KERATOMETRY

Keratometry is measurement of curvature of the anterior surface of cornea across a

fixed chord length, usually 2-3 mm, which lies within the optical spherical zone of the
cornea.

PRINCIPLE:

1. Cornea as a Mirror

• The anterior surface of the cornea acts as a convex mirror.

• It reflects light to form an image (first Purkinje image).

• The size of this reflected image depends on the curvature of the cornea.

• Greater corneal curvature → smaller image.

• From the image size, the radius of curvature of the cornea can be calculated.

The figure illustrates the principle of keratometry using light reflection from the
corneal surface.

Explanation of the Figure:

1. Object (AB):

• Represents the original object whose reflection is being analyzed.

• It forms an image (A’B’) after reflection from the anterior corneal surface.

2. Reflected Rays:

• Ray AC: Passes through the corneal center of curvature (C) and reflects back on
itself.

• Ray AQ: Reflects towards QS and appears to meet AC at A’, forming the reflected
image (A’B’).

3. Focal Distance (BP = u):

• When the object (AB) is at infinity, the image (A’B’) is very small and located at the
focal point (F).
• The relationship between object size, image size, and corneal curvature is used to
calculate the radius (r).

Formula Derived from Figure:

• Using the reflection principle:

• Consider an object AB forming an image A’B’ after reflection.

• The focal point (F) is at half of the corneal radius (r/2).

• The equation used:

where O = object size, I = image size, and u = fixed distance from instrument.

• By keeping u constant, measuring the image size allows calculation of r.

• The eye cannot be fully immobilized.

• Specialized devices overcome this issue.

Image Doubling in Keratometers

1. Why Image Doubling?

• To accurately measure the reflected corneal image, keratometers use image

doubling.

• This prevents errors caused by eye movements.

2. Types of Doubling Mechanisms

• Rotating Glass Plates

• Two glass plates rotate to produce a double image.

• The lower edge of one image aligns with the upper edge of the other.

• If the eye moves, both images move together, reducing errors.

• The amount of rotation needed to double the image helps calculate its size.

• Fixed Doubling with Variable Object Size

• Instead of adjusting image doubling, the size of the external object is changed.

3. Helmholtz’s Contribution (1854)

• Helmholtz invented the first keratometer.

• He originally called it an ophthalmometer, but keratometer became the preferred

term.

Simplified Takeaways

• Keratometry measures the curvature of the cornea using the reflection principle.

• Smaller reflected image → steeper corneal curvature.

• The radius of curvature is determined using a formula.

• Image doubling techniques help reduce measurement errors.

• Helmholtz (1854) invented the keratometer for clinical use.

HELMHOLTZ KERATOMETER:

Though presently not in use, the Helmholtz keratometer is described here as a

tribute to the inventor.

Structure of Helmholtz Keratometer:

 Consists of two plates

o Each plate displaces the image through half its length
o Total displacement gives the size of the image
 Doubling of image:
o Dispenses with immobilizing the living eye
o If eye moves, both images move together
o Hence, difficulties in adjustment are avoided
 Glass plates:
o Of known thickness and index of refraction
o Placed side by side, each covers half of the object of a short-distance
telescope
 The axis of the telescope:
o Coincides with the plane of separation of glass plates
 Plates can be:
o Inclined to each other at known angles
 o The angle of incidence of incoming light can be varied and measured

Optics of Helmholtz Keratometer:

 Rays from point O meet the plates at U and E, and undergo lateral
displacement after refraction
 As viewed through L, the two objects appear at A and B
 The eyepiece M is arranged such that:
o Its principal focus coincides with the images A’ and B’
o It receives parallel rays, which come to focus without accommodation
on the retina at a and b
 If the plates are positioned such that:
o The two images A and B just touch at O
o Then each plate has displaced the image through half its length
o The total displacement gives the size of the image

Modern Use and Improvements:

 The original instrument has undergone several modifications

 Nowadays, several keratometers are in use
 An ideal keratometer:
o Must measure radii in various meridians about the axis of the cornea
 So, instruments are designed to be rotated with respect to a particular axis
 The objects used are called mires
 To avoid error from constant motion of eyes:
o A doubling device has been introduced

