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Corneal Higher-Order Aberrations in Eyes With Corneal Scar After Traumatic

Perforation

Article  in  Eye & Contact Lens Science & Clinical Practice · July 2018
DOI: 10.1097/ICL.0000000000000530

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 ARTICLE
Corneal Higher-Order Aberrations in Eyes With Corneal Scar
AU1 After Traumatic Perforation
Eisuke Shimizu, M.D., Takefumi Yamaguchi, M.D.,
Objectives: To evaluate corneal higher-order aberrations (HOAs) in eyes with
corneal scar after traumatic perforation and their correlation with visual acuity.
Methods: This retrospective consecutive case study included 40 eyes of 40
consecutive patients (mean age, 39.2621.6 years), treated for traumatic
corneal perforation at Tokyo Dental College, and 18 normal control eyes.
Higher-order aberrations of anterior and posterior corneal surfaces and total
cornea were analyzed by swept-source optical coherence tomography. Cor-
relations between corneal HOAs and visual acuity were analyzed.
Results: Higher-order aberrations within 4-mm diameter were significantly
larger in eyes with corneal perforation (anterior surface, 0.5160.54 mm; pos-
terior surface, 0.2060.14; and total cornea, 0.5260.50) as compared to normal
controls (0.1060.02, 0.0260.01, and 0.0960.02, respectively; all P,0.001).
Higher-order aberrations within 6-mm diameter were significantly larger in
eyes with corneal perforation (anterior surface, 1.1561.31; posterior surface,
0.3160.23; and total cornea, 1.0961.28) as compared to normal controls
(0.2160.06, 0.0660.01, and 0.1960.06, respectively; all P,0.001). The most
common topography pattern observed was the minimal change pattern
(37.5%), followed by asymmetric pattern (30.0%). Visual acuity significantly
correlated with corneal HOAs (anterior surface: R¼0.646, P,0.001; posterior
surface: R¼0.400, P¼0.033; and total cornea: R¼0.614, P,0.001).
Conclusions: Corneal scar after traumatic perforations not only induces
corneal opacity, but also increases corneal HOAs, which indicates a direct
effect on visual acuity.
Key Words: Higher-order aberration—Corneal scar—Traumatic
perforation—Visual acuity—Irregular astigmatism.
(Eye & Contact Lens 2018;00: 1–8)
C orneal perforation is an unfortunate sequela of trauma and
infectious and inflammatory keratitis.1–3 Ocular trauma is the
main cause of corneal perforations (accounting for approximately
From the Department of Ophthalmology (E.S., T.Y., K.T., J.S.), Ichikawa
General Hospital, Tokyo Dental College, Chiba, Japan; and Department of
Ophthalmology (E.S., T.Y., K.T., J.S.), Keio University School of Medicine,
Tokyo, Japan.
The authors have no funding or conflicts of interest to disclose.
Supplemental digital content is available for this article. Direct URL
citations appear in the printed text and are provided in the HTML and PDF
versions of this article on the journal’s Web site (www.
eyeandcontactlensjournal.com).
All authors certify that they have no involvement with any entity or
organization with any financial interest in the subject matter or materials
discussed in the manuscript.
Address correspondence to Takefumi Yamaguchi, M.D., Department of
Ophthalmology, Tokyo Dental College Ichikawa General Hospital, 5-11-
13, Sugano, Ichikawa, Chiba 272-8513, Japan; e-mail: tym.i.eye.i@gmail.
AU3 com
Accepted May 15, 2018.
DOI: 10.1097/ICL.0000000000000530
Eye & Contact Lens  Volume 00, Number 00, Month 2018
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2018 Contact Lens Association of Ophthalmologists, Inc. Unauthorized reproduction of this article is prohibited.
Kazuo Tsubota, M.D., Ph.D., and Jun Shimazaki, M.D., Ph.D.
70% of total cases), followed by infectious keratitis (approximately
25%).1 Traumatic corneal perforation is caused by accidents, such
as falling, sports, and animal bites. Its frequency is remarkably
high among younger individuals, and the damage is often serious.4
Primary repair treatments, such as using 10-0 nylon sutures, cor-
neal gluing, and bandage contact lenses, are recommended.5 How-
ever, the overall visual prognosis is sometimes poor due to corneal
scar formation, corneal irregular astigmatism, or other ocular co-
morbidities, such as retinal/lens complications.4–6
Wavefront analyses to quantify the Zernike higher-order
aberrations (HOAs) have provided an explanation for the
decreases in visual acuity and contrast sensitivity in normal
eyes7 and other ocular pathologies.8–11 Swept-source optical
coherence tomography (SS-OCT) is commonly used to obtain
precise data on the cornea and the anterior portion of the
eye.12 Swept-source OCT allows deeper observation in opaque
tissues because it uses an infrared light source. Using SS-OCT,
we have recently reported that corneal HOAs correlated with
a reduction in visual acuity in eyes with infectious keratitis13,14
and corneal stromal dystrophies.15 However, to the best of our
knowledge, the corneal HOAs and their influence on visual acu-
ity in eyes with a history of traumatic corneal perforation have
been poorly understood.
To improve visual acuity in eyes with corneal scar after
traumatic perforation, rigid gas-permeable contact lenses
(RGPCLs) are used and often found to be effective even in eyes
with mild to moderate corneal opacities (Fig. 1, case 1) because it F1
corrects refractive errors and the HOAs of anterior surface. How-
ever, in eyes with irregular posterior surface, RGPCL is not effec-
tive (Fig. 1, case 2). Thus, we hypothesized that increased HOAs in
eyes after corneal perforation lead to decreased visual acuity. In an
attempt to evaluate our hypotheses, we first calculated the corneal
HOAs in eyes with corneal scar after corneal perforation and com-
pared them with HOAs in normal subjects. Second, with the aim of
identifying the effects of HOAs on visual acuity, we evaluated the
correlation between visual acuity and HOAs in eyes after corneal
perforations.
PATIENTS AND METHODS
This retrospective study was performed in accordance with the
Declaration of Helsinki. It was approved by the institutional ethics
review board of Tokyo Dental College, Ichikawa General Hospital
(Chiba, Japan) (I-15-51). Our Institutional Review Board waived
the requirement for informed consent for this retrospective study.
Patient data were anonymized before access and/or analysis.
1
 E. Shimizu et al. Eye & Contact Lens  Volume 00, Number 00, Month 2018

