444 Journal of Refractive Surgery Volume 18 July/August 2002

ABSTRACT
PURPOSE: To determine directly measured ver-
tex distances in a consecutive series of patients
refracted at a refractor and to examine the clinical
importance of such a measurements for improving
refractive surgical results.
METHODS: Vertex distance measurements were
obtained in 189 consecutive patients by using a new
device capable of taking direct and accurate mea-
surements behind a refractor. Eyelid thickness was
measured with an industrial caliper in five
patients.
RESULTS: The average true vertex distance was
20.4 mm with a range of 10 to 34 mm. Eyelid thick-
ness was 3 mm in all five patients.
CONCLUSIONS: Precise measurement of true
refractor vertex distance is important for accuracy
of refractive surgical procedures. The practice of
assuming an average vertex distance of 12 to 14 mm
for all refractive patients underestimates the ver-
tex distance in many patients refracted at the
refractor, resulting in overcorrecting minus and
undercorrecting plus refractions. [J Refract Surg
2002;18:444-448]
V
er tex di stance, or the di stance fr om the
cornea to the spectacl e tri al l ens, has been
tradi ti onal l y measured by the Di stometer
(Haag-Strei t, Wal dwi ck, NJ), a devi ce desi gned to
take vertex measurements over a range of 7 to
23 mm from behi nd a spectacl e or tri al l ens. Thi s
devi ce works wel l for most spectacl e readi ngs l ess
than 23 mm, but because of i ts desi gn and sci ssors-
l i ke acti on, cannot physi cal l y take any ver tex
measurements behi nd most refractors.
Sol uti ons devi sed by r efr actor manufactur er s
i nvol ve esti mati on by di rect si ghti ng and through
90 mi rrors l ocated at the si de of the refractor al ong
wi th compl i cated correcti on factor tabl es. Al though
when used correctl y, these methods can yi el d true
vertex di stance measurements, i n cl i ni cal practi ce
the headrest i s correctl y adjusted onl y i nfrequentl y,
and correcti on factor tabl es are sel dom used. When
we tri ed the aforementi oned methods accordi ng to
the refractor manufacturer s i nstructi ons (even wi th
separ ate hand-hel d cor neal i l l umi nati on fr om
behi nd the refractor), we found them to be ti me-con-
sumi ng and awkwar dhamper ed by par al l ax
errors, di m l i ghti ng, and poor vi sual i zati on.
Many refracti ve surgeons assume an average ver-
tex di stance of 12 to 14 mm for al l pati ents wi thout
measuri ng vertex di stance. One publ i shed source of
thi s commonl y accepted conventi on i s the
Di stometer operati ng i nstructi ons, whi ch state that
cl i ni cal experi ence has establ i shed that thespec-
tacl e l enses, when fi tted properl y, are pl aced on
average 8 to 12 mm from the cornea (Di stometer:
I nstructi ons for Use. Di stri buted by Haag-Strei t
Servi ce. Wal dwi ck, New Jersey). Another source of
thi s conventi on may be that when the forehead i s
adjusted so that, accor di ng to the Rei cher t
Ul tramati c RX Master Phoroptor i nstructi ons, the
corneal apex i s al i gned wi th the zero si ghti ng l i ne,
the vertex di stance from the corneal apex to the pos-
teri or l ens surface i s desi gned to be 13.75 mm wi th
thi s phoropter.
We i ntroduce an al ternati ve method of di rectl y
obtai ni ng the vertex di stance. We set out to con-
veni entl y and accuratel y measure the refractor
vertex di stance and found that i t was al most al ways
greater than commonl y assumed. We exami ned the
cl i ni cal i mpl i cati ons of under esti mati ng thi s
di stance for achi evi ng predi ctabl e resul ts i n refrac-
ti ve procedures.
Clinical Importance of Accurate Refractor Vertex
Distance Measurements Prior to Refractive
Surgery
Richard A. Weiss, MD; William Berke, OD; Larry Gottlieb, OD; Peter Horvath, OD
From the Department of Ophthalmology, University of California,
Irvine, CA.
Dr. Weiss holds patent rights to device mentioned herein. The remain-
ing authors have no proprietary interest in the materials mentioned
herein.
