1.ocular Biometry (Full) SEGi U

1
Ocular Biometry (Week 1)

PowerPoint Slides by Foo Say Kiang
23 January 2014
Learning Objectives
To understand the basic optic principles of the instruments used to measure the parameters in the eye To learn how to operate the instruments and the purpose of using the instruments
OPT3024 Ocular Optics I
Learning Outcomes
Recall the general purpose and clinical utility of a variety of biometric techniques.
Describe the basic principles of the biometric technique

Understand and able to interpret the readings obtained through the biometric instruments and use it for further investigations
Subtopics
Keratometry Pachometry & phakometry Ultrasonography Interferometry Pupillometry
Keratometry
For measuring the radius of curvature of the anterior surface of the cornea Jesse Ramsdenm, an optical instrument maker invented keratometer in 1769 Helmholtz improved Ramsdems design and developed an instrument similar to the manual keratometer used today
Keratometer
Has variety clinical uses:

Used in fitting contact lenses Serve as an objective method of monitoring corneal changes in anomalies such as keratoconus Used to measure corneal astigmatism, can be used to predict the total astigmatism of the eye (C = 1.25A 0.50) Also used in research to evaluate the contribution of the cornea to refractive development of the eye Can be used to check the radii of curvature of both hard and soft contact lenses
The basic components of a keratometer are a) an object to be reflected from the cornea b) a lens system to give the examiner a magnified view of the reflected image c) a system to keep the reflected image in focus d) a system to measure image size
Figure 5.4
Optics of the Keratometer The size of a reflected image is a function of the radius of the curvature of the surface from which it is reflected This relationship can be determined by finding the magnification (m), which is the ratio of image size to object size (h/h) Newtons equation states that the magnification of a reflected image is equal to the focal length of the reflecting surface divided by the distance (x) from the object to the focal point, f/x
Figure 5.1
The distance between the object and the anterior surface of the cornea is quite long relative to the focal length of the anterior corneal surface The virtual image formed by reflection from the anterior surface of the cornea is very close to the focal point (F) of the corneal surface d, the distance from the object to the image formed by reflection from the cornea, is close approximation to x h/h f/d
because the focal length of a mirror is equal to the radius of the curvature divided by two,
h/h (r/2)/d r = (2d)(h/h) = 2dm
r = 2dm
d is constant as long as the image reflected from patients cornea in focus h also constant r can be determined by measuring h (fixed mire keratometer) r = (2d)(h/h) = 2dm
r h
Measurement of the Reflected Image

A relatively large luminous circular object is placed in front of the eye Reflection of this light from the anterior corneal surface produces a first Purkinje image , which is a greatly minified virtual image circle located behind the cornea
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Measurement of the Reflected Image

Keratometers use a telemicroscope to view the image An objective lens projects a real image of the virtual image between the objective lens and the observer
This image is then observed with an eyepiece The eye undergoes constant small involuntary movements, keratometer image also moves, even though the movements are small, they are large relative to the size of the Purkinje image To overcome the difficulty of measuring a moving target, keratometers employ a doubling principle Part of the image beam that travels through the keratometer to intercepted by a prism and is deflected. Another part of the beam bypasses the prism and is not deflected
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Figure 5.2
As the eye moves, both images still move, but they move together so that their separation remains constant If the amount of image separation is varied until it equals the image size, the image size could be calculated by noting the prism necessary to do this Instead of use prism of different powers to change the image separation, movement of one prism along the optical axis of the keratometer is used to vary effective prism power
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The prism is moved until the two images just overlap on one border The image dimension in the direction of doubling is then equal to the amount of deflection The keratometer dial that moves the prism could then be calibrated to indicate the amount of prism movement Calculations are avoided by calibrating the dial to read the radius of curvature of the cornea directly
Different keratometers employ either variable or fixed doubling