FIG. 1. Representative case of corneal perforation. Figure 1 shows typical cases of corneal perforation:
in case 1, visual acuity improved to 20/20 with rigid gas permeable contact lens (RGPCL), whereas in
case 2, visual acuity was only 20/1000 with the RGPCL wear, which necessitated penetrating kerato-
plasty (PKP). Case 1 is a 27-year-old male patient with corneal and lens perforation due to penetrating
injury with a knife (A). Corneal suture and lens aspiration combined with intraocular lens implantation
were performed. Sixteen months after the surgery, slit-lamp examination revealed lateral wound at the
center of the cornea (B). Corneal topography map showed protrusion pattern (C). His vision improved
to 20/200 with spectacle correction and 20/20 with RGPCL wear. Swept-source optical coherence
tomography (SS-OCT) showed smooth posterior surface of the cornea (D). Case 2 is a 35-year-old male
patient with corneal scar due to traumatic perforation (E). His visual acuity was 20/2000 with spectacle
correction and 20/1000 with RGPCL wear. Corneal topography showed protrusion pattern (F), and SS-
OCT showed severely irregular posterior surface (G). He underwent PKP combined with pupilloplasty
(H), and his vision improved to 20/32 with spectacle correction and 20/20 with RGPCL wear. After PKP,
SS-OCT showed smooth posterior surface of the cornea (I).

Study Participants
This study included patients with a corneal scar after traumatic
corneal perforation, who visited Tokyo Dental College Ichikawa
General Hospital. We screened patients with corneal perforation
using medical records between March 2010 and March 2017. The
Ichikawa General Hospital database contains detailed medical data
pertaining to 158,469 visits of 20,954 patients from January 2010
to July 2017. The data set contains information regarding the age,
diagnosis, prescriptions, and referral letters. We searched for
evidence of traumatic corneal perforation based on the diagnosis
reported and stored in the database, using the key words “corneal
perforation,” “corneal trauma, and “traumatic perforation,” and 263
patients with corneal perforation were identified. A corneal special-
ist (E.S.) checked the patients’ medical records and included pa-
tients on the bases of the following criteria: diagnosis was based on
clinical history, episode of traumatic corneal perforation, and slit-
lamp examination. We exclude cases with nontraumatic perfora-
tions, such as due to autoimmune disorders (e.g., Stevens–Johnson
syndrome and Mooren’s ulcer), chemical burn, infectious keratitis,
and nonperforating superficial corneal trauma, as well as cases with
a history of corneal transplantation. Consequently, 40 eyes of 40
patients were included in the study. Furthermore, 18 healthy eyes
were included as normal controls.
Data Analysis
The participants were examined for several parameters including
routine examinations, slit-lamp microscopy, fundus examinations,
and SS-OCT. Visual acuity was measured using a standard Snellen
chart, and the best-corrected visual acuities with spectacle
correction and RGPCL wear were recorded. The spectacle-
corrected visual acuity values were converted to logarithm of
the minimal angle of resolution (logMAR) units. Severity of
corneal opacity was graded by a blinded observer (E.S.) on the
basis of slit-lamp examination with a previously described system:
grade 0, clear or a trace haze; grade 1, a mild opacity; grade 2,
a moderately dense opacity partially obscuring the details of the
iris; and grade 3, a severely dense opacity obscuring the details of
the intraocular structure (Fig. 2).16 To assess the depth of the F2
traumatic perforation, we defined the perforation depth as reported
previously17: zone 1: injury limited to cornea without involvement
of the lens or the iris, zone 2: injury involves structures in the
anterior segment to the posterior capsule, and zone 3: injury

