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Applications of corneal topography and tomography: a review: Applications of

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Clinical and Experimental Ophthalmology 2018; 46: 133–146 doi: 10.1111/ceo.13136

Review

Applications of corneal topography and

tomography: a review
Rachel Fan MBBS,1 Tommy CY Chan FRCS,2 Gaurav Prakash MD3 and Vishal Jhanji MD
FRCOphth2,4,5
1
Faculty of Medicine, The University of Hong Kong, 2Department of Ophthalmology & Visual Sciences, The Chinese University
of Hong Kong, Hong Kong; 3NMC Eye Care, NMC Specialty Hospital, Abu Dhabi, United Arab Emirates; 4Department
of Ophthalmology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA; and 5Centre for Eye Research Australia,
University of Melbourne, Melbourne, Victoria, Australia

ABSTRACT write”). Corneal topography is a non-contact imaging

Corneal imaging is essential for diagnosing and man-
agement of a wide variety of ocular diseases. Corneal
topography is used to characterize the shape of the cor-
nea, specifically, the anterior surface of the cornea. Most
corneal topographical systems are based on Placido disc
that analyse rings that are reflected off the corneal sur-
face. The posterior corneal surface cannot be character-
ized using Placido disc technology. Imaging of the
posterior corneal surface is useful for diagnosis of cor-
neal ectasia. Unlike corneal topographers, tomographers
generate a three-dimensional recreation of the anterior
segment and provide information about the corneal
thickness. Scheimpflug imaging is one of the most com-
monly used techniques for corneal tomography. The
cross-sectional images generated by a rotating Scheimp-
flug camera are used to locate the anterior and posterior
corneal surfaces. The clinical uses of corneal topography
include, diagnosis of corneal ectasia, assessment of cor-
neal astigmatism, and refractive surgery planning. This
review will discuss the applications of corneal topogra-
phy and tomography in clinical practice.
Key words: agreement, cornea, repeatability, tomogra-
phy, topography.
INTRODUCTION
‘Topography’ is derived from the Greek words ‘topo’
(meaning ‘to place’) and ‘graphien’ (meaning “to
technique that maps the shape and features of the
corneal surface. Corneal topographers such as a Pla-
cido disc, analyse the pattern of light rays reflected
off the cornea and tear film-air interface and recon-
struct the corneal shape. Although modern topogra-
phy devices are able to map a large part of the
anterior segment, a complete pachymetric evaluation
is not possible without information of the posterior
corneal surface. Contrary to topography, corneal
tomography (‘tomos’: ‘section’; and ‘graphien’: ‘to
write)’ evaluates the whole cornea by obtaining
information from both anterior and posterior corneal
surfaces. The corneal tomographers are able to recon-
struct three-dimensional images of the anterior seg-
ment. A good understanding of corneal imaging
techniques is essential for its successful clinical appli-
cations. This review will cover the indications and
interpretation of corneal topography.
PRINCIPLES OF CORNEAL TOPOGRAPHY
Placido disk-based keratoscopy
Placido disk consists of a circular target of alternating
concentric light and dark rings and a central aperture
for observing the corneal reflections of these light-
and-dark bands over the cornea (Fig. 1).1 Examina-
tion of the reflected rings gives information about
the shape of the cornea. The initial use of Placido
disc was more qualitative; and yet with the develop-
ment of sophisticated software, the reflection

Correspondence: Dr Vishal Jhanji, UPMC Eye Center, Department of Ophthalmology, University of Pittsburgh School of Medicine, 203 Lothrop
Street, Pittsburgh, PA 15213, USA. Email: jhanjiv@upmc.edu
Received 16 August 2017; accepted 14 December 2017.
Conflict of interest: None declared.
Funding sources: None declared.

