Patricia Rosales

Tilt and decentration of intraocular lenses in vivo from Purkinje and Scheimpflug imaging. Validation study.

PURPOSE: To measure tilt and decentration of intraocular lenses (IOLs) with Scheimpflug and Purkinje imaging systems in physical model eyes with known amounts of tilt and decentration and patients. SETTING: Instituto de Óptica Daza de Valdés, Consejo Superior de Investigaciones Científicas, Madrid, Spain. METHODS: Measurements of IOL tilt and decentration were obtained using a commercial Scheimpflug system (Pentacam, Oculus), custom algorithms, and a custom‐built Purkinje imaging apparatus. Twenty‐five Scheimpflug images of the anterior segment of the eye were obtained at different meridians. Custom algorithms were used to process the images (correction of geometrical distortion, edge detection, and curve fittings). Intraocular lens tilt and decentration were estimated by fitting sinusoidal functions to the projections of the pupillary axis and IOL axis in each image. The Purkinje imaging system captures pupil images showing reflections of light from the anterior corneal surface and anterior and posterior lens surfaces. Custom algorithms were used to detect the Purkinje image locations and estimate IOL tilt and decentration based on a linear system equation and computer eye models with individual biometry. Both methods were validated with a physical model eye in which IOL tilt and decentration can be set nominally. Twenty‐one eyes of 12 patients with IOLs were measured with both systems. RESULTS: Measurements of the physical model eye showed an absolute discrepancy between nominal and measured values of 0.279 degree (Purkinje) and 0.243 degree (Scheimpflug) for tilt and 0.094 mm (Purkinje) and 0.228 mm (Scheimpflug) for decentration. In patients, the mean tilt was less than 2.6 degrees and the mean decentration less than 0.4 mm. Both techniques showed mirror symmetry between right eyes and left eyes for tilt around the vertical axis and for decentration in the horizontal axis. CONCLUSIONS: Both systems showed high reproducibility. Validation experiments on physical model eyes showed slightly higher accuracy with the Purkinje method than the Scheimpflug imaging method. Horizontal measurements of patients with both techniques were highly correlated. The IOLs tended to be tilted and decentered nasally in most patients.

Crystalline lens radii of curvature from Purkinje and Scheimpflug imaging

We present a comparison between measurements of the radius of the anterior and posterior lens surface, which was performed using corrected Scheimpflug imaging and Purkinje imaging in the same group of participants (46 for the anterior lens, and 34 for the posterior lens). Comparisons were also made as a function of accommodation (0 to 7 D) in a subset of 11 eyes. Data were captured and processed using laboratory prototypes and custom processing algorithms [for optical and geometrical distortion correction in the Scheimpflug system and using either equivalent mirror (EM) or merit function (MF) methods for Purkinje]. We found statistically significant differences in 4 of 46 eyes for the anterior lens radius, and 10 of 34 eyes for the posterior radius (using the MF and individual biometric data to process the Purkinje images). For the anterior lens, the agreement increases using individual biometry as opposed to biometric data from a model eye. For the posterior lens, the agreement increases using the MF as opposed to the EM method. For the changes during accommodation, no significant difference between the two techniques was found. In conclusion, the results of the cross-validation using the Scheimpflug and Purkinje imaging technique show that both techniques provide comparable lens radii and similar changes with accommodation. Purkinje tends to overestimate posterior lens radius, whereas pupil size limits the acquisition of posterior lens data with the Scheimpflug camera. Computer simulations using the Scheimpflug data as input show that the consistent slight overestimation of the posterior lens radius using Purkinje imaging can be partly attributed to the asphericity of the lens surface.