Correspondence: Richard A. Weiss, MD, 360 San Miguel Drive, Suite
403, Newport Beach, CA 96660. Tel: 949.720.1400; Fax: 949.720.1457;
E-mail: drweiss@drweiss.com
Received: July 28, 1999
Accepted: December 10, 2001
PATIENTS AND METHODS
One of the authors (RAW) has i nvented a new
devi ce (Fi g 1), cal l ed the Wei ss Ver texometer
(OASI S Medi cal , Gl endora, CA), to di rectl y measure
corneal vertex di stance from behi nd the refractor or
tri al l ens. Four i nvesti gators used thi s devi ce to
measure the refractor vertex di stances for the ri ght
eye of 189 consecuti ve pati ents presenti ng for rou-
ti ne refracti on. Two types of refractors were used,
the Ni dek TS 1200 (Ni dek, Gamagori , Japan) and
the Rei cher t Ul tr amati c RX Master Phor optor
(Rei chert Ophthal mi c I nstruments, Buffal o, NY).
Pati ents wer e pl aced behi nd the r efr actor and
al i gned i n the usual manner, wi thout maki ng any
changes i n the refractor posi ti on (forehead bar) set-
ti ngs.
Pati ents were i nstructed to keep thei r foreheads
pr essed agai nst the headr est, whi ch r emai ned
untouched i n a neutral posi ti on and unadjusted
throughout the study, correspondi ng to the method
of dai l y cl i ni cal use of thi s devi ce i n these offi ces.
The vertex measurement was taken by havi ng the
pati ent cl ose thei r eyes and careful l y posi ti oni ng the
Vertexometer between the pati ent and the refractor
(Fi gs 2, 3). One si de of the Vertexometer ti p was
gentl y pl aced on the apex of the cl osed eyel i d and a
fl exi bl e measuri ng devi ce was advanced from the
opposi te si de of the ti p to make l i ght contact wi th
the l ens i nsi de the refractor. The vertex di stance
was i ndi cated on a scal e at the base of the
Vertexometer.
Measurements were taken di rectl y agai nst the
posteri or l ens surface on the Rei chert Ul tramati c
RX Master Phor optor. The Ni dek TRS 1200
refractor has a protecti ve l ens cover over the l ens
aperture, so di rect measurements were taken from
the back of the l ens cover to the cl osed eyel i d and
corrected by addi ng the di stance from the l ens cover
to the refractor l ens system pl anes, as suppl i ed by
Ni dek (4 mm).
Eyel i d thi ckness was measured i n fi ve randoml y
sel ected eyel i d surgi cal pati ents. The eyel i d was
everted and the central thi ckness was determi ned
wi th an i ndustri al mi crometer after the conjuncti va
was anestheti zed wi th a topi cal anestheti c.
RESULTS
The average measured di stance from the refrac-
ti ve l ens pl ane to the cl osed eyel i d was 17.4 mm.
Eyel i d thi ckness i n al l fi ve pati ents was 3.0 mm.
Thus, the average true vertex di stance i n thi s seri es
Journal of Refractive Surgery Volume 18 July/August 2002 445
Refractor Vertex Distance Measurement Before Refractive Surgery/Weiss et al
Figure 1. Weiss Vertexometer, with a tip that can directly measure
vertex distance to the lens system within the refractor tube.
Figure 2. Diagram of Weiss Vertexometer
(prototype) in place between patient and
refractor.
was 20.4 mm. The true vertex range (eyel i d thi ck-
ness i ncl uded) was 10 to 34 mm.
DISCUSSION
Al most al l refracti ve surgi cal methods al ter the
refracti ve power of the cornea at the pl ane of the
corneal apex (the onl y excepti on to thi s bei ng refrac-
ti ve i ntraocul ar l enses). Spectacl e tri al l enses and
refractors each measure the correcti ng refracti ve
power of a l ens i n a pl ane other than the cornea.
Therefore, the measured power at the correcti ve
l ens pl ane must be converted to the correcti ve power
that i s needed at the pl ane of the corneal apex,
where the actual corneal power change takes pl ace.
Ver tex di stance i s defi ned as the di stance
between the back surface of the refracti ve l ens and
the corneal apex.
1
Thi s measurement i s cri ti cal
because i t i s an i mportant vari abl e i n the equati on
that converts di optri c power at the refracti ve l ens
pl ane to di optri c power at the corneal apex, or the
corneal vertex di opter power (D
cv
).
That equati on i s D
cv
= D
vp
/(1-d*D
vp
), where D
cv
i s
the di optri c power at the corneal pl ane, D
vp
i s the
power at the posteri or l ens pl ane, and d i s the ver-
tex di stance i n meters.
2
Usi ng thi s equati on, we can
exami ne the effect of vertex di stance (wi thi n the
range of our measured true vertex di stances) on the
cor neal ver tex di optr i c power wi th i ncr easi ng
phoropter l ens powers (Tabl e).