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 Eye & Contact Lens  Volume 00, Number 00, Month 2018 Corneal Higher-Order Aberrations in Eyes After Corneal Perforation

FIG. 2. Corneal opacity grading in representative cases. Corneal opacity grading was performed as
follows: grade 0, clear or a trace haze; grade 1, a mild opacity; grade 2, a moderately dense opacity
partially obscuring the details of the iris; and grade 3, a severely dense opacity obscuring the details of
the intraocular structure.16 Grade 1 corneal opacity after a perforating injury in the center of the cornea
due to a stapler in a 51-year-old man (A). His visual acuity was 20/32 with 22.00/22.00 D·150. The
corneal topography map showed slight steepening in the inferior cornea (B). Grade 2 corneal opacity
after corneal rupture due to the direct impact of a golf ball in a 74-year-old woman (C). Her visual acuity
was 20/125 with 21.50 D. The corneal topography map showed a moderate protrusion pattern (D).
Grade 3 dense corneal opacity after corneal perforation and crystalline lens laceration due to a wire
injury in a 60-year-old man (E). He underwent corneal suturing, lens aspiration, and vitrectomy. His
visual acuity was 20/1000 with +15.00/22.00 D·140. The corneal topography map showed a severe
asymmetric pattern (F).

involves posterior segment structures through the cornea, the iris,
and the lens.
Anterior Segment Optical
Coherence Tomography
The eyes of control subjects and patients after corneal perfora-
tion were routinely examined using SS-OCT. All subjects were
examined until at least two sets of excellent images were obtained.
Sixteen rotating SS-OCT scans were used to reconstruct three-
dimensional models of the entire corneal structure. The CASIA
system (SS-1000; Tomey, Nagoya, Japan) corrected distortions in
the SS-OCT images based on the refractive index of the anterior
surface. Two corneal specialists (T.Y. and E.S.) carefully checked
all SS-OCT images to ensure that the surface digitalization
recognized by the automated inbuilt software was correct. Zernike
coefficients were calculated using Zernike analysis as previously
reported.12 In brief, the anterior and posterior corneal surfaces were
reconstructed as a 3-dimensional model from the corneal height
data. The anterior, posterior, and total (anterior +posterior) HOAs
at diameters of 4 and 6 mm were calculated separately with the
CASIA ray tracing software (version 5.1). The refractive indices of
the cornea and aqueous humor were set at 1.376 and 1.336, respec-
tively. The corneal HOAs were calculated with the analysis posi-
tion set in the corneal center. The wavefront aberration was
expanded with normalized Zernike polynomials up to the eighth
order. Higher-order aberration was defined as the root mean square
(RMS) of the third- to eighth-order Zernike coefficients. Spherical
aberration (SA) was defined as the RMS of Z40 (spherical aberra-
tion) and Z60 (secondary spherical aberration). Coma aberration
(Coma) was defined as the RMS of Z321 and Z31.
Characterization of Corneal Perforation Based
on the Topographic Map
The topography map patterns of the anterior corneal surface
were characterized and classified into 4 types as were defined
previously: (1) asymmetric pattern (Fig. 3A,E,I); (2) protrusion F3
pattern (Fig. 3B,F,J); (3) flattening pattern (Fig. 3C,G,K); and
(4) minimal change (Fig. 3D,H,L).13,14 Subsequently, to evaluate
the association between location of opacity and topographical pat-
terns, we defined location of opacity in 3 areas17: (1) central area
(within a 6-mm diameter across the cornea); (2) peripheral area (the
area beyond the central area [within a 6- to 10-mm diameter across
the cornea]); and (3) exterior area (outside of peripheral area).
Statistical Analysis
The data were analyzed using Prism software (ver. 6.0 g for Mac
OS X; GraphPad Software, Inc., San Diego, CA). The D’Agostino
and Pearson omnibus normality test was used to assess the normal

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 E. Shimizu et al. Eye & Contact Lens  Volume 00, Number 00, Month 2018

FIG. 3. Representative cases of topographic patterns. Topographic patterns were categorized into four
types: 1. asymmetric pattern (A, E, and I), 2. protrusion pattern (B, F, and J), 3. flattening pattern (C, G,
and K), and 4. minimal change (D, H, and L). Each image shows representative slit-lamp photographs
(A–D), swept-source optical coherence tomography images (E–H), and topographical maps of anterior
corneal surface (I–L).