© 2017 Royal Australian and New Zealand College of Ophthalmologists

134
Figure 1. Placido disc and representative patterns of corneal
shapes.
patterns can be used to create quantitative data and
colour-coded maps as seen in videokeratographs.
More sophisticated Placido disk-based devices com-
bine the Placido disk with other technologies such
as Scheimpflug images and scanning-slit technology.
Slit-scanning elevation topography
The scanning slit system [e.g. Orbscan (Bausch &
Lomb, Orbtek Inc., UT, USA)] is a projective tech-
nique that measures the triangulation between the
reference slit beam surface and the reflected beam
captured by a camera. It combines a three-
dimensional scanning slit beam system with an
added Placido attachment. Forty slits are projected
sequentially on the cornea (20 nasal, 20 temporal)
during image acquisition to create an overlapping
Figure 2. Overlapping scanning slits to map the cornea in
devices with scanning slit technology such as Orbscan.
© 2017 Royal Australian and New Zealand College of Ophthalmologists
Fan et al.
pattern of scanning slits (Fig. 2). This data is inter-
preted using triangulation, and the final image is
represented as a three-dimensional topographic map
including curvature, elevation and pachymetry maps
of the entire corneal surface.
Scheimpflug imaging
A problem noted with centrally located scanning slit
based cameras was that there was poor/unreliable
capture of the corneal data from the periphery, caused
by the non-planar shape of the cornea. Scheimpflug
principle eliminates this problem.2 If the refracting
lens plane and the desired image plane are parallel,
an object, which is parallel to the lens, will form a
plane of focus that is also parallel to the lens plane.
However, if some parts of the object to be mapped are
not parallel to the prospective image plane, it will not
be possible to focus the entire image on a plane paral-
lel to image plane. As a result, it may lead to image
distortion. The Scheimpflug principle states that when
a planar subject is not parallel to the image plane, an
oblique tangent can be drawn from the image, object
and lens planes, and the point of intersection is called
Scheimpflug intersection (Fig. 3). A careful manipula-
tion of the image plane and the lens plane are used to
obtain a focused and sharp image of the non-parallel
object.3 The commonly used Scheimpflug devices
include Pentacam (Oculus, Wetzlar, Germany), TMS-5
(Tomey Corp., Nagoya, Japan), Galilei (Ziemer, Port,
Switzerland) and Sirius (CSO, Costruzione Strumenti
Oftalmici, Florence, Italy). The Pentacam has a single
rotating camera and a static camera. The Galilei and
the Sirius are both Scheimpflug-Placido devices inte-
grating a Placido topographer with a dual and single
rotating Scheimpflug camera, respectively.
Optical coherence tomography
Optical coherence tomography (OCT) is based on
the principle of low-coherence interferometry.4 It
compares the time-delay of infrared light reflected
from the anterior segment structures against a ref-
erence reflection. There are currently two types of
OCTs available: time-domain and Fourier-domain
OCT. Time-domain OCT produces cross-sectional
images by varying the position of a reference mir-
ror, whereas Fourier-domain OCT has a fixed mir-
ror. An interference between the sample and the
reference reflections produces cross-sectional
images.5 Fourier-domain OCT has a faster acquisi-
tion time compared to time-domain OCT, therefore
it reduces the motion artefacts due to eye move-
ments. This results in low signal to noise ratios,
provides better resolution and improves the char-
acterization of normal structures as well as that of
ocular pathology.
Corneal topography and tomography 135

Figure 3. Principle of Scheimpflug

imaging; (a) object and image plane
are parallel. Therefore, the image is
sharp and focused; (b) object and
image plane are not parallel. There-
fore, the image is not focused in
entirety; (c) Object and image plane
are not parallel; however, the image
plane has been rotated in accordance
with the Scheimpflug principle to cre-
ate an image focused in entirety.

CLINICAL APPLICATIONS OF CORNEAL Diagnosis of keratoconus

TOPOGRAPHY
Keratoconus
Keratoconus is an ectatic corneal dystrophy.6 It is
characterized by progressive thinning of the cornea
with resultant irregular astigmatism and loss of
visual acuity (Figs. 4 and 5).
The Global Consensus on Keratoconus and Ectatic
Disease (2015),7 recommended the following criteria
for diagnosis of keratoconus: abnormal posterior ele-
vation, abnormal corneal thickness distribution and
corneal thinning. Corneal tomography (e.g.
Scheimpflug or OCT) is the most commonly used
modality to diagnose keratoconus due to its ability