Mostly variable doubling In instruments that have fixed doubling, object size is varied to obtain a set criterion image size
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Figure 5.4
One pair of holes, oriented horizontally isolates portions of the beam so that they go separately The other pair of holes, oriented vertically forms a Scheiners disc, used to assist in focusing --- allows a single image to be seen when the mires are in focus, but two images more sensitive than blur that results from defocus
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Examiners view of the reflected pattern Out of focus, rotate the control knob, changes the distance of the objective lens from patients eye until the images merge
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Next adjusts the instrument for the proper axis of the astigmatism by rotating the entire optical assembly until the axes of the plus and minus signs that flank the prism-doubled mires line up with the central cross Then the examiner turns the two knob that move the doubling prisms in order to superimpose the two plus signs in the lower right and lower left images, and minus signs in the lower right and the top images
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When alignment is achieved the scales on the knobs yield the dioptric keratometer powers Two doubling prism in B&L keratometer with axes 90 degrees to one another allows both meridians to be measured while the keratometer is rotated to only one meridian
Calibration index The radius is the more direct measure because it is found by using the keratometer equation The total corneal power may be calculated by modeling the cornea as a single refractive surface whose radius is the actual anterior corneal radius as determined by the keratometer Most keratometers use a calibration index of 1.3375, although some use calibration index of 1.336 or 1.332
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If the cornea of the Gullstrand schematic eye No. 1 were examined with a keratometer with a calibration index of 1.3375, the dioptric power read from the instrument would be:
n' n r
1.3375 1.00 0.0077 m
43.83 D
The dioptric power given by a keratometer is only an estimate of the total dioptric power of the cornea Bausch & Lomb Keratometer is the most widely used keratometer Varies the amount of doubling but the object size constant
Area of the Cornea Measured

Corresponds to the distance on the cornea between the location where on the cornea between the locations where the two plus signs and between where the two minus signs are projected onto the cornea The separations of these corneal regions vary somewhat with the radius of the curvature of the cornea
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B&L keratometer the separation between the corneal points is between about 3.0 and 3.2 mm for the most corneal radii This area is referred to as the corneal cap The validity of the keratometric values for the points within the cap are uncertain and the validity for points outside the cap are unknown
Corneal Astigmatism
The meridian of the eye are expressed in degrees from 0 to 180 degrees The meridians of greatest and least power are called the principal meridians These meridians are generally 90 degrees apart regular astigmatism
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With the rule (WTR) - greatest power (steepest) within 30 degrees of the vertical (90 degrees) meridian Against the rule (ATR) greatest power within 30 degrees of the horizontal (180 degrees) meridian Oblique one principal meridian is between 31 and 59 and the other is between 121 and 149 Cylinder lens --- corrects the astigmatism
The meridian of maximum power is called the power meridian and the meridian of zero power is called the axis meridian
Exp: -1.00 x 180, with the rule or +1.00 x 90 -1.00 x 90, against the rule 44 D @ 90, 45D @ 180, corneal astig. = -1.00 x 90 , ATR
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The cornea is the main contributor to the astigmatism of the eye but rarely total astig. of the eye exactly equal the amount of the corneal astig.
a) b) c) d) The optical axis of the cornea does not coincide with the line of sight of the eye The posterior surface of the cornea and crystalline lens may have astigmatism The crystalline lens may be tilted within the eye Keratometry is measured at the cornea while correcting lenses are placed in the spectacle plane Calibration index used in the keratometer differs from the index of refraction of the cornea
e)
* The tilt of the cornea and the crystalline lens probably account for the most
Total astigmatism can be predicted from the corneal astigmatism

Javals rule: Total astigmatism = 1.25 (CA) + (-0.50 D x 90) Grosvenor and colleagues simplified Javals rule: Total astigmatism = CA + (-0.50 D x 90)
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Pachometry
Also pachymetry Measurement of corneal thickness
a) b) Monitoring corneal edema induced by contact lens wear and various corneal conditions Determine the depth of cuts or ablation in refractive surgery
Ultrasonic pachometry uses a probe that produces sound at a frequency high above the range of human hearing is placed on the cornea
Ultrasound directed into the cornea echoes from both anterior and posterior surface of the cornea The difference in echo times is then measured to calculate the time taken for the ultrasound to traverse the cornea
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Using a known sound velocity for corneal tissue, corneal thickness is then calculated Ultrasonic pachometers give more accurate measurements of corneal thickness than optical pachometry Optical pachometry can be performed with an attachment to a slit lamp biomicroscope but ultrasonic pachometry needs a separate instrument
Optical pachometry masks the illumination beam to form a slit of light so that only a cross section of cornea is illuminated
The slit beam passes through two glass plates, a bottom plate is kept perpendicular to the observation axis and an upper plate can be rotated about a vertical axis When upper plate is rotated, the image of the upper corneal section is displaced horizontally relative to the lower corneal section
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Figure 5.15
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When turns the plate enough to align the back surface of the upper half image of cornea with front surface of the lower half image of the cornea, the amount of displacement equals the projected depth of the beam through the cornea. The amount of rotation of the upper glass plate yields a measure of the lateral projected thickness (D) of the cornea. l , is the apparent thickness of the cornea, the distance from the anterior corneal surface to the image of the posterior corneal surface
Apparent thickness, l can be calculated from D and
' D / sin
The actual thickness l can be calculated from apparent thickness
L L' F n / n' / ' F

