which was measured by a single Scheimpflug camera.

Table 2. Pearson correlation coefficient (r) and p-values for correlation of mean corneal power and cylinder power among the ante-
rior and posterior corneal surfaces and the total cornea
Anterior vs. posterior Anterior vs. total
r p-value r p-value
Keratoconus (n = 33)
Corneal power -0.866 <0.001 0.983 <0.001
Cylinder power 0.686 <0.001 0.908 <0.001
Control (n = 33)
Corneal power -0.871 <0.001 0.962 <0.001
Cylinder power 0.650 <0.001 0.963 <0.001

and total cornea was positively correlated with posterior The mean magnitude of the vector difference between
corneal cylinder power (R 2 = 0.240 and p = 0.004 in the the astigmatism of the simulated K and the total cornea of
keratoconus group, R 2 = 0.592 and p < 0.001 in the control the keratoconus group, 0.67 ± 0.67 CD, was significantly
group) (Fig. 3) and negatively correlated with the absolute greater than that of the control group, 0.28 ± 0.12 CD ( p =
flat meridian difference between the simulated K and total 0.002) (Table 3 and Fig. 5A, 5B), although the mean abso-
cornea in both groups (R 2 = 0.370 and p < 0.001 in the ker- lute corneal power difference between the simulated K
atoconus group, R 2 = 0.592 and p < 0.001 in the control and total cornea was not significantly different between
group) (Fig. 4). the two groups. The magnitude of the vector difference

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 Y Choi, et al. Corneal Astigmatism in Keratoconus Eyes

2.0 9.0

8.0

7.0
1.5
Posterior corneal cylinder power (CD)

Total corneal cylinder power (CD)

6.0

5.0
1.0
4.0

3.0

0.5
2.0

1.0

0.0 0.0
0.0 1.0 2.0 3.0 4.0 5.0 6.0 7.0 8.0 9.0 0.0 1.0 2.0 3.0 4.0 5.0 6.0 7.0 8.0 9.0
Anterior corneal cylinder power (CD) Anterior corneal cylinder power (CD)

Fig. 1. Linear regression analysis of the relationship between Fig. 2. Linear regression analysis of the relationship between an-
anterior and posterior corneal cylinder power. The solid line rep- terior and total corneal cylinder power. The solid line represents
resents a linear regression line (Y = 0.156X + 0.270, R 2 = 0.470, a linear regression line (Y = 0.914X + 0.361, R 2 = 0.824, p < 0.001)
p < 0.001) for the keratoconus group (filled triangles), and the for the keratoconus group (filled triangles), and the dashed line
dashed line represents a linear regression line (Y = 0.174X + 0.194, represents a linear regression line (Y = 0.894X - 0.011, R 2 = 0.928,
R 2 = 0.422, p < 0.001) for the normal controls (open circles). CD = p < 0.001) for the normal controls (open circles). CD = cylinder
cylinder diopters. diopters.

2.5 2.5

2.0 2.0

1.5 1.5
Cylinder power difference between the
Cylinder power difference between the

simulated K and total cornea (CD)

simulated K and total cornea (CD)

1.0 1.0

0.5 0.5

0.0 0.0

-0.5 -0.5

-1.0 -1.0

-1.5 -1.5

-2.0 -2.0

-2.5 -2.5
0.0 0.5 1.0 1.5 2.0 0 15 30 45 60 75 90
Posterior corneal cylinder power (CD) Absolute flat meridian difference between
simulated K and total corner (˚)

Fig. 3. Linear regression analysis of the relationship between pos- Fig. 4. Linear regression analysis of the relationship between ab-
terior corneal cylinder power and cylinder power difference be- solute flat meridian difference and cylinder power difference be-
tween the simulated keratometry (K) and total cornea. The solid tween the simulated keratometry (K) and total cornea. The solid
line represents a linear regression line (Y = 0.928X - 0.868, R 2 = line represents a linear regression line (Y = -0.027X + 0.249, R 2 =
0.240, p = 0.004) for the keratoconus group (filled triangles), and 0.370, p < 0.001) for the keratoconus group (filled triangles), and
the dashed line represents a linear regression line (Y = 0.786X - the dashed line represents a linear regression line (Y = -0.010X
0.172, R 2 = 0.592, p < 0.001) for the normal controls (open circles). + 0.300, R 2 = 0.592, p < 0.001) for the normal controls (open cir-
CD = cylinder diopters. cles). CD = cylinder diopters.