Figure 4. Swept source optical coherence tomography showing inferior corneal steepening and corneal thinning in keratoconus.
© 2017 Royal Australian and New Zealand College of Ophthalmologists
136
Figure 5. Pentacam depicting inferior corneal steepening and posterior corneal elevation in keratoconus.
to detect posterior corneal elevation abnormalities
even in mild or subclinical disease.8
Several indices such as the inferior–superior
index and KISA% index may facilitate the differen-
tiation of keratoconus from normal corneas.9,10 The
central K value, an expression of central corneal
steepening, is the average of the dioptric powers on
rings 2–4 of the Placido disc and a central K value
≥47.2 diopters is indicative of keratoconus.10 The
inferior–superior index (I–S index), an expression of
inferior–superior dioptric asymmetry, is the differ-
ence in dioptric power between the inferior and
superior cornea. An I–S value ≥1.4 is suggestive of
keratoconus.10 The KISA% index, introduced by
Rabinowitz and Rasheed,10 is a topography-based
index which is to quantify the asymmetry of the cor-
neal surface. It is derived from four indices includ-
ing central K value (K), I–S index, astigmatism
(AST) index and skewed radial axis index (SRAX).
The AST index quantifies the degree of regular cor-
neal astigmatism (SimK1–SimK2) and the SRAX
index is an expression of irregular astigmatism
occurring in keratoconus.10,11 The KISA index is cal-
culated as: KISA% = (K × I–S × AST × SRAX ×
100)/300. The KISA% index has an excellent clini-
cal correlation.10 A value of 100% is diagnostic of
keratoconus, and it is highly sensitive and specific.
A KISA% index range between 60–100% is consid-
ered keratoconus-suspect or subclinical keratoconus
whereas KISA% < 60% is considered to be
normal.10
© 2017 Royal Australian and New Zealand College of Ophthalmologists
Fan et al.
The use of displays such as the belin/ambrosio
enhanced ectasia display (BAD) on Pentacam can be
employed for detection of keratoconus.12 The BAD
comprises deviation of normality of the front eleva-
tion, back elevation, pachymetric progression, cor-
neal thinnest point and relational thickness. The
Pentacam software classifies BAD value as normal
(< 1.6 standard deviation (SD) from the population
mean), suspicious (≥ 1.6 and <2.6 SD), and patho-
logic (≥ 2.6 SD) (Fig. 6).
Classification of keratoconus
The Amsler–Krumeich keratoconus classification
(Table 1) is the oldest and most commonly used
classification system for keratoconus.13 It relies on
anterior surface topography. The severity of kerato-
conus is graded from stage 1–4 using refractive error
of patient, central keratometry, presence or absence
of scarring and central corneal thickness.
A new classification/staging ABCD keratoconus
grading system was proposed in 2016 utilizing cur-
rent tomographic data and it is dependent on cor-
neal tomography.12 The ABCD keratoconus grading
system includes the anterior (i) and posterior
(ii) average radii of curvature, thinnest pachymetric
values (iii) and best distance visual acuity (iv) as
well as the degree of scarring. The system classifies
keratoconus into five stages from 0 to 4. Although it
is claimed to better reflect the anatomical changes
seen in keratoconus compared to the existing
Corneal topography and tomography 137

Figure 6. Belin Ambrosio detection software showing high D value in a case with keratoconus.