n = the index of refraction of the cornea n= the index of refraction of air F = the refractive power of the anterior surface of the cornea
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Figure 5.16
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Phakometry
A technique that employs direct observation or photography of the Purkinje images to measure the radii of curvature of the anterior and posterior surface of the crystalline lens Two primary methods of phakometry: Tschernings method of ophthalmophakometry and comparison phakometry Both based on the principle that the magnification of a reflected image is proportional to the radius of curvature of the reflecting surface
Phakometry
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Several assumptions are made: a) Because the Purkinje image II is very difficult to see and photograph, the cornea is assumed to be a single refracting surface with its refractive power equal to the keratometer power b) Index of refraction values for the ocular media are given standard values c) The crystalline lens is treated as a homogeneous medium with a single index of refraction
d)
e)
The ocular refracting surfaces are assumed to be spherical rather aspheric The eye is assumed to be coaxial system with the centers of curvature of the refracting surfaces falling on a single line
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Comparison Phakometry
A photograph is taken of the Purkinje images of a pair of lights The separation of the pair of lights is measured for each of the Purkinje images The apparent radius of a surface is the distance from the surface to the point where an image would be formed of the center of curvature of that surface
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The apparent radius of curvature of the crystalline lens surface is determined by :
size of Purkinje III size of Purkinje I
apparent radius, anterior lens radius of curvature , anterior cornea
The apparent radius of curvature of the posterior crystalline lens surface is determined in the same way:
size of Purkinje IV size of Purkinje I
apparent radius, posterior lens radius of curvature, anterior cornea
Using the solved values for the apparent radii of curvature, the locations of the apparent centers of curvature can be determined. Then the location of the actual centers of curvature can be determined by where the actual centers of curvature as objects would have to be located in order to be imaged at the locations of the apparent centers of curvature Finally, the actual radii of curvature are the distances from the actual surfaces to their respective actual centers of curvature
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The Gullstrand-Emsley schematic eye is used Radius of curvature of the anterior corneal surface & total power of cornea are obtained from keratometry The actual centers of curvature of the anterior and posterior lens surfaces are located by raytrace using the locations of the apparent centers of curvature as images
Refer to appendix 5.1 pg 132 134 (Goss DA et al.)