distribution of the collected data. Mann–Whitney test was used to
compare the differences in HOAs between normal subjects and
patients with corneal scar after traumatic perforation. Spearman’s
correlation analysis was used to evaluate correlations among log-
MAR, corneal HOAs, depth of injury (zone 1–3), and corneal
opacity grades. All data were expressed as mean 6 SD. P value
less than 0.05 was considered to indicate statistical significance.
RESULTS
Patient Demographics
The mean age of the study participants in the control group was
55.1618.5 years (6 men and 12 women), whereas that in the
perforation group was 39.2621.6 years (28 men and 12 women).
Mean logMAR was 20.0360.05 in the control group and
0.8160.85 (ranging from 0.07 to 2.70) in the perforation group,
which improved to 0.5860.67 with the use of RGPCL wear. The
mean opacity grade was 1.7860.89. The major causes of corneal
perforations in the study population were injury due to wire (7/40,
17.5%), iron (5/40, 12.5%), plastic (5/40, 12.5%), pencil or pen (4/
40, 10.0%), glass (3/40, 7.5%), tree and shrub (3/40, 7.5%), scis-
sors (2/40, 5.0%), and others (6/40 15.0%; for example, doors,
arrows, stones, and cards). The mean spherical equivalent was
20.166.0 diopters (D), ranging from 213.5 D to +13.0 D in eyes
with traumatic corneal scars. The mean astigmatism was 2.661.5
D, ranging from 0 to 7.0 D in eyes with traumatic corneal scars.
The number of eyes with abnormal pupil size and shape was as
follows: iris defect, 9/40 (22.5%; total aniridia in 3 eyes and partial
iris defects in 6 eyes), and dilated pupil, 11/40 (27.5%).
Higher-Order Aberration in Eyes With Corneal
Scar After Traumatic Perforation
Table 1 shows the HOAs of Zernike coefficients of 4- and 6-mm T1
diameters in each group. We observed that as compared to the
healthy controls, all parameters, including HOAs, SA, and coma
aberrations (total/anterior/posterior and 4/6 mm), were significantly
higher in eyes with corneal scar after traumatic perforation
(P,0.05, Mann–Whitney test). Moreover, the HOAs (total/ante-
rior/posterior and 4/6 mm) were significantly larger in eyes with
grade 3 opacity than in those with grade 1 opacity (see Table 1,
Supplemental Digital Content 1, http://links.lww.com/ICL/A85 all
P#0.01). The corneal HOAs of the total cornea and posterior
surface were significantly larger in eyes with grade 3 opacity than
in those with grade 2 opacity (P¼0.02 and P¼0.01, respectively).
The HOAs of the posterior surface were significantly larger in
eyes having zone 2 injury (cornea to lens) as compared to those
having zone 1 injury (limited to cornea, 4-mm diameter, P¼0.04).
No significant differences were observed in other corneal HOAs
between zone 1 and zone 2 injuries, although a tendency was
present for increased corneal HOAs with increased in the depth
of injury (see Table 2, Supplemental Digital Content 1, http://links.
lww.com/ICL/A85).

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 Eye & Contact Lens  Volume 00, Number 00, Month 2018 Corneal Higher-Order Aberrations in Eyes After Corneal Perforation

