A O S 1999

Magnification changes in specular

microscopy after corneal refractive
surgery
Peter Isager, Jesper Ø. Hjortdal and Niels Ehlers
Department of Ophthalmology, Århus University Hospital, Denmark

ABSTRACT.
Purpose: To describe the effect of corneal refractive surgery on the magnifi- Results
cation of a contact and a non-contact specular microscope.
Magnification of the contact specular
Method: The magnification of a contact specular microscope (Konan Clinical
microscope
Specular Microscope) and a non-contact specular microscope (Topcon SP-
1000) was experimentally and theoretically studied as a function of anterior In a previous study the magnification (M)
of the contact specular microscope (Kon-
corneal refractive power and central corneal thickness.
an Clinical Specular Microscope) was ex-
Results: The magnification of the contact and non-contact specular microscope
perimentally found to decrease linearly
was found to decrease slightly with decreasing central corneal thickness. In
and equally in the horizontal and vertical
addition, the magnification of the non-contact specular microscope decreased dimension with decreasing focusing dis-
slightly with decreasing anterior corneal refractive power. tance. The magnification (M2) of a
Conclusion: As the preoperative and postoperative measuring conditions are photomicrograph therefore decreased as
different in patients undergoing corneal refractive surgery a correction for mag- a second order function (Isager et al.
nification changes is necessary when small changes in endothelial cell density 1996). The normalized magnification
are looked for. (M2/M 2) at different CCT’s was calcu-
æ
lated (Fig. 1 and Table 1).
Key words: magnification – specular microscope – contact – noncontact – refractive keratectomy –
refractive surgery – excimer laser – endothelium – cell density – human – cornea. Magnification of the non-contact specular
microscope
Acta Ophthalmol. Scand. 1999: 76: 391–393 The magnification of the non-contact
Copyright c Acta Ophthalmol Scand 1999. ISSN 1395-3907 specular microscope can be calculated
from theoretical considerations.
The light reflected from the corneal en-
dothelium is refracted at the anterior cor-
neal surface (representing a certain an-

C urrently, an important clinical ques-

tion is whether corneal refractive
surgery, especially excimer laser photore-
fractive keratectomy (Isager et al. 1998),
affect the corneal endothelial cell density.
In specular microscopy of the endo-
thelium, light is refracted at the anterior
corneal surface. Refractive surgery for
myopia reduces the corneal power and in
photorefractive keratectomy for myopia
also the central corneal thickness (CCT).
The preoperative and postoperative
measuring conditions for specular micro-
scopy are therefore not the same. The aim
of this study is to describe the effect of
changing anterior corneal refractive
power and changing CCT on the magni-
fication of a contact and a non-contact
specular microscope.
Methods
In contact specular microscopy the endo-
thelium is imaged after applanation of the
corneal surface. By manual focusing of the
Konan Clinical Specular Microscope a
sharp image of the endothelium can be
made. Without touching the cornea the
non-contact specular microscope Topcon
SP-1000 automatically takes a picture
when the endothelium is in focus.
In this study the Konan Clinical Specu-
lar Microscope was calibrated at a CCT of
520 microns giving a certain magnification
(M ). The Topcon SP-1000 is standard
æ
calibrated by the company at a CCT of Fig. 1. Normalized magnification of the con-
500 microns and an anterior corneal ra- tact and non-contact specular microscope ver-
dius of 8.00 mm (M ) (Personal communi- sus CCT for different values of anterior cor-
æ
cation with Topcon Europe B.V.). neal radius (r).