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Table 3. Comparison of corneal power difference, magnitude of the vector difference of astigmatism, and flat meridian difference
between simulated K and the total cornea (Student’s t-test)
Parameter Keratoconus (n = 33) Control (n = 33) p-value
MAKDSimK-Tot (D) 1.14 ± 0.39 0.98 ± 0.39 0.119
MMVDSimK-Tot (CD) 0.67 ± 0.67 0.28 ± 0.12 0.002
MAMDSimK-Tot (degree) 2.3 ± 3.8 9.2 ± 12.6 0.005
Values are presented as mean ± standard deviation.
K = keratometry; MAKDSimK-Tot = mean absolute corneal power (K) difference between the simulated K and total cornea; D = diopters;
MMVDSimK-Tot = mean magnitude of vector difference between the astigmatism of the simulated K and total cornea; CD = cylinder diop-
ters; MAMDSimK-Tot = mean absolute flat meridian difference between the simulated K and total cornea.

A B

Centroid = 0.06 ± 0.67 @ 178° Centroid = 0.23 ± 0.12 @ 5°

Mean magnitude = 0.67 D Mean magnitude = 0.28 D

Each ring = 0.5 D, outer ring = 3.0 D Each ring = 0.5 D, outer ring = 3.0 D

Fig. 5. Double-angle plots of the vector difference between the astigmatism of the anterior corneal surface and total cornea. The red el-
lipse indicates one standard deviation. (A) Keratoconus group. (B) Normal controls. D = diopters.

between the astigmatism of the simulated K and total cor- Our analysis indicated that 100.0% of the keratoconus
nea was a maximum of 2.42 CD in the keratoconus group group and 87.9% of the control group had WTR astigma-
and 0.77 CD in the control group. In contrast, the mean ab- tism on the anterior corneal surface, and 93.9% of the ker-
solute flat meridian difference between the simulated K atoconus group and 90.9% of the control group had ATR
and total cornea of the keratoconus group, 2.3 ± 3.8 de- astigmatism on the posterior corneal surface (Table 4).
grees, was significantly smaller than that of the control There were no significant differences between the two
group, 9.2 ± 12.6 degrees ( p = 0.005) (Table 3). The per- groups in the proportions of anterior and posterior corneal
centage of eyes with a flat meridian difference between the astigmatism according to the flat meridian.
simulated K and total cornea >10 degrees in the keratoco-
nus group, 9.1%, was significantly smaller than that in the
control group, 30.3% (p = 0.030).

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 Y Choi, et al. Corneal Astigmatism in Keratoconus Eyes

Table 4. Anterior and posterior corneal astigmatism proportions according to the flat meridian in each group (chi-square test)
Anterior corneal astigmatism Posterior corneal astigmatism
WTR Oblique ATR WTR Oblique ATR
Keratoconus (n = 33) 33 (100.0) 0 (0.0) 0 (0.0) 2 (6.1) 0 (0.0) 31 (93.9)
Control (n = 33) 29 (87.9) 3 (9.1) 1 (3.0) 1 (3.0) 2 (6.1) 30 (90.9)
p-value 0.119 0.309
Values are presented as number (%).
WTR = with-the-rule astigmatism; ATR = against-the-rule astigmatism.