TABLE 1. Higher-Order Aberrations (Microns) in Corneal Scars After r¼0.620, P,0.001), posterior (4 mm; r¼0.530, P,0.001, 6 mm;
Traumatic Perforation r¼0.670, P,0.001), and total cornea (4 mm; r¼0.650, P,0.001,
Control, n¼18 Perforation, n¼40 P 6 mm; r¼0.640, P,0.001) (Spearman’s correlation). The depths of
traumatic perforation were positively correlated with corneal
HOA (4 mm)
Total 0.0960.02 0.5260.50 ,0.0001a
HOAs of anterior (4 mm; r¼0.409, P¼0.010, 6 mm; r¼0.413,
Anterior 0.1060.02 0.5160.54 ,0.0001a P¼0.009), posterior (4 mm; r¼0.365, P¼0.022, 6 mm; r¼0.422,
Posterior 0.0260.01 0.2060.14 ,0.0001a P¼0.007), and total cornea (4 mm; r¼0.374, P¼0.019, 6 mm;
HOA (6 mm)
Total 0.1960.06 1.0961.28 ,0.0001a r¼0.389, P¼0.014).
Anterior 0.2160.06 1.1561.31 ,0.0001a
Posterior 0.0660.01 0.3160.23 ,0.0001a
SA (4 mm) The Corneal Higher-Order Aberrations in Each
Total 0.0760.02 0.2560.25 ,0.0001a Corneal Topography Pattern
Anterior 0.0860.02 0.2360.26 0.0001a
Posterior 0.0260.00 0.1060.08 ,0.0001a The HOAs, SA, and coma of the total cornea were significantly
SA (6 mm) larger than those of the normal controls (Fig. 5, all P,0.05). F5
Total 0.1360.06 0.4860.58 ,0.0001a Although there were no significant differences due to the small
Anterior 0.1460.03 0.5160.56 ,0.0001a
Posterior 0.0560.01 0.1760.14 ,0.0001a number of cases showing each pattern, corneal HOAs tended to
Coma (4 mm) be greater in the asymmetric pattern, protrusion pattern, flattening
Total 0.0660.02 0.4460.45 ,0.0001a
Anterior 0.0660.02 0.4560.49 ,0.0001a
pattern, and minimal change pattern in that order.
Posterior 0.0160.01 0.1760.13 ,0.0001a
Coma (6 mm)
Total 0.1460.07 0.9661.15 ,0.0001a
Anterior 0.1560.07 1.0261.19 ,0.0001a
Posterior 0.0360.02 0.2560.20 ,0.0001a DISCUSSION
Traumatic ocular injury is one of the major causes of visual loss
Data shown by mean6SD (mm).
a
in developed and developing countries.17–19 To the best of our
P values: Mann–Whitney test. knowledge, this is the first report quantifying the detailed HOAs
of eyes with corneal scar after traumatic perforation. In this study,
Topographic Patterns and Depth of Injury we observed that the corneal HOAs correlated significantly with
In the current study on eyes with corneal scar after traumatic visual acuity in eyes with corneal scar after traumatic perforations.
perforations, minimal change was the most common alteration (15/ We have also previously reported that increased corneal HOAs
40, 37.5%), followed by asymmetric pattern (12/40, 30.0%), reduced visual acuity in eyes after infectious keratitis and eyes with
protrusion pattern (8/40, 20.0%), and flattening pattern (5/40 corneal dystrophies.13–15 Thus, the quantification of corneal HOAs
T2 12.5%) (Table 2). Moreover, the most frequent depth of wound can be one of the objective indices to assess the corneal optical
was zone 2 (cornea to lens; 19/40, 47.5%), followed by zone 1 function that further reflects visual functions in actual patients.
(involved only cornea; 14/40, 35%), and zone 3 (cornea to retina; It is a well-known fact that irregular astigmatism increases after
4/40, 10.0%). corneal scar formation because of traumatic perforation.20–22 How-
ever, the types and amount of irregular astigmatism in eyes with
Correlation Between Higher-Order Aberration, corneal scar after traumatic perforations are still poorly understood.
Visual Acuity, and Corneal Opacity In the current study, we characterized the topographic patterns in
Visual acuity (logMAR) was positively correlated with corneal eyes with corneal scar after traumatic perforations and revealed the
F4
T3 HOAs of the anterior (Fig. 4, and Table 3, 4 mm; r¼0.646, differences in the depth of injury along with the causes of previous
P,0.001, 6 mm; r¼0.692, P,0.001), posterior (4 mm; r¼0.400, trauma. Assessing the relationship among the severity of corneal
P¼0.033, 6 mm; r¼0.600, P,0.001), and total cornea (4 mm; perforation, extent of trauma, and topographic patterns may serve
r¼0.614, P,0.001, 6 mm; r¼0.653, P,0.001) (Spearman’s cor- as a potential parameter to predict the visual prognosis and evaluate
relation). Corneal opacity grades were positively correlated with the efficacy of different treatments, such as sutures, or bandage
corneal HOAs of anterior (4 mm; r¼0.600, P,0.001, 6 mm; contact lenses.

TABLE 2. Corneal Topography Patterns and Depth of the Injury in Corneal Scar After Traumatic Perforation
Pattern Asymmetric 11 (27.5) Protrusion 7 (17.5) Flattering 4 (10.0) Minimal Change 15 (37.5) Unknown 3 (7.5) Total 40 (100.0)

Location
Central 3 (15.0) 4 (20.0) 0 (0.0) 12 (60.0) 1 (5.0) 20 (50.0)
Peripheral 6 (50.0) 2 (16.7) 1 (8.3) 3 (25.0) 0 (0.0) 12 (30)
Corneoscleral 1 (20.0) 1 (20.0) 3 (60.0) 0 (0.0) 0 (0.0) 5 (12.5)
Unknown 1 (33.3) 0 (0.0) 0 (0.0) 0 (0.0) 2 (66.7) 3 (7.5)
Depths
Zone 1 (cornea) 3 (21.4) 0 (0.0) 2 (14.3) 7 (50.0) 2 (14.3) 14 (35.0)
Zone 2 (cornea lens) 7 (36.8) 4 (21.0) 1 (5.3) 6 (31.6) 1 (5.3) 19 (47.5)
Zone 3 (cornea retina) 1 (25.0) 1 (25.0) 1 (25.0) 1 (25.0) 0 (0.0) 4 (10.0)
Unknown 0 (0.0) 2 (66.7) 0 (0.0) 1 (33.3) 0 (0.0) 3 (7.5)

Data shown as no. eyes (%).