Table 1. Amsler–Krumeich classification for keratoconus flattening of Kmax is used to gauge treatment effect
after interventions such as corneal collagen crosslink-
Stage I Eccentric steepening ing. The Global Consensus on Keratoconus and Ecta-
Myopia and astigmatism <5.00 D
sic7 defined ectasia progression as a consistent change
Mean central K readings <48.00 D
Stage II Myopia and astigmatism 5.00–8.00 D over time in at least two of the followings – steepen-
Mean central K readings <53.00 D ing of the anterior corneal surface, steepening of the
Absence of scarring posterior corneal surface and thinning and/or an
Minimum corneal thickness > 400 m increase in the rate of corneal thickness change from
Stage III Myopia and astigmatism 8.00–10.00 D the periphery to the thinnest point. These changes can
Mean central K readings >53.00 D be monitored by corneal tomography.
Absence of scarring
Minimum corneal thickness 300–400 m
Stage IV Refraction not measurable Contact lens fitting in keratoconus
Mean central K reading >55.00 D
Central corneal scarring Contact lens fitting is challenging especially when
Minimum corneal thickness 200 m the corneal apex become steeper in advanced kerato-
conus. Furthermore, there is also an increased risk of
complications from a poorly fitted contact lens. Most
classification systems, further studies are warranted topographers are equipped with topography assisted
for its validation on a large number of patients contact lens fitting software enabling more complete
before it can be recommended for clinical use. data collection and analysis of eyes with keratoconus.
It helps to assess the severity of keratoconus and pro-
vides details of the shape of the cone (nipple, oval or
Assessment of ectasia progression globus).14 The parameters obtained on corneal topog-
Evaluation of disease progression is important for the raphy can reduce contact lens fitting time and help in
formulation of a management plan. Kmax (maximum achieving a better fit of RGP or Rose K (multicurve
anterior sagittal curvature) is one of the most com- lenses with small optical zone) contact lenses.15
monly used parameters to detect or document progres-
sion. Since most of the commercially available corneal
Corneal crosslinking in keratoconus
tomography devices have a repeatability that does not
exceed 0.5 to 1 diopter, a change of > 1 diopter is con- Corneal crosslinking is indicated for slowing down
sidered to depict disease progression. Furthermore, or stopping the progression of keratoconus.16
© 2017 Royal Australian and New Zealand College of Ophthalmologists
138
Wollensak et al. were the first to show clinical effect
of crosslinking on keratoconus in 2003.17 A random-
ized controlled study by Wittig-Silva et al. reported a
significant decrease in maximal keratometry in kera-
toconus patients after crosslinking.18 Crosslinking
has also shown promising results for post-refractive
surgery keratectasia.19 Steinberg et al. reported cor-
neal topography to be useful in post-crosslinking
follow-up due to significant changes in the keratome-
try of the cornea.20 They also reported that assess-
ment of posterior corneal surface is important in
addition to the anterior corneal surface as increasing
posterior elevation values might be a sign of ongoing
ectatic changes despite a stable anterior cornea.20
Refractive surgery
Preoperative ectasia risk assessment
Corneal ectasia is an uncommon but severe sight-
threatening complication after refractive surgery.
Randleman et al.21 identified abnormal preoperative
corneal topography as the most important risk factor
for developing ectasia after LASIK. The other risk
factors included low residual stromal bed thickness,
age of the patient and preoperative corneal thick-
ness. Santhiago et al.22 recommended that preopera-
tive screening before refractive surgery should
include analysis of intrinsic biomechanical proper-
ties (data obtained from corneal topography/tomog-
raphy and patient’s age) and the analysis of
alterable biochemical properties (data obtained from
the amount of tissue altered by surgery and the
remaining load-bearing tissue). Ectasia could occur
after laser refractive surgery in three scenarios:
either in a cornea with intrinsic corneal disease
associated with fragility such as keratoconus or, in a
preoperatively weak but clinically stable cornea
with subtle topographic or tomographic signs of
abnormality or, in a relatively normal cornea which
is weakened with biomechanical instability after
surgery due to a high percentage of tissue altered.22
It should be noted that the risk of biomechanical
instability could still be increased in eyes that have
subtle abnormal topographic patterns that are not
associated with keratoconus even with a low value
of percentage of tissue altered. Cases of ectasia after
LASIK without risk factors have also been
reported.23,24
In contrast to a diagnostic test, a screening test for
keratoconus requires high sensitivity. The use of
segmental tomography together with epithelial
thickness measurement has been reported to be
useful.25–27 The use of epithelial thickness mapping