Phakometry and lens tilt and decentration using a custom-developed Purkinje imaging apparatus: validation and measurements

We present a Purkinje imaging system for phakometry and measurement of tilt and decentration of crystalline and intraocular lenses (IOLs). Crystalline lens radii of curvature were estimated by using both a merit function and the equivalent mirror approaches. Tilts and decentrations were estimated by using Phillipss linear analysis. We present a complete validation of the technique through exhaustive computer simulations and control experiments, and measurements in 17 normal eyes (mean age 26.67 +/- 2.31) and nine postcataract surgery eyes (mean age 74 +/- 2.3). Crystalline lens radii ranged from 12.7 to 8.81 mm and from -5.64 to -7.09 mm for anterior and posterior surfaces, respectively. Crystalline lens tilt ranged from 2.8 to -2.87 deg horizontally and from 2.58 to -1 deg vertically. Crystalline lens decentration ranged from 0.09 to 0.45 mm horizontally and from 0.09 to -0.22 mm vertically. IOL tilt ranged from 3.6 to -1.51 deg horizontally and from 5.97 to -1.85 deg vertically. IOL decentration ranged from 0.53 to -0.31 mm horizontally and from 0.13 to -0.96 mm vertically.

Change in corneal aberrations after cataract surgery with 2 types of aspherical intraocular lenses

PURPOSE: To study the effect of cataract surgery through 3.2 mm superior incisions on corneal aberrations with 2 types of monofocal intraocular lenses (IOLs) with an aspherical design. SETTING: Instituto de Optica, Consejo Superior de Investigaciones Científicas, and Fundación Jiménez Díaz, Madrid, Spain. METHODS: Corneal topography of 43 eyes was obtained before and after small corneal incision cataract surgery. Twenty‐two eyes had implantation of a Tecnis Z9000 silicone IOL (Advanced Medical Optics) and 21 had implantation of an AcrySof IQ SN60WF acrylic IOL (Alcon Research Labs) using the recommended injector for each IOL type. The intended incision size (3.2 mm) was similar in the 2 groups. Corneal aberrations were estimated using custom‐developed algorithms (based on ray tracing) for 10.0 mm and 5.0 mm pupils. Comparisons between preoperative and postoperative measurements and across the groups were made for individual Zernike terms and root‐mean‐square (RMS) wavefront error. RESULTS: The RMS (excluding tilt and defocus) did not change in the AcrySof IQ group and increased significantly in the Tecnis group with the 10.0 mm and 5.0 mm pupil diameters. Spherical aberration and coma‐like terms did not change significantly; however, vertical astigmatism, vertical trefoil, and vertical tetrafoil changed significantly with surgery with the 10.0 mm and 5.0 mm pupil diameters (P<.0005). The induced wave aberration pattern for 3rd‐ and higher‐order aberrations consistently showed a superior lobe, resulting from a combination of positive vertical trefoil (Z3−3) and negative tetrafoil (Z44). The mean vertical astigmatism increased by 2.47 μm ± 1.49 (SD) and 1.74 ± 1.44 μm, vertical trefoil increased by 1.81 ± 1.19 μm and 1.20 ± 1.34 μm, and tetrafoil increased by −1.10 ± 0.78 μm and −0.89 ± 0.68 μm in the Tecnis group and AcrySof IQ group, respectively. There were no significant differences between the corneal aberrations in the 2 postoperative groups, although there was a tendency toward more terms or orders changing statistically significantly in the Tecnis group, which had slightly higher amounts of induced aberrations. CONCLUSIONS: Cataract surgery with a small superior incision induced consistent and significant changes in several corneal Zernike terms (vertical astigmatism, trefoil, and tetrafoil), resulting in a significantly increased overall corneal RMS wavefront error. These results can be used to improve predictions of optical performance with new IOL designs using computer eye models and identify the potentially different impact of incision strategies on cataract surgery.