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Anterior chamber depth and lens thickness must be obtained from some method such as ultrasonography The actual radii of curvature are the distances between the actual crystalline lens surfaces and their actual centers of curvature
Tschernings Ophthalmophakometry
Has been largely replaced by comparison phakometry Methods of measurement was different Separation of the pair of lamps that produced Purkinje image I was varied until two corneal reflections had the same separation as the two reflections from anterior and posterior crytalline lens surfaces
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The primary use for phakometry is for the study of the contribution of the crystalline lens to refractive errors
Purkinje images have also been used to study crystalline lens changes in accommodation and night myopia
Ultrasonography
Measurement of the distances between ocular surfaces Ultrasound is an acoustic wave with a frequency higher than the human audible range (human eye can detect tones with frequencies from 20 to 20,000 cycles per second) An ultrasound wave is produced by a transducer through the application of an alternating electrical current to a piezoelectric crystal
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The crystal vibrates at a frequency that matches the frequency of the driving current Transducer directs bursts of ultrasound pulses into the eye at about one thousand bursts per second The intervals between bursts are used to register the echoes coming back into the transducer after being reflected from surfaces within the eye The crystal produces electrical energy when it is mechanically vibrated by the returning ultrasound waves
The time between the echoes returning from two axially separated tissue interfaces is measured, and converted into distance measurements using known velocities of ultrasound in the ocular tissues
d = (V)(t/2)
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The range of ultrasound frequencies that have been used for various ophthalmic applications is about 5 million to 25 million cycles per second (megahertz) The frequencies used in ultrasonic pachometry cannot be used to measure axial length because attenuation is too great (attenuation is a progressive loss of ultrasound amplitude as a result of scattering and absorption)
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A-scan Ultrasonography
Amplitude modulation, unidimensional display of the amplitude of echoes Spikes on an oscilloscope trace correspond to echoes from the cornea, the anterior and posterior surfaces of the crystalline lens and the retina The main application of A-scan is the measurement of intraocular distances
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Intraocular distances are determined using the formula for distance as a function of time and velocity Commercially available ultrasound units will give measurement for the distance from the anterior surface of the cornea to the anterior surface of the crystalline lens ( referred to as anterior chamber depth), crystalline lens thickness, and vitreous chamber depth. The sum of these will be the axial length of the eye
Used in studies of the relationship of the ocular optical components to refractive error and in calculations to predict the best lens implant power for replacement of a crystalline lens removed in cataract surgery It is important to align the ultrasound probe as close as possible with the line of sight of the eye If not, the axial length will be too high Another error is press against the globe with the probe rather than just touch the surface of the cornea give low measures of anterior chamber depth and axial length
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B-Scan Ultrasonography Brightness mode or intensity modulation ultrasonography Two dimensional, cross-sectional representation of the eye The brightness of each spot in B-scan image is proportional to the ultrasound energy reflected from the corresponding tissue surface B-scan can be used to evaluate portions of the eye that may be obscured from visual inspection by media opacities
Video : How Does an A-Scan Become a B-Scan?
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The primary uses of B-scan ultrasonography are the detection and localization of conditions such as intraocular tumors, retinal detachment, vitreous hemorrhage, and other intraocular tissue anomalies, also can be used for examination of orbital conditions
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Partial Coherence Interferometry

Uses interference of light to measure axial lengths in the eye Has the potential to achieve measurements ten times as precise as ultrasouond Zeiss IOLMaster Intrared light from superluminescent diode is directed through an interferometer
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A Fabry Perot interferometer consisting of two parallel, partially transmitting mirrors is used One component of the IR beam goes directly through the two mirrors without reflection The other component is reflected twice by the two mirrors before it rejoins the direct component
Figure 5.19
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The reflected component of beam travels an additional distance that is twice the separation (d) between the two mirrors With a diode light source the difference in distances traveled exceeds the difference in distance over which the light remains coherent (only about 9m) so interference fringes are not seen The two components of the beam are directed into the eye along its optical axis
If the beams reflected from anterior and posterior cornea receive an opposite phase shift, the phase shift induced by the interferometer will be nullified and interference fringes will result.
When fringes are sensed by the fringe detector, the thickness (t) of the cornea equals the separation (d) of the interferometer mirrors divided by the refractive index of the cornea, t = d/n
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Partial coherence interferometer has relatively high order of dioptric resolution for axial length ( 0.03D)
non-contact device with up to 0.01mm for axial length measurements