Center, within 5-mm diameter; Exterior, outside of 10-mm diameter; Peripheral, 5- to 10-mm diameter.

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 E. Shimizu et al. Eye & Contact Lens  Volume 00, Number 00, Month 2018

FIG. 4. Correlations among corneal HOAs, logMAR, corneal opacity grades and perforation depth. The
logMAR visual acuity was significantly correlated with HOAs (4 mm) of the anterior, posterior, and total
cornea (P,0.001, P¼0.033, and P,0.001, respectively). Corneal opacity grade was also significantly
correlated with HOAs (4 mm) of the anterior, posterior, and total cornea (all, P,0.001). Perforation
depth was significantly correlated with HOAs (4 mm) of the anterior, posterior, and total cornea
(P¼0.010, P¼0.022 and P¼0.019, respectively). HOA, higher-order aberrations; logMAR, logarithm of
the minimal angle of resolution.

The visual acuity improved from 0.81 logMAR to 0.58 logMAR
with the use of RGPCL in patients with corneal scar after traumatic
perforations. RGPCL can correct refractive error and significant
degree of irregular astigmatism of the corneal anterior surface, as
was in case 1 depicted in Figure 1.21–23 However, the HOAs of the
posterior surface cannot be corrected by RGPCL, as was in case 2
depicted in Figure 1. To optimize the efficacy of RGPCL, infor-
mation regarding HOAs of the posterior surface is essential
because the amount of HOAs of the posterior surface can influence
the visual acuity after the use of RGPCL. Thus, when we
suture traumatic corneal perforations, we need to be careful by
ensuring that the edges of the posterior surfaces match each other.
Furthermore, if the corneal HOAs of the posterior surface
stay minimal, patients will be able to obtain good vision with
RGPCL wear even when they have moderate corneal opacities
and HOAs of the anterior surface after corneal perforation. In eyes
with large HOAs of the posterior surface, corneal transplantation is
necessary to improve visual acuity as we recently reported in her-
petic keratitis.24
Higher-order aberrations can be measured using several techni-
ques, including the Hartmann–Shack aberrometer, the Pentacam
system, and SS-OCT. Whole-eye ocular aberrations are influenced
by the HOAs of the lens and related accommodations. The Penta-
cam system obtains corneal data using a short wavelength of 475

TABLE 3. Correlations Among Corneal Higher-Order Aberrations, Visual Acuity, Corneal Opacity, and Depth of Injury
Total Cornea Anterior Surface Posterior Surface

Corneal HOAs 4 mm 6 mm 4 mm 6 mm 4 mm 6 mm

Visual acuity (logMAR) 0.614 (,0.001) 0.653 (,0.001) 0.646 (,0.001) 0.692 (,0.001) 0.400 (0.033) 0.598 (0.002)
Corneal opacity (grade 1–3) 0.650 (,0.001) 0.640 (,0.001) 0.600 (,0.001) 0.620 (,0.001) 0.530 (,0.001) 0.670 (,0.001)
Depth of injury 0.374 (0.019) 0.389 (0.014) 0.409 (0.010) 0.413 (0.009) 0.365 (0.022) 0.422 (0.007)

Spearman’s correlation analysis. Correlation coefficient (P value).

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 Eye & Contact Lens  Volume 00, Number 00, Month 2018
FIG. 5. Corneal HOAs in different corneal topography patterns. The corneal HOAs (total HOAs, SA, and
coma) within a 4-mm diameter were significantly larger in all topography patterns than those in normal
controls (*P,0.001, unpaired t test, **P,0.05, unpaired t test, ***P,0.001, Mann–Whitney test). HOA,
higher-order aberrations; SA, Spherical aberration.
nm, whereas the CASIA uses a longer wavelength of 1,310 nm.
This longer wavelength has the advantage that it can penetrate
deeper with less reflection in eyes with corneal opacities such as
corneal scar and hereditary corneal dystrophies.13–15 Therefore, we
used the CASIA system in our study.
The optical consequence of a corneal scar may differ from the
findings in a normal cornea because of the influence of light scatter,
light absorption, and changes in the refractive index. Regarding
light scatter, previous reports have shown that corneal opacity
causes light scatter and decreases contrast sensitivity in eyes with
Fuchs endothelial corneal dystrophy or after corneal transplanta-
tion.25,26 However, it is difficult to quantify corneal scatter in eyes
with dense corneal opacity. In addition, because light scatter is
dependent on the wavelength used for measurement, quantification
of corneal scatter using single-wavelength approaches, such as SS-
OCT or the Scheimpflug-based imaging system, may not accu-
rately reflect the corneal scattering of visible light. Regarding light
refraction, previous studies have reported changes in refractive
index because of age and dehydration of the cornea: the refractive
index can increase by up to 1.406 with age and as a result of air
exposure.27,28 We previously evaluated the influence of the theo-
retical refractive index change using optical software.24 Theoreti-
cally, a change in the refractive index from 1.376 to 1.391 and
1.406 (estimated maximum change, based on the previous reports)
will result in changes of 2.1% and 4.3%, respectively, in corneal
HOAs.24 Thus, we considered that the influence of refractive index
alterations due to corneal scarring on corneal HOAs seems to be
small. In the current study, the corneal HOAs determined using our
method were correlated with the actual visual acuity of the patients,
as we showed in other corneal diseases.13–15 Therefore, we believe
that the corneal HOA data are valid and can reflect patients’ visual
function.
This study has several limitations. First, the younger age of the
subjects in the traumatic corneal scar group could have caused bias.
The frequency of eye injuries among children is relatively high,4
and the current study included 5 patients younger than 10 years and
5 teenagers in the traumatic corneal scar group, reducing the mean
age of this group. However, the age-related change in corneal