Discussion tween the astigmatism of the simulated K and total cornea

in eyes with keratoconus is that the flat meridians of the
In this study, we compared the anterior, posterior, and anterior and posterior corneal surfaces tended to be the
total corneal measurements of healthy eyes and eyes with same as those of healthy eyes. In the keratoconus group,
grade I or II keratoconus. The results of this study indicat- the flat anterior corneal meridian was horizontally aligned
ed that both eyes with keratoconus and healthy eyes in 100.0% of patients, and the flat posterior corneal meridi-
showed a significant correlation among anterior, posterior, an was horizontally aligned in 93.9%. As a result, in 90.9%
and total corneal astigmatisms. These results are similar to of eyes with keratoconus, the flat meridian difference be-
previous studies that showed that the correlation between tween the anterior corneal surface and the total cornea was
anterior and posterior corneal astigmatism was good in less than or equal to 10 degrees. In line with this study, Sa-
eyes with keratoconus [9-11]. In addition, the analysis of vini et al. [18] demonstrated that eyes with keratoconus
this study determined that eyes with keratoconus had a showed a tendency for the steep meridians of the anterior
large vector difference but a small flat meridian difference and posterior corneal surfaces to be aligned regardless of
between the astigmatism of the simulated K and total cor- the type of astigmatism (WTR, ATR, or oblique astigma-
nea compared to healthy eyes. The results indicated that tism). In that study, the steep meridian difference between
the amount of posterior corneal astigmatism rather than the anterior corneal surface and the total cornea was great-
the posterior corneal flat meridian had a greater effect on er than 10 degrees in only 8.4% of eyes with keratoconus
the total corneal astigmatism in eyes with grade I or II ker- [18].
atoconus. In this study, the cylinder power difference between the
The magnitude of vector difference between the astig- simulated K and total cornea was positively correlated
matism of the simulated K and total cornea was up to 2.42 with posterior corneal cylinder power and negatively cor-
CD in the keratoconus group and 0.77 CD in the control related with the absolute flat meridian difference between
group. In addition, the range of cylinder power difference the simulated K and total cornea in both groups. Similar to
between the simulated K and total cornea was wider in the the results of this study, a previous study showed the same
keratoconus group than the control group. The cause of correlations among the posterior corneal cylinder power,
this wide range of cylinder power difference between the the absolute f lat meridian difference, and the cylinder
simulated K and total cornea is mainly due to the diversity power difference between the simulated K and total cor-
of the posterior corneal curvature in eyes with keratoconus nea in healthy eyes [6]. These results mean that the cylin-
[9-11]. The mean posterior corneal cylinder power of the der power of simulated K tends to overestimate total cor-
keratoconus group (0.95 CD) was significantly greater than neal cylinder power as the posterior corneal cylinder
that of the control group (0.39 CD) in this study. Thus, pos- power increases or as the absolute flat meridian difference
terior corneal astigmatism has more influence on the total decreases in both healthy and keratoconus eyes. To avoid
corneal astigmatism in eyes with keratoconus, and there incorrect estimation of the total corneal astigmatism in
could be a large vector difference in eyes with keratoconus eyes with keratoconus, it is necessary to measure the cyl-
compared to healthy eyes. inder power and axis of the posterior corneal surface, be-
The reason for the small f lat meridian difference be- cause the estimation error for total corneal cylinder power

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Korean J Ophthalmol Vol.32, No.3, 2018

from anterior corneal measurements is larger in eyes with Conflict of Interest

keratoconus. The importance of posterior corneal surface
measurement when considering toric IOL should be em- No potential conflict of interest relevant to this article
phasized for patients with keratoconus. was reported.
Pinero et al. [16] demonstrated that the central corneal
power, which was estimated with a single value of the ker-
atometric index (n k = 1.3375), is imprecise in eyes with Acknowledgements
keratoconus, and that overestimation was observed in most
cases compared to the true net power determined with the This research was supported by the Basic Science Re-
Gaussian equation. There was also a significant difference search Program through the National Research Foundation
in corneal power between the conventional keratometric of Korea (NRF) funded by the Ministry of Education
approach and the Gaussian equation in normal healthy (2016R1D1A1A02937003), by a Korea University Grant
eyes [19-21]. The results of this study were similar to the (K1625491), and by the Alumni of the Department of Oph-
results of previous studies [16,19-21]. In this study, the an- thalmology, Korea University College of Medicine in 2017.
terior corneal power, which was estimated with a kerato-
metric index of 1.3375, was significantly larger than the to-
tal corneal power, which is the true net power, in both References
groups. Park et al. [22] reported that the IOL power calcu-
lation that used the conventional keratometric approach 1. Rabinowitz YS. Keratoconus. Surv Ophthalmol 1998;42:297-
was inaccurate and showed a hyperopic shift in patients 319.
with posterior keratoconus. This hyperopic shift occurs 2. Wittig-Silva C, Chan E, Islam FM, et al. A randomized,
because the conventional keratometric approach ignores controlled trial of corneal collagen cross-linking in pro-
the posterior corneal surface and overestimates the corneal gressive keratoconus: three-year results. Ophthalmology
power. 2014;121:812-21.
There were some limitations to this study. First, the 3. Guell JL, Morral M, Malecaze F, et al. Collagen crosslink-
sample size was relatively small, and medical records were ing and toric iris-claw phakic intraocular lens for myopic
reviewed retrospectively. Second, for eyes with grade I or astigmatism in progressive mild to moderate keratoconus.
II keratoconus, this study did not verify whether the con- J Cataract Refract Surg 2012;38:475-84.
dition had progressed or remained stable, although pro- 4. Eom Y, Nam KT, Kang SY, et al. Axis difference between
gression of keratoconus induces severe irregular myopic corneal and internal astigmatism to consider for toric intra-
astigmatism [23], and corneal astigmatism correction using ocular lenses. Am J Ophthalmol 2013;156:1112-9.
toric IOLs is more suitable for eyes with stable keratoco- 5. Koch DD, Ali SF, Weikert MP, et al. Contribution of pos-
nus. Third, the mean age of the patients in this study was terior corneal astigmatism to total corneal astigmatism. J
28 years, which is too young for typical cataract surgery. Cataract Refract Surg 2012;38:2080-7.
Therefore, a prospective study to assess posterior and total 6. Eom Y, Kang SY, Kim HM, Song JS. The effect of pos-
corneal astigmatism in a large number of patients with terior corneal f lat meridian and astigmatism amount on
keratoconus is necessary. the total corneal astigmatism estimated from anterior cor-
In conclusion, eyes with keratoconus had larger posteri- neal measurements. Graefes Arch Clin Exp Ophthalmol
or corneal astigmatism and greater estimation errors of to- 2014;252:1769-77.
tal corneal astigmatism based on anterior corneal mea- 7. Eom Y, Rhim JW, Kang SY, et al. Toric intraocular lens
surements than healthy eyes. Thus, posterior corneal calculations using ratio of anterior to posterior corneal cyl-
surface measurement should be emphasized for patients inder power. Am J Ophthalmol 2015;160:717-24.
that are considering toric IOL in eyes with keratoconus. 8. Eom Y, Ryu D, Kim DW, et al. Development of a program
for toric intraocular lens calculation considering posterior
corneal astigmatism, incision-induced posterior corneal
astigmatism, and effective lens position. Graefes Arch Clin