BAUSCH AND LOMB KERATOMETER

Principle:

 The working of Reichert (Bausch and Lomb) keratometer is based on the

principle of:
o Constant object size
o Variable image size

Optical System and Other Parts:

1. Object (Mire):
o A circular mire with two plus and two minus signs (Fig. 6.8)
o A lamp illuminates the mire via a diagonally placed mirror
o Light from the mire strikes the patient’s cornea and forms a diminished
image behind it
o This image becomes the object for the rest of the optical system
2. Objective Lens:
 o Focuses light from the image of the mire (now the new object)
o Light is focused along the central axis
3. Diaphragm and Doubling Prisms:
o A four-aperture diaphragm is located near the objective lens
o Beyond the diaphragm are two doubling prisms:
 One with its base up
 One with its base out
o Prisms can move independently, parallel to the central axis
o Light pathway:
 Left aperture → deviated above the axis by base-up prism
 Right aperture → deviated rightward by base-out prism
 Upper and lower apertures → light passes through unaltered,
forming image on the axis
o The total area of upper and lower apertures = area of each of the other
two → equal image brightness
o Upper and lower apertures also function as Scheiner’s disc:
 Double the central image if not focused properly
 Helps in continuous focus monitoring
o Unique image-doubling mechanism:
 Double images are produced side by side and 90° from each
other
 So, corneal power can be measured in two meridians without
rotating the instrument
 Hence, also called ‘one-position keratometer’
o The doubling device moves parallel to the control axis → Separation
amount adjustable
4. Eyepiece Lens:
o Enables the examiner to observe a magnified view of the doubled
image

Procedure of Keratometry

1. Instrument Adjustment

 The instrument is calibrated before use.

 A white paper is held in front of the objective piece and a black line is focused
sharply on it.
 The keratometer is then calibrated with steel balls:
o A steel ball of known radius of curvature is placed before the
keratometer.
o Its value is set on the scale or dial.
 The mires are focused by clockwise and anti-clockwise movement of the
eyepiece (trial and error).
 When mires are in focus, the calibration is complete.
2. Patient Adjustment

 The patient is seated in front of the instrument with chin on the chin rest and
head against the headrest.
 The eye not being examined is covered with the occluder.
 The chin is raised or lowered till the patient’s pupil and the projective knob
are at the same level.

3. Focusing of Mire

 After adjusting instrument and patient, the mire is focused in the centre of the
cornea.
 Figure 6.8 shows the patient’s view of the mire.
 Figure 6.9A shows the examiner’s first view:
o The central image is doubled, indicating incorrect focus on corneal
image.

4. Measurement of Corneal Curvature

 The instrument is correctly focused when the central image is no longer

doubled (Fig. 6.9B).
 To measure curvature in horizontal meridian:
o Plus signs of the central and left images are superimposed using
horizontal measuring control.
o The reading is noted (Fig. 6.9C).
 To measure curvature in vertical meridian:
o Minus signs of the central and upper images are coincided using
vertical measuring control.
o The reading is noted (Fig. 6.9D).

Regular Astigmatism

 For each eye, the difference between horizontal and vertical dioptre readings
gives the approximate corneal astigmatism.
 Normally, horizontal and vertical readings are 90 degrees apart.

Oblique Astigmatism

 In presence of oblique astigmatism:

o The two plus signs will not be aligned (Fig. 6.9E).
o The entire instrument is rotated till the two plus signs are aligned (Fig.
6.9F).
 A scale associated with the instrument rotation:
o Indicates, in degrees, one meridian of the oblique astigmatism.
  Corneal radius of power is then measured in this meridian and in the meridian
90° to it, as described above.

Interpreting the Findings

Spherical Cornea

 No difference in the power between two principal meridians

 Mires seen as perfect sphere

Astigmatism

 Difference in the power between two principal meridians

 Horizontally oval mires → seen in with-the-rule astigmatism
 Vertically oval mires → seen in against-the-rule astigmatism

Oblique