Customized computer models of eyes with intraocular lenses

We compared experimental wave aberrations in pseudophakic eyes with aspheric intraocular lenses (IOLs) to simulate aberrations from numerical ray tracing on customized computer eye models using corneal topography, angle lambda, ocular biometry, IOL geometry, and IOL tilt and decentration measured on the same eyes. We found high correlations between real and simulated aberrations even for the eye with only the cornea, and these increased on average when the IOL geometry and position were included. Relevant individual aberrations were well predicted by the complete eye model. Corneal spherical aberration and horizontal coma were compensated by the IOL, and in 58.3% of the cases IOL tilt and decentration contributed to compensation of horizontal coma. We conclude that customized computer eye models are a good representation of real eyes with IOLs and allow understanding of the relative contribution of optical, geometrical and surgically-related factors to image quality. Corneal spherical aberration is reduced by aspheric IOLs, although other corneal high order aberrations are still a major contributor to total aberrations in pseudophakic eyes. Tilt and decentration of the IOLs represent a relatively minor contribution of the overall optical quality of the eye.

Pentacam Scheimpflug Quantitative Imaging of the Crystalline Lens and Intraocular Lens

PURPOSE To implement geometrical and optical distortion correction methods for anterior segment Scheimpflug images obtained with a commercially available system (Pentacam, Oculus Optikgeräte GmbH). METHODS Ray tracing algorithms were implemented to obtain corrected ocular surface geometry from the original images captured by the Pentacams CCD camera. As details of the optical layout were not fully provided by the manufacturer, an iterative procedure (based on imaging of calibrated spheres) was developed to estimate the camera lens specifications. The correction procedure was tested on Scheimpflug images of a physical water cell model eye (with polymethylmethacrylate cornea and a commercial IOL of known dimensions) and of a normal human eye previously measured with a corrected optical and geometrical distortion Scheimpflug camera (Topcon SL-45 [Topcon Medical Systems Inc] from the Vrije University, Amsterdam, Holland). RESULTS Uncorrected Scheimpflug images show flatter surfaces and thinner lenses than in reality. The application of geometrical and optical distortion correction algorithms improves the accuracy of the estimated anterior lens radii of curvature by 30% to 40% and of the estimated posterior lens by 50% to 100%. The average error in the retrieved radii was 0.37 and 0.46 mm for the anterior and posterior lens radii of curvature, respectively, and 0.048 mm for lens thickness. CONCLUSIONS The Pentacam Scheimpflug system can be used to obtain quantitative information on the geometry of the crystalline lens, provided that geometrical and optical distortion correction algorithms are applied, within the accuracy of state-of-the art phakometry and biometry. The techniques could improve with exact knowledge of the technical specifications of the instrument, improved edge detection algorithms, consideration of aspheric and non-rotationally symmetrical surfaces, and introduction of a crystalline gradient index.

Changes in crystalline lens radii of curvature and lens tilt and decentration during dynamic accommodation in rhesus monkeys

Dynamic changes in crystalline lens radii of curvature and lens tilt and decentration were measured during centrally stimulated accommodation in four iridectomized eyes of two adolescent rhesus monkeys. Phakometry measurements were performed dynamically using a custom-built, video-based, Purkinje-image instrument. Lens anterior and posterior radii were calculated from reflections of paired light sources from the ocular surfaces (Purkinje images PI, PIII, and PIV). Lens tilt and decentration were calculated assuming linearity between Purkinje image positions, eye rotation, lens tilt, and decentration. Because the monkey eyes were iridectomized, Purkinje images were referred to the mid-point of the double first Purkinje image (PI). Mean unaccommodated values of anterior and posterior lens radii of curvature were 11.11 +/- 1.58 mm and -6.64 +/- 0.62 mm, respectively, and these decreased relatively linearly with accommodation in all eyes, at a rate of 0.48 +/- 0.14 mm/D and 0.17 +/- 0.03 mm/D for anterior and posterior lens surfaces, respectively. Tilt and decentration did not change significantly with accommodation except for tilt around the horizontal axis, which changed at a rate of 0.147 +/- 0.25 deg/D. These results are important to fully characterize accommodation in rhesus monkeys.