in addition to corneal topography may pick out false
positive ‘at risk’ cases that would have been other-
wise excluded by topography alone.28 Furthermore,
© 2017 Royal Australian and New Zealand College of Ophthalmologists
Fan et al.
devices such as the Galilei dual-Scheimpflug analy-
ser have an automated detection program which
includes 56 parameters derived from topography,
elevation maps, pachymetry and wavefront for anal-
ysis. It has a sensitivity of 93.7% and a specificity of
97.2%.29
In addition to preoperative evaluation, it may be
beneficial to measure flap thickness and residual
bed thickness intraoperatively in order to identify
cases that may be at risk for postoperative ectasia
despite a lack of risk preoperatively.30
Measurement of surgical outcomes in
refractive surgery
LASIK causes changes on the anterior as well as the
posterior corneal surface.31 Chan et al. used OCT to
depict the fluctuation in posterior corneal elevation
after LASIK and photorefractive keratectomy
(PRK).32 Corneal topography is useful postopera-
tively to look for increased corneal toricity with
topographic abnormality, progressive corneal thin-
ning and myopic refractive error with increased
astigmatism.33 After hyperopic corrections, the kera-
tometry and the epithelial thickness may show dis-
agreement. The use of postoperative keratometry
together with central epithelial thickness measure-
ment can determine whether a retreatment is needed
in these patients.34 In post-LASIK patients, Penta-
cam can be used to study the corneal thickness,
anterior and posterior curvature due to its high
repeatability.35
Complications after refractive surgeries: epithelial
ingrowth, diffuse lamellar keratitis and central toxic
keratopathy.
The majority of cases with epithelial growth after
LASIK can be managed conservatively until their
spontaneous resolution. The decision to intervene
surgically is dependent upon symptoms such as
glare and loss of visual acuity.36 Serial corneal topo-
graphic changes in these eyes are an indication for
surgical intervention. Majority of the times, change
in corneal thickness and keratometry occurs in par-
allel to change in manifest refraction.37
Diffuse lamellar keratitis is the infiltration of
white blood cell between the flap and stromal bed
after LASIK.38 Corneal topography shows notable
focal flattening corresponding to the focal haze
noted on slit-lamp examination.37 Likewise, central
toxic keratopathy is an uncommon, non-
inflammatory central corneal opacification that can
be observed after uneventful LASIK or surface abla-
tion surgery.39 Significant focal flattening can be
demonstrated in sagittal curvature map correspond-
ing to focal corneal haze on slit-lamp
examination.37
Corneal topography and tomography
Cataract and intraocular lens power
calculation
Similar to its application in refractive surgery, cor-
neal topography and tomography enable preopera-
tive screening of patients with irregular corneas.
Surgeons can attempt to minimize induced or pre-
existing astigmatism by combined use of corneal
topography and preoperative refraction to plan the
placement of corneal incisions.40 In refractive cata-
ract surgery, the outcomes are influenced by corneal
asphericity assessed on corneal topographers.41
Savini et al. reported that axial length and keratome-
try measurements obtained by the Aladdin – an
optical biometer combined with a Placido-ring
topographer, can reliably calculate intraocular lens
power when using third-generation power formulas
in unoperated eyes undergoing cataract surgery.42
The anterior segment OCT has been used to eval-
uate the accuracy of a new formula for predicting
postoperative anterior chamber depth with preoper-
ative angle-to-angle depth.43 The preoperative
angle-to-angle depth was found to be the most effec-
tive parameter for predicting postoperative anterior
chamber depth. The new regression formula with
three variables; angle-to-angle depth, preoperative
anterior chamber depth, and axial length, predicted
postoperative anterior chamber depth more accu-
rately than the SRK/T and Haigis formulas.43
Corneal topography determines the corneal
power using the anterior surface curvature multi-
plied by an index of refraction which assumes a
fixed relationship between the anterior and poste-
rior curvatures.44,45 Corneal topography has been
proven to be fairly accurate in determining the
refractive power of regular and unoperated corneas
by analysing the anterior corneal surface, but they
may be inaccurate in measuring corneas that have
irregular astigmatism and corneas that have under-
gone refractive surgery.46,47 It was suggested that
the inaccuracy in the default index of refraction and
the corneal power is due to the change in relation-
ship between the anterior and posterior surfaces
after refractive surgery.44,45 However, corneal
tomography such as computerized scanning slit
videokeratography, analyses both the anterior and
posterior corneal surfaces and elevation data gives
better estimations of corneal power in patients with
irregular corneal astigmatism.48