391
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A O S 1999

Table 1. Normalized magnification. of the image was calculated. The normal-

ized magnification (M2/M 2) at different
Specular microscope æ
CCT’s and anterior corneal radii is
Non-contact Contact shown in Fig. 1 and Table 1.
Anterior corneal radius/mm
Correction for magnification changes
CCT/microns 7 8 9 10 The endothelial cell density is normally
estimated by counting the number of en-
300 0.9892 0.9862 0.9840 0.9822 0.9753
350 0.9931 0.9897 0.9870 0.9849 0.9809
dothelial cells within a certain area of a
400 0.9970 0.9931 0.9900 0.9876 0.9865 photomicrograph of the endothelium.
410 0.9978 0.9938 0.9906 0.9882 0.9876 The size of the endothelial cells is de-
420 0.9986 0.9945 0.9913 0.9887 0.9888 pendent on the magnification of the
430 0.9994 0.9952 0.9919 0.9892 0.9899 specular microscope. When the magnifi-
440 1.0002 0.9958 0.9925 0.9898 0.9910 cation is low the endothelial cells look
450 1.0010 0.9965 0.9931 0.9903 0.9921 small. The estimated endothelial cell den-
460 1.0018 0.9972 0.9937 0.9909 0.9932 sity will be too large as more cells will be
470 1.0026 0.9979 0.9943 0.9914 0.9944
counted within a certain counting area.
480 1.0034 0.9986 0.9949 0.9920 0.9955
To obtain the real endothelial cell density
490 1.0042 0.9993 0.9955 0.9925 0.9966
500 1.0050 1.0000 0.9961 0.9931 0.9977 the apparent endothelial cell density has
510 1.0058 1.0007 0.9968 0.9936 0.9989 to be multiplied by the normalized mag-
520 1.0066 1.0014 0.9974 0.9942 1.0000 nification (M2/M 2) at a specific value of
æ
530 1.0074 1.0021 0.9980 0.9947 1.0011 anterior corneal refractive power and
540 1.0082 1.0028 0.9986 0.9953 1.0023 CCT. See Fig. 2.
550 1.0090 1.0035 0.9992 0.9958 1.0034
560 1.0098 1.0042 0.9998 0.9964 1.0045 Clinical examples of changes in
570 1.0106 1.0049 1.0005 0.9969 1.0056 magnification
580 1.0114 1.0056 1.0011 0.9975 1.0068
Radial keratotomy (RK) and implan-
590 1.0122 1.0063 1.0017 0.9981 1.0079
600 1.0130 1.0070 1.0023 0.9986 1.0090 tation of an intracorneal ring segment
650 1.0171 1.0105 1.0054 1.0014 1.0147 (ICRS) result in a decrease in anterior
700 1.0212 1.0140 1.0085 1.0042 1.0204 corneal refractive power without chang-
ing CCT. Photorefractive keratectomy
(PRK) for myopia reduces anterior cor-
neal refractive power as well as CCT. In
nonrefractive phototherapeutic keratec-
terior corneal refractive power (P)) before M2Ω(ª1.376/CCT)2/
tomy used for treatment of superficial
being imaged by the specular microscope. (ª1.376/CCTπ0.376/r)2
corneal scars CCT is reduced, prefer-
From fundamental equations of geo-
For different CCT’s and anterior corneal ably without changing the anterior cor-
metric optics (Rubin 1993) the following
refractive powers the magnification (M2) neal refractive power. The endothelial
calculations can be done:
UπPΩV (1) where
P is the anterior corneal refractive power
Ω(n(cornea) – n(air))/r (2) where
n(cornea) is the refractive index of cor-
nea (1.376) (Mandell 1994)
n(air) is the refractive index of air (1.0)
rΩanterior corneal radius
U is the reduced vergence power of the
object
Ωn(cornea)/object distance (3)
V is the reduced vergence power of the
image
Ωn(air)/image distance
Convergence is defined as positive and di-
vergence as negative.
The magnification of the image (two di-
mensions) is
M2ΩU2/V2 (4) Fig. 2. A counting area of the endothelium before and after refractive surgery for myopia (large
respectively small hexagons) is illustrated. In this example the preoperative magnification (M(pre))
By substituting (1), (2), and (3) in (4) the in the vertical and horizontal dimension is two times larger than the postoperative magnification
magnification can be expressed as (M(post)) giving the normalized magnification M(post)2/M(pre)2Ω1/4.

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 16000420, 1999, 4, Downloaded from https://onlinelibrary.wiley.com/doi/10.1034/j.1600-0420.1999.770405.x by CAPES, Wiley Online Library on [04/04/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
A O S 1999

Table 2. Examples of overestimation of endothelial cell density after different corneal surgical
procedures. References
Borish IM (1975): Clinical refraction, 3rd edi-
Overestimation of tion, Vol 1, p 72.
endothelial cell density (per cent) Hansen FK (1971): A clinical study of the nor-
Corneal mal human central corneal thickness. Acta
Specular microscope
surgical Reduction in Reduction in anterior Ophthalmol (Copenh) 49: 82–89.
procedure CCT (microns) corneal power (dioptres) Non-contact Contact Isager P, Hjortdal JØ & Ehlers N (1996): The
effect of 193 nm excimer laser radiation on
PRK 90 10 1.28 1.02 the human corneal endothelial cell density.
RK/ICRS 0 5 0.38 0 Acta Ophthalmol Scand 74: 224–227.
PTK 90 0 0.64 1.02 Isager P, Guo S, Hjortdal JØ & Ehlers N
(1998): Endothelial cell loss after photore-
PRK: Photorefractive keratectomy fractive keratectomy for myopia. Acta
RK: Radial keratotomy Ophthalmol Scand 76:304–307.
ICRS: Intracorneal ring segment Mandell RB (1994): Corneal power correction
PTK: Phototherapeutic keratectomy. factor for photorefractive keratectomy. J Re-
fract Corneal Surg 10: 125–128.
Rubin ML (1993): Optics for Clinicians: pp
cell density will, as shown in Table 2, be fication of the contact and non-contact 67–75 and pp 345–46.
overestimated after these corneal surgi- specular microscope decreases slightly
Received on December 6th, 1998.
cal procedures if not corrected for mag- with decreasing central corneal thickness.
Accepted on March 11th, 1999.
nification changes. The calculations are In addition, the magnification of the non-
based on surgery on an average cornea contact specular microscope decreases
with an anterior corneal radius of 7.76 slightly with decreasing anterior corneal
mm (Borish 1975) and a CCT of 520 refractive power. As the preoperative and Corresponding author:
microns (Hansen 1971). postoperative measuring conditions are
Peter Isager
different in patients undergoing corneal Department of Ophthalmology
refractive surgery a correction for magni-
Conclusion fication changes has to be done when
Århus University Hospital
Norrebrogade 44
From experimental and theoretical small changes in endothelial cell density DK-8000 Århus C
studies it has been shown that the magni- are looked for. Denmark.

393