A l ens power of -3.00 D corresponds to a corneal
vertex power of -2.90 D wi th a 12-mm vertex di s-
tance and -2.71 D wi th a 35-mm vertex di stance, a
di fference of onl y 0.19 D over thi s range, possi bl y
cl i ni cal l y i nsi gni fi cant. However, as we i ncrease the
l ens power, the di fferences become l arger and more
meani ngful .
Consi der what happens when we assume an aver-
age unmeasured vertex di stance of 12 mm that i s
real l y 25 mm. I n a -6.00-D myope, we wi l l try correct
-5.60 D at the corneal pl ane when we shoul d have
corrected -5.22 D, resul ti ng i n an overcorrecti on of
0.38 D. I n the cases of -12.00 D and -15.00 D of
myopi a, we wi l l theoreti cal l y overcorrect by 1.26 D
and 1.81 D, respecti vel y. Si mi l arl y, we can cal cul ate
that for a +5.00-D hyperope, we wi l l undercorrect by
0.39 D. These di fferences are si gni fi cant.
Li kewi se, usi ng an average unmeasured 12-mm
vertex di stance that i s real l y 35 mm wi l l resul t i n
l ar ger theor eti cal i naccur aci es; over cor r ecti ng
-6.00 D, -12.00 D, and -15.00 D by 0.61 D, 2.04 D,
and 2.87 D, r especti vel y, and under cor r ecti ng
+5.00 D of hyperopi a by 0.74 D. Parentheti cal l y, i t i s
of cl i ni cal i nterest to note that current software ver-
si ons of many exci mer l aser systems do not al l ow
entry of vertex di stances greater than 25 mm, a sub-
group consi sti ng of 24 or 12.4% of our pati ents.
These exampl es i l l ustrate that underesti mati ng
the refractor vertex di stance wi l l resul t i n overcor-
recti ng the myope and undercorrecti ng the hyper-
ope. We bel i eve that i naccuracy of vertex di stance
measurements at the refractor may account for
some of the unpredi ctabi l i ty of refracti ve outcomes
i n previ ousl y reported studi es, speci fi cal l y, overcor-
recti ons i n hi gher myopes and undercorrecti ons i n
hi gher hyperopes.
A cruci al questi on i s whether di rect measurement
from the cornea to the posteri or presenti ng l ens sur-
face i s the true vertex di stance i n al l cases. Rei chert
Ophthal mi c I nstruments confi rms that al l l enses i n
thei r Phoroptor are referenced to the posteri or l ens
surface (cl osest to the eye) of the l enses i n the strong
sphere l ens pl ane. Fi gure 4 i s an i nternal schemati c
of the l ens pl acements wi thi n the Phoroptor.
I nsi de the Phoroptor, the l enses are di vi ded i nto
pl anes that correspond to di fferent rotary di al s that
hol d di ffer ent power l enses; one each for an
446 Journal of Refractive Surgery Volume 18 July/August 2002
Refractor Vertex Distance Measurement Before Refractive Surgery/Weiss et al
Figure 3. Weiss Vertexometer in place between patient and
refractor.
Table
Effect of Vertex Distance on the Corneal
Plane Dioptric Power With Increasing
Refractor Lens Powers
Lens Power Vertex Distance (D)
(D) 12 mm 25 mm 35 mm
-3.00 -2.90 -2.79 -2.71
-6.00 -5.60 -5.22 -4.99
-12.00 -10.49 -9.23 -8.45
-15.00 -12.71 -10.90 -9.84
+5.00 +5.32 +5.71 +6.06
auxi l i ary bank, strong sphere bank, weak sphere
bank, strong cyl i nder bank, weak cyl i nder bank,
accessory cyl i nder bank, rotary pri sm l oupe, and
cross cyl i nder l oupe, wi th successi ve pl anes bei ng
l ocated further from the eye, i n the above order.
As menti oned, al l l enses i n the Phoroptor are
referenced to the back surface of the pl ane of the
strong sphere. For al l l enses i n thi s pl ane (+3.00 D,
+6.00 D, +9.00 D, +12.00 D, +15.00 D, -3.00 D,
-6.00 D, -9.00 D, -12.00 D, -15.00 D, -18.00 D) the
marked power i s the same as the actual l ensometer
power.