It takes approximately 0.4 sec for a measurement
Pupillometry Measurement of apparent pupil diameter Measure of the image (the entrance pupil) of the anatomical pupil as seen through the cornea, which functions as a magnifying lens The apparent pupil is about 12 % larger and 0.5 mm closer to the cornea than the anatomical pupil is Differences in the pupil size between the two eyes or anomalies in the pupil reaction to light or accommodation can be signs of ocular or neurological disease
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Simple Methods
Holding ruler in front of the pupil Compare the pupil in question to a series of black halfcircles on a ruler (Pupil gauges in Rosenbaum cards)
Brocas pupillometer uses two pinhole to measure ones own pupil diameter When two pinholes are held close to the eye, they form blur circles on the retina. The edges of the two blur circles appear to just touch when the separation of the two pinholes equals the pupil diameter
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Doubling methods, such as biprism also use same principle Ruler and comparison gauge pupil measurement is subject to variety of errors: intraobserver variability, lack of standardized illumination control, patient accommodation, papillary unrest, and difficulty visualizing the pupil under the true scotopic conditions
Instrumentation Methods
Infrared can avoid the activation of the papillary reflex Infrared pupillometer:
Colvard pupillometer Pupilscan 2
Colvard pupillometer superimposes a millimeter scale over a view of anterior segment, allowing examiner to easily measure the pupil size to an accuracy of approximately 0.5 mm
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Pupilscan 2 provides a digital readout of the pupil diameter to the nearest 0.1 mm derived from a pixelized liquid crystal display of the pupil and iris The number of dark pixels is counted by a microprocessor, and using a conversion factor, the diameter of the pupil extrapolated
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Some systems deriving pupil diameter from the amount of a broad beam of infrared being reflected or monitoring whether a small infrared scanned across the pupil and iris is reflected Dynamic bilateral infrared pupillometer Procyon P2000SA Consists of dual eyepieces with eyecups to completely control illumination coupled to an infrared camera and a computer interface
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References
GOSS DA & WEST RW (2002) Introduction to the Optics of the Eye. Boston: ButterworthHeinemann. RABBETS, R (1998) Bennett & Rabetts Clinical Visual Optics. 3rd ed. Oxford: ButterworthHeinemann HENSON DB (January 1996) Optometric Instrumentation. 2nd ed. Butterworth-Heinemann
Learning Outcomes
Recall the general purpose and clinical utility of a variety of biometric techniques. Describe the basic principles of the biometric technique Understand and able to interpret the readings obtained through the biometric instruments and use it for further investigations
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Ocular Biometry (Week 1)

OPT3024 Ocular Optics I

Describe the basic principles of the biometric technique

OPT3024 Ocular Optics I

OPT3024 Ocular Optics I

OPT3024 Ocular Optics I

OPT3024 Ocular Optics I

OPT3024 Ocular Optics I

Has variety clinical uses:

OPT3024 Ocular Optics I

OPT3024 Ocular Optics I

OPT3024 Ocular Optics I

OPT3024 Ocular Optics I

OPT3024 Ocular Optics I

OPT3024 Ocular Optics I

OPT3024 Ocular Optics I

h/h (r/2)/d r = (2d)(h/h) = 2dm

OPT3024 Ocular Optics I

Measurement of the Reflected Image

OPT3024 Ocular Optics I

Measurement of the Reflected Image

OPT3024 Ocular Optics I

OPT3024 Ocular Optics I

OPT3024 Ocular Optics I

Different keratometers employ either variable or fixed doubling

OPT3024 Ocular Optics I

OPT3024 Ocular Optics I

OPT3024 Ocular Optics I

OPT3024 Ocular Optics I

OPT3024 Ocular Optics I

OPT3024 Ocular Optics I

OPT3024 Ocular Optics I

OPT3024 Ocular Optics I

1.3375 1.00 0.0077 m

Area of the Cornea Measured

OPT3024 Ocular Optics I

OPT3024 Ocular Optics I

OPT3024 Ocular Optics I

OPT3024 Ocular Optics I

OPT3024 Ocular Optics I

Total astigmatism can be predicted from the corneal astigmatism

OPT3024 Ocular Optics I

OPT3024 Ocular Optics I

OPT3024 Ocular Optics I

OPT3024 Ocular Optics I

OPT3024 Ocular Optics I

OPT3024 Ocular Optics I

OPT3024 Ocular Optics I

OPT3024 Ocular Optics I

OPT3024 Ocular Optics I

Apparent thickness, l can be calculated from D and

The actual thickness l can be calculated from apparent thickness

L L' F n / n' / ' F

OPT3024 Ocular Optics I

OPT3024 Ocular Optics I

OPT3024 Ocular Optics I

OPT3024 Ocular Optics I

OPT3024 Ocular Optics I

OPT3024 Ocular Optics I

OPT3024 Ocular Optics I

The apparent radius of curvature of the crystalline lens surface is determined by :

size of Purkinje III size of Purkinje I