2018 Contact Lens Association of Ophthalmologists
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2018 Contact Lens Association of Ophthalmologists, Inc. Unauthorized reproduction of this article is prohibited.
Corneal Higher-Order Aberrations in Eyes After Corneal Perforation
HOAs is very small,29 compared with the increase in corneal
HOAs as a result of corneal perforation. Therefore, we think that
the age-related bias is minimal. Another limitation of this study is
that there might be some differences in refractive indices between
normal corneas and corneas with stromal opacities, which may
have influenced our estimated HOAs. The true refractive index
of a cornea with stromal scars is still poorly understood. Nonethe-
less, the HOAs we calculated based on the refractive index of
a normal cornea showed a significant correlation with the patients’
visual acuity, suggesting that this calculation method has clinical
relevance. Third, 22.5% to 27.5% of the subjects in the current
study had eyes with an abnormal pupil or iris defects, which could
have affected the actual corneal HOAs and visual acuity because
the extent of corneal HOAs is theoretically dependent on pupil
size. In the current study, we presented the data for corneal HOAs
with a diameter of 4 and 6 mm to allow for comparison of the
findings with our previous results.13–15 The HOAs calculated based
on the patient’s actual pupil diameter reflect the patient’s contrast
sensitivity.30 Therefore, iris defects and pupil diameter must be
taken into consideration in assessments of the influence of corneal
HOAs on patients’ vision, especially in eyes with abnormal pupils
in clinical setting. The other limitation is related to the method used
for visual acuity measurement, which may cause measurement
errors. In this regard, the Bailey–Lovie or Early Treatment Dia-
betic Retinopathy Study (ETDRS) charts are more reliable than the
Snellen chart used in the current study.
In conclusion, we found that HOAs of the total cornea and
anterior and posterior surfaces were larger in eyes with corneal scar
after traumatic perforations as compared to the normal subjects,
suggesting that the stromal scar after traumatic perforations induces
not only scatter, but also morphometric changes on the anterior and
posterior surfaces that increase corneal HOAs. We also classified
the irregular astigmatism patterns into four types, based on corneal
topographical maps, and found that the most common type was
the minimal change pattern, followed by asymmetric pattern.
Furthermore, increase in HOAs was significantly correlated with
visual acuity, depth of perforation, and grades of corneal opacities,
indicating that HOAs have a direct effect on visual acuity.
7
 E. Shimizu et al.
ACKNOWLEDGMENTS
The funding organization had no role in the design or conduct of
this research. The authors thank Editage company for English
language editing.
REFERENCES
1. Xie L, Zhai H, Dong X, et al. Primary diseases of corneal perforation in
Shandong Province, China: A 10-year retrospective study. Am J Ophthal-
mol 2008;145:662–666.
2. Jhanji V, Young AL, Mehta JS, et al. Management of corneal perforation.
Surv Ophthalmol 2011;56:522–538.
3. Loya-Garcia D, Serna-Ojeda JC, Pedro-Aguilar L, et al. Non-traumatic
corneal perforations: Aetiology, treatment and outcomes. Br J Ophthalmol
2017;101:634–639.
4. Niiranen M, Raivio I. Eye injuries in children. Br J Ophthalmol 1981;65:
436–438.
5. Nobe JR, Moura BT, Robin JB, et al. Results of penetrating keratoplasty for
the treatment of corneal perforations. Arch Ophthalmol 1990;108:939–941.
6. Sharkey TG, Brown SI. Transplantation of lacerated corneas. Am J Oph-
thalmol 1981;91:721–725.
7. Oshika T, Okamoto C, Samejima T, et al. Contrast sensitivity function and
ocular higher-order wavefront aberrations in normal human eyes. Ophthal-
mology 2006;113:1807–1812.
8. Montes-Mico R, Alio JL, Charman WN. Dynamic changes in the tear film
in dry eyes. Invest Ophthalmol Vis Sci 2005;46:1615–1619.