170
 Y Choi, et al. Corneal Astigmatism in Keratoconus Eyes

Exp Ophthalmol 2016;254:1977-86. of the central corneal power in keratoconus: theoretical

9. Tomidokoro A, Oshika T, Amano S, et al. Changes in ante- and clinical assessment of the error of the keratometric ap-
rior and posterior corneal curvatures in keratoconus. Oph- proach. Cornea 2014;33:274-9.
thalmology 2000;107:1328-32. 17. Holladay JT, Moran JR, Kezirian GM. Analysis of aggre-
10. Pinero DP, Alio JL, Aleson A, et al. Corneal volume, pa- gate surgically induced refractive change, prediction error,
chymetry, and correlation of anterior and posterior corneal and intraocular astigmatism. J Cataract Refract Surg
shape in subclinical and different stages of clinical kerato- 2001;27:61-79.
conus. J Cataract Refract Surg 2010;36:814-25. 18. Savini G, Naeser K, Schiano-Lomoriello D, Mularoni A.
11. Montalban R, Alio JL, Javaloy J, Pinero DP. Correlation of Influence of posterior corneal astigmatism on total corneal
anterior and posterior corneal shape in keratoconus. Cor- astigmatism in eyes with keratoconus. Cornea 2016;35:1427-
nea 2013;32:916-21. 33.
12. Alio JL, Pena-Garcia P, Abdulla Guliyeva F, et al. MICS 19. Fam HB, Lim KL. Validity of the keratometric index:
with toric intraocular lenses in keratoconus: outcomes and large population-based study. J Cataract Refract Surg
predictability analysis of postoperative refraction. Br J 2007;33:686-91.
Ophthalmol 2014;98:365-70. 20. Olsen T. On the calculation of power from curvature of the
13. Muftuoglu O, Ayar O, Ozulken K, et al. Posterior cor- cornea. Br J Ophthalmol 1986;70:152-4.
neal elevation and back difference corneal elevation in 21. Ho JD, Tsai CY, Tsai RJ, et al. Validity of the keratometric
diagnosing forme fruste keratoconus in the fellow eyes of index: evaluation by the Pentacam rotating Scheimpf lug
unilateral keratoconus patients. J Cataract Refract Surg camera. J Cataract Refract Surg 2008;34:137-45.
2013;39:1348-57. 22. Park DY, Lim DH, Chung TY, Chung ES. Intraocular lens
14. Krumeich JH, Daniel J, Knulle A. Live-epikeratophakia power calculations in a patient with posterior keratoconus.
for keratoconus. J Cataract Refract Surg 1998;24:456-63. Cornea 2013;32:708-11.
15. Choi JA, Kim MS. Progression of keratoconus by longitu- 23. Visser N, Gast ST, Bauer NJ, Nuijts RM. Cataract surgery
dinal assessment with corneal topography. Invest Ophthal- with toric intraocular lens implantation in keratoconus: a
mol Vis Sci 2012;53:927-35. case report. Cornea 2011;30:720-3.
16. Pinero DP, Camps VJ, Caravaca-Arens E, et al. Estimation

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