Thus, di rect measurement of vertex di stance to
the back surface of l enses i n the strong sphere pl ane
Journal of Refractive Surgery Volume 18 July/August 2002 447
Refractor Vertex Distance Measurement Before Refractive Surgery/Weiss et al
Figure 4. Internal schematic of the Reichert
Ultramatic RX Master Phoroptor. Vertex
distance of 13.75 mm assumes headrest is
set properly for cornea to be aligned with zero
sighting line.
Figure 5. Patients with different vertex
distances (Left: 14 mm vs. Right: 26 mm) due
to differences in forehead anatomy. Same
investigator, refractor, and headrest setting.
(Courtesy of William Berke, OD)
i s val i d. By di rect measurement, we found that the
strong sphere l ens pl ane i s al ways i n thi s posi ti on
for marked powers of greater than -1.00 D and
greater than +2.00 D, as l ong as the auxi l i ary bank
i s not i n pl ace at the ti me of measurement, as i t usu-
al l y i s not. The onl y excepti on when di rect measure-
ment i s not val i d i s for pl ano-cyl i ndri cal powers i n
an open tube phoropter (wi thout a l ens aperture
cover), i n whi ch case the di rect measurement woul d
be to the more di stant cyl i nder pl ane, an over-
esti mati on of the vertex di stance.
Wi th thi s excepti on i n mi nd, we excl uded fi ve
pati ents wi th pl ano-cyl i ndri cal refracti ons from our
seri es. I n retrospect, these were not val i d vertex
measur ements. I nter esti ngl y, the l ar gest ver tex
measurement i n the enti re seri es was taken at a
cl osed tube phoropter.
Weak sphere and al l cyl i nder l enses are al so ref-
erenced to the posteri or surface of the strong sphere
pl ane. For exampl e, the actual l ensometer power for
a marked +5.00-D cyl i nder l ens i s +4.674 D, whi ch
corresponds to the 12.14-mm di stance from one l ens
pl ane to the other.
The above confi rms the val i di ty of the fact that
two l enses i n combi nati on correspond exactl y to the
marked Phoroptor power, wi th a vertex di stance
bei ng referenced to the back surface of the strong
sphere l ens pl ane (cl osest to the eye), whi ch can
then be di rectl y measured for moderate and hi gher
refracti ve errors.
Accuracy of i ndi vi dual refracti ve resul ts requi res
accurate vertex di stance measurements i n each
pati ent because thi s di stance vari es i n each pati ent.
We shoul d be l ess compl acent about enteri ng the
vertex di stance i nto the l aser. The average vertex
di stance shoul d not be appl i ed to everyone, and has
no cl i ni cal useful ness.
A more si gni fi cant fi ndi ng i s the wi de range (10 to
34 mm) of measured vertex di stances even among
pati ents of the same i nvesti gator, whi ch agai n
emphasi zes the need for accurate i ndi vi dual mea-
surements. Thi s rel ati vel y wi de range was due i n
part to anatomi c vari ati ons, di fferences i n basel i ne
phoropter headrest posi ti on, posture, and effort.
There i s certai nl y no uni formi ty about the starti ng
posi ti on of the refractor headrest among di fferent
exami ner s. Fi gur e 5 shows two pati ents wi th
markedl y di fferent vertex di stances, the farthest
measur i ng 26 mm and the near est measur i ng
14 mm.
The average vertex di stance i n thi s study was
20.4 mm (range of 10 to 34 mm). Thi s i s substan-
ti al l y l arger than commonl y used val ues and may be
r esponsi bl e for cer tai n cases of over cor r ected
myopes and undercorrected hyperopes i n previ ous
studi es.
Accurate refractor vertex measurements i n every
pati ent ar e essenti al i n pr oduci ng pr edi ctabl e
refracti ve surgi cal resul ts, especi al l y i n pati ents
wi th moderate to severe refracti ve errors. Thi s may
be especi al l y rel evant wi th i ncreasi ng demands for
accuracy of refracti ve resul ts.
REFERENCES
1. Benjami n WJ. Bori sh's Cl i ni cal Refracti on. Phi l adel phi a,
PA: WB Saunders Company; 1998:968.
2. Cogger TJ. Correcti on wi th hard contact l enses. I n: Duane
TD, ed. Cl i ni cal Ophthal mol ogy. Hagerstown, MD: Harper &
Row; 1980: chapter 54, p 22.
448 Journal of Refractive Surgery Volume 18 July/August 2002
Refractor Vertex Distance Measurement Before Refractive Surgery/Weiss et al
Journal of Refractive Surgery Volume ?? Month/Month 1997 449
Running title/Author