Balance of corneal horizontal coma by internal optics in eyes with intraocular artificial lenses : Evidence of a passive mechanism

It is well known that the aberrations of the cornea are partially compensated by the aberrations of the internal optics of the eye (primarily the crystalline lens) in young subjects. This effect has been found not only for the spherical aberration, but also for horizontal coma. It has been debated whether the compensation of horizontal coma is the result of passive mechanism [Artal, P., Benito, A., & Tabernero, J. (2006). The human eye is an example of robust optical design. Journal of Vision, 6 (1), 1-7] or through an active developmental feedback process [Kelly, J. E., Mihashi, T., & Howland, H. C. (2004). Compensation of corneal horizontal/vertical astigmatism, lateral coma, and spherical aberration by internal optics of the eye. Journal of Vision, 4 (4), 262-271]. In this study we investigate the active or passive nature of the horizontal coma compensation using eyes with artificial lenses, where no active developmental process can be present. We measured total and corneal aberrations, and lens tilt and decentration in a group of 38 eyes implanted with two types of intraocular lenses designed to compensate the corneal spherical aberration of the average population. We found that spherical aberration was compensated by 66%, and horizontal coma by 87% on average. The spherical aberration is not compensated at an individual level, but horizontal coma is compensated individually (coefficients of correlation corneal/internal aberration: -0.946, p<0.0001). The fact that corneal (but not total) horizontal coma is highly correlated with angle lamda (computed from the shift of the 1st Purkinje image from the pupil center, for foveal fixation) indicates that the compensation arises primarily from the geometrical configuration of the eye (which generates horizontal coma of opposite signs in the cornea and internal optics). The amount and direction of tilts and misalignments of the lens are comparable to those found in young eyes, and on average tend to compensate (rather than increase) horizontal coma. Computer simulations using customized model eyes and different designs of intraocular lenses show that, while not all designs produce a compensation of horizontal coma, a wide range of aspheric biconvex designs may produce comparable compensation to that found in young eyes with crystalline lenses, over a relatively large field of view. These findings suggest that the lens shape, gradient index or foveal location do not need to be fine-tuned to achieve a compensation of horizontal coma. Our results cannot exclude a fine-tuning for the orientation of the crystalline lens, since cataract surgery seems to preserve the position of the capsule.

Intraocular lens alignment from Purkinje and Scheimpflug imaging

The improved designs of intraocular lenses (IOLs) implanted during cataract surgery demand understanding of the possible effects of lens misalignment on optical performance. In this review, we describe the implementation, set‐up and validation of two methods to measure in vivo tilt and decentration of IOLs, one based on Purkinje imaging and the other on Scheimpflug imaging. The Purkinje system images the reflections of an oblique collimated light source on the anterior cornea and anterior and posterior IOL surfaces and relies on the well supported assumption of the linearity of the Purkinje images with respect to IOL tilt and decentration. Scheimpflug imaging requires geometrical distortion correction and image processing techniques to retrieve the pupillary axis, IOL axis and pupil centre from the three‐dimensional anterior segment image of the eye. Validation of the techniques using a physical eye model indicates that IOL tilt is estimated within an accuracy of 0.261 degree and decentration within 0.161 mm. Measurements on patients implanted with aspheric IOLs indicate that IOL tilt and decentration tend to be mirror symmetric between left and right eyes. The average tilt was 1.54 degrees and the average decentration was 0.21 mm. Simulated aberration patterns using custom models of the patients eyes, built using anatomical data of the anterior cornea and foveal position, the IOL geometry and the measured IOL tilt and decentration predict the experimental wave aberrations measured using laser ray tracing aberrometry on the same eyes. This reveals a relatively minor contribution of IOL tilt and decentration on the higher‐order aberrations of the normal pseudophakic eye.

Performance of Aspheric IOLs

Aspheric IOLs induce negative spherical aberration in order to emulate young crystalline lenses. We present optical aberrations in pseudophakic eyes, the effect of misalignment on optical performance, using customized eye models, and new aspheric designs.