COMPARISON AMONG DIFFERENT DEVICES:
REPEATABILITY AND AGREEMENT
Repeatability refers to the variation in measure-
ments obtained by the same observer under same
conditions over a short period of time. Agreement
quantifies the similarity between any two
© 2017 Royal Australian and New Zealand College of Ophthalmologists
139
measurements using different methods on the same
subject. The limits of agreement, described by Bland
and Altman,49 are defined as the mean difference
 1.96 SD of differences. Repeatability of an instru-
ment is an important feature to consider in clinical
practice as well as research. It is important to under-
stand that a large variability in measurements can
lead to a false impression in the trend of postopera-
tive changes after refractive surgeries such as
LASIK. Modern devices have an excellent repeat-
ability in normal as well as postoperative corneas.
However, it is imperative that the agreement
between these devices is good enough so that the
readings can be used interchangeably.
Keratometry
Repeatability
Keratometry measures the corneal curvature and
determines the corneal power. It also detects and mea-
sures corneal astigmatism. Keratometric measurements
are crucial for refractive surgery, intraocular lens
power calculation, and diagnosis of keratoconus. Good
repeatability of corneal power measurements across
devices have been reported.50–52 A meta-analysis com-
paring the repeatability of multiple topographic
devices including the Pentacam, Galilei, Sirius, Orbs-
can, Placido, IOLMaster (Zeiss Humphrey, Dublin,
CA, USA), Lenstar (Haag Streit, Köniz, Switzerland)
and Aladdin in terms of keratometric parameters in
normal eyes was performed by Rozema et al.52 For
mean anterior and posterior keratometry, the authors
reported narrow ranges of combined measurement
errors (from across studies) except an outlier in both
parameters with Orbscan. For steep and flat kerato-
metric parameters, the study reported measurement
error ranging from 0.10 to 0.24D, whilst Sirius and the
IOLMaster had the lowest error values.
Agreement
In a meta-analysis of agreement of biometry values
provided by various ophthalmic devices, significant
differences were observed in mean posterior kerato-
metry between Pentacam and Sirius, and between
Pentacam and TMS-5.52 Significant difference in
steep posterior keratometry was also noted between
Pentacam and Galilei. Pentacam was found to be
equivalent to Placido-based imaging for anterior
keratometry, to Galilei for selected anterior and pos-
terior keratometry parameters (anterior steep kerato-
metry, posterior: mean, steep and flat simulated
keratometry) and to the Sirius for anterior flat kera-
tometry and anterior chamber depth measurement.
On the other hand, Orbscan was found to be equiv-
alent to Galilei for anterior flat simulated and steep
keratometry measurements.52
140
In a comparison between Scheimpflug and Scan-
ning slit-Placido devices, Orbscan measurements
were equivalent to and could be used interchangeably
with Galilei for anterior keratometry measurements
(anterior simulated flat and steep keratometry).52 In
other studies, Orbscan consistently underestimated
flat keratometry and overestimated simulated kerato-
metry compared to Pentacam and Sirius. Sirius was
shown to have better agreement compared to Penta-
cam in keratometry compared to Orbscan.53–56 Good
agreement in anterior keratometry was observed
between Pentacam and another Placido disk device,
OphthaTOP.57
A good agreement was noted between Scheimpflug
and OCT devices in unoperated eyes, but most studies
only confirmed the high correlations of measurements
among devices without affirming their interchange-
ability. In other studies, significant differences were
shown in mean keratometry between Pentacam and
different OCT devices.58–60 Good agreement in ante-
rior and posterior keratometric indices was reported
between Scheimpflug (Pentacam and Galilei, respec-
tively) and Swept source OCT (Casia) in normal cor-
neas.58,60 Good agreement for anterior keratometry
measurement was reported between Pentacam and
Visante (time-domain anterior segment OCT).59 High
degree of agreement in anterior keratometry but not
posterior keratometry was found between Galilei and
Casia Swept source OCT.58
Studies comparing Scheimpflug topographers and
optical biometers have shown potential interchange-
ability in keratometry readings between them. Clini-
cally interchangeable K readings between Pentacam
HR and AL-Scan (an optical biometer) was
reported.61 Good agreement and interchangeable ker-
atometry readings was reported between Sirius and
Lenstar LS900.62 No significant difference in kerato-
metric measurements was found in Pentacam AXL
and biometer IOLMaster 500, but caution was war-
ranted when using them interchangeably.63 It was
shown that Sirius cannot be used interchangeably
with Aladdin optical biometer for flat keratometry
readings.64 The mean corneal power measurements
with IOLMaster were significantly higher than the
Galilei as reported in two studies.65,66
Pachymetry
Repeatability