9. Yamaguchi T, Negishi K, Yamaguchi K, et al. Effect of anterior and pos-
terior corneal surface irregularity on vision after descemet-stripping endo-
thelial keratoplasty. J Cataract Refract Surg 2009;35:688–694.
10. Yamaguchi T, Negishi K, Yamaguchi K, et al. Comparison of anterior and
posterior corneal surface irregularity in descemet stripping automated endo-
thelial keratoplasty and penetrating keratoplasty. Cornea 2010;29:
1086–1090.
11. Tomida D, Yamaguchi T, Ogawa A, et al. Effects of corneal irregular
astigmatism on visual acuity after conventional and femtosecond laser-
assisted descemet’s stripping automated endothelial keratoplasty. Jpn J
Ophthalmol 2015;59:216–222.
12. Yamaguchi T, Ohnuma K, Tomida D, et al. The contribution of the poste-
rior surface to the corneal aberrations in eyes after keratoplasty. Invest
Ophthalmol Vis Sci 2011;52:6222–6229.
13. Shimizu E, Yamaguchi T, Yagi-Yaguchi Y, et al. Corneal higher-order
aberrations in infectious keratitis. Am J Ophthalmol 2017;175:148–158.
14. Kashizuka E, Yamaguchi T, Yaguchi Y, et al. Corneal higher-order aberra-
tions in herpes Simplex keratitis. Cornea 2016;35:1562–1568.
8 Eye & Contact Lens  Volume 00, Number 00, Month 2018
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15. Yagi-Yaguchi Y, Yamaguchi T, Okuyama Y, et al. Corneal higher order
aberrations in granular, lattice and macular corneal dystrophies. PLoS One
2016;11:e0161075.
16. Fantes FE, Hanna KD, Waring GO III, et al. Wound healing after excimer
laser keratomileusis (photorefractive keratectomy) in monkeys. Arch Oph-
thalmol 1990;108:665–675.
17. Pieramici DJ, Sternberg P Jr, Aaberg TM Sr, et al. A system for classifying
mechanical injuries of the eye (globe). The Ocular Trauma Classification
Group. Am J Ophthalmol 1997;123:820–831.
18. Pieramici DJ, Au Eong KG, Sternberg P Jr, et al. The prognostic signifi-
cance of a system for classifying mechanical injuries of the eye (globe) in
open-globe injuries. J Trauma 2003;54:750–754.
19. Whitcher JP, Srinivasan M, Upadhyay MP. Corneal blindness: A global
perspective. Bull World Health Organ 2001;79:214–221.
20. Titiyal JS, Sinha R, Sharma N, et al. Contact lens rehabilitation following
repaired corneal perforations. BMC Ophthalmol 2006;6:11.
21. Zheng B, Shen L, Walker MK, et al. Clinical evaluation of rigid gas perme-
able contact lenses and visual outcome after repaired corneal laceration. Eye
Contact Lens 2015;41:34–39.
22. Pradhan ZS, Mittal R, Jacob P. Rigid gas-permeable contact lenses for visual
rehabilitation of traumatized eyes in children. Cornea 2014;33:486–489.
23. Luo WL, Tong JP, Shen Y. Rigid gas-permeable contact lens for visual
rehabilitation in aphakia following trauma. Clin Exp Optom 2012;95:
499–505.
24. Shimizu E, Yamaguchi T, Tomida D, et al. Corneal higher-order aberrations
and visual improvement following corneal transplantation in treating herpes
simplex keratitis. Am J Ophthalmol 2017;184:1–10.
25. Patel SV, Baratz KH, Hodge DO, et al. The effect of corneal light scatter on
vision after descemet stripping with endothelial keratoplasty. Arch Ophthal-
mol 2009;127:153–160.
26. Watanabe S, Oie Y, Fujimoto H, et al. Relationship between corneal guttae
and quality of vision in patients with mild Fuchs’ endothelial corneal dys-
trophy. Ophthalmology 2015;122:2103–2109.
27. Meek KM, Dennis S, Khan S. Changes in the refractive index of the stroma
and its extrafibrillar matrix when the cornea swells. Biophys J 2003;85:
2205–2212.
28. Patel S, Alio JL, Amparo F, et al. The influence of age on the refractive
index of the human corneal stroma resected using a mechanical microker-
atome. Cornea 2011;30:1353–1357.
29. Namba H, Kawasaki R, Narumi M, et al. Ocular higher-order wavefront
aberrations in the Japanese adult population: The Yamagata Study (funaga-
ta). Invest Ophthalmol Vis Sci 2014;56:90–97.
30. Yamaguchi T, Dogru M, Yamaguchi K, et al. Effect of spherical aberration
on visual function under photopic and mesopic conditions after cataract
surgery. J Cataract Refract Surg 2009;35:57–63. AU2