Pachymetry is important in the diagnosis and man-
agement of corneal diseases as well as in preopera-
tive screening of patients before laser refractive
surgery. Ultrasound pachymetry is currently consid-
ered as the gold standard for central corneal thick-
ness measurement.67 In a meta-analysis comparing
multiple topographic devices including the
© 2017 Royal Australian and New Zealand College of Ophthalmologists
Fan et al.
Pentacam, Galilei, Sirius, Orbscan (with and with-
out acoustic correction), ultrasound pachymetry,
Artemis (ArcScan Inc., Morrison, CO, USA), Visante
(Carl Zeiss Meditec, Dublin, CA, USA), RTVue
(Optovue Inc, Fremont, CA, USA), SL-OCT (Heidel-
berg Engineering, Dossenheim, Germany), Lenstar,
OA-1000 (Tomey, Nagoya, Japan) and specular
microscopy, the range of combined measurement
error across studies in central corneal thickness
among multiple devices was small. The Galilei
obtained the lowest measurement error of 1.76 μm
followed by RTVue (2.56 μm) and Sirius (3.75 μm).
The highest measurement errors were obtained in
specular microscopy and Arc Scan.52
Agreement
A meta-analysis reported statistically significant dif-
ferences in pair-wise comparison between Pentacam
and TMS-5, Orbscan with acoustic factor, Visante/
Stratus, SL-OCT and specular microscopy. Significant
differences were noted between Orbscan (with acous-
tic factor) and Pentacam, and between Orbscan (with-
out acoustic factor) and ultrasound. Only Pentacam
and ultrasound can be considered clinically equiva-
lent for central corneal thickness measurements.52
Multiple studies have reported significantly dif-
ferent central corneal thickness measurements
obtained with Pentacam, Sirius, Orbscan, Corvis
(Oculus, Wetzlar, Germany) and ultrasound
pachymetry.53,54,68–71 Recently, it was reported that
the differences in central corneal thickness measure-
ments between Sirius–Corvis, Pentacam–Orbscan
and Orbscan–ultrasound pachymetry pair-wise com-
parisons were not statistically significant thereby
suggesting that these devices could be used inter-
changeably for central corneal thickness measure-
ments in healthy eyes.54
Significant differences in central corneal thickness
measurements between Scheimpflug and Scanning slit-
Placido devices are generally reported.52 It has been
shown that Orbscan obtained lower central corneal
thickness measurements than Pentacam in healthy
eyes.72–75 Underestimation of central corneal thickness
measurements using Orbscan II persisted even after the
acoustic correction factor was applied.76–79 Therefore,
these devices cannot be used interchangeably for cen-
tral corneal thickness measurements.
Pentacam and ultrasound was shown to have a
good agreement for central corneal thickness mea-
surements in normal eyes.52 However, the inter-
changeability does not seem to apply to other
Scheimpflug-Placido devices. The central corneal
thickness measurements by TMS-5 (Scheimpflug-
Placido) were only found to be in moderate agree-
ment with ultrasound pachymetry.80 Sirius and
ultrasound pachymetry were not recommended to
Corneal topography and tomography
be used interchangeably for central corneal thick-
ness measurement.81,82 Multiple studies reported
differences in corneal thickness values in Sirius
compared to ultrasound pachymetry.55,82,83 Pachy-
metry measurements were thicker when measured
with Sirius compared to ultrasound pachymetry.84
However, a better agreement was reported between
Sirius and ultrasound pachymetry compared to the
agreement between Orbscan and ultrasound pachy-
metry.73 A significant difference was reported for
central corneal thickness measurements between
Orbscan (without acoustic factor) and ultrasound,52
but the difference was not significant once the
acoustic factor was in place for Orbscan. It was sug-
gested that central corneal thickness measurements
with Orbscan (with acoustic factor) and ultrasound
are interchangeable despite the fact that Orbscan
reported higher (but not significant) estimates of
central corneal thickness measurements compared to
ultrasound.54,85 Overall, it has been established that
Orbscan overestimates central corneal thickness as
compared to ultrasound pachymetry.86–88
A comparison between Scheimpflug and OCT
devices in normal eyes showed significant differ-
ences in central corneal thickness measurement
between Pentacam and Visante/Stratus OCT and
between Pentacam and SL-OCT.89 Multiple studies
have shown that since Scheimpflug devices
(Pentacam, Sirius) overestimate and OCT devices
(Visante, RTVue) underestimate central corneal
thickness measurements,74,90–92 they should not be
used interchangeably.62
Comparison of OCT devices and ultrasound
pachymetry showed that central corneal thickness
measurements with anterior segment OCT were sig-
nificantly thinner than ultrasound pachymetry.93,94
Previous retinal OCT studies also showed that
although anterior segment OCT pachymetry corre-
lated well with ultrasound but it tends to underesti-
mate ultrasound pachymetry values.95–97 However,
in one study, it was showed that retinal OCT over-
estimated the CCT measured by ultrasound
instead.98 The central corneal thickness values
obtained with anterior segment OCT and ultrasound
pachymetry showed no significant difference in
some studies.99,100 The difference in conclusions
between studies could be attributed to different
study populations. Overall, CCT measurements
should be interpreted in the context of the instru-
ment used.101
In a comparison between Fourier-domain optical
coherence tomography (FD-OCT) and time-domain
OCT (TD-OCT) for agreement, mean CCT obtained
by FD-OCT (RTVue) was showed to be significantly
higher than that obtained by TD-OCT (Visante).
Fourier-domain OCT has better sensitivity than TD-
OCT systems.102–104
© 2017 Royal Australian and New Zealand College of Ophthalmologists
141
When comparing Scanning slit-Placido and OCT
devices, central corneal thickness measurements
obtained with AS-OCT were thinner compared to
Orbscan II. Therefore, Visante AS-OCT and Orbscan
II should not be used interchangeably for assess-
ment of corneal thickness.74,105 Similarly, corneal
thickness and elevation measurements were signifi-
cantly different between swept source OCT (Casia)
and slit-scanning topography (Orbscan).106
Previous studies have reported good agreement and
possible interchangeability between Scheimpflug
devices and optical biometers. It was reported that
IOLMaster 700 (SS-OCT optical biometer) overesti-
mates central corneal thickness measurements in nor-
mal eyes compared to Pentacam but this difference
was not significant statistically.107 Good agreement
and interchangeability were reported for central cor-
neal thickness measurements between Scheimpflug
topographers (Sirius and Pentacam, respectively) and
Lenstar LS900 OLCR biometer.62,108 Good agreement
and clinically interchangeable measurements in cen-
tral corneal thickness values were also reported
between Scheimpflug topographers (Pentacam and
Galilei) and Nidek (Nidek Co., Aichi, Japan) AL-Scan
(a new optical biometer).61,109 However, other studies
showed that they are not interchangeable. The central
corneal thickness measured with Nidek AL-Scan was
reportedly thinner as compared to Sirius.110
It is noteworthy that not all Scheimpflug devices
are interchangeable for central corneal thickness
measurement. Corvis ST and Pentacam are inter-
changeable for central corneal thickness measure-
ment.54,111 Sirius 3D and Galilei G2 can be used
interchangeably with Pentacam for anterior radius
of curvature, central corneal thickness, and anterior
chamber depth, but not for maximum anterior and
posterior corneal elevation and total higher-order
aberrations.112 Corneal thickness measurements by
Galilei and Pentacam can be considered inter-
changeable for purposes such as IOL power calcula-
tion with no need for IOL constant adjustment.113
The pachymetry measured with Sirius was thicker
as compared to Pentacam.84,114
Agreement of devices for post-LASIK
corneal measurements
Nassiri et al.115 compared mean CCT measurements
with ultrasound, Pentacam and Orbscan II in high
myopic eyes before and after PRK. Both Pentacam
and Orbscan II measurements were lower than
those obtained with ultrasound. Ultrasound was
preferred postoperatively. On the contrary, Ho
et al.105 showed no statistically significant difference
in corneal pachymetry assessment between United
States and Orbscan measurements 6 months after
LASIK. Pentacam and Visante, on the other hand,
142
showed underestimation of corneal thickness com-
pared to US measurement.
Park et al.116 compared central corneal thickness
measurements using slit-scanning imaging (Orbscan),
rotating Scheimpflug imaging (Pentacam), dual-
Scheimpflug system (Galilei) to ultrasound pachyme-
try measurements in normal and post-LASIK eyes and
concluded that refractive surgery had an effect on the
agreement of measurements among devices, with Pen-
tacam or Galilei showing better agreement than Orbs-
can II in general, and after surgery in particular.
Measurements using Orbscan were significantly thin-
ner than other modalities. Similar findings were
obtained in other studies comparing after LASIK, and
PRK.76 Chan et al.117 reported a significantly higher
repeatability of swept source OCT compared with
Scheimpflug imaging for post-LASIK corneal mea-
surements, and suggested that factors such as patient’s
age, spherical equivalent, and residual bed thickness
measurements need to be considered during follow-
up and evaluation of post-LASIK patients for any fur-
ther surgical interventions.
CONCLUSIONS
The technological advances in corneal imaging have
made precise measurement of both anterior and pos-
terior corneal curvatures and corneal thickness pos-
sible. Corneal tomography enables imaging of
corneal elevation. OCT provides additional informa-
tion on corneal pathology making it easier to corrob-
orate the clinical findings with corneal topographic
changes. All together, these devices enable better
diagnosis, classification and monitoring of progres-
sion of corneal diseases leading to a better under-
standing of pathophysiology of corneal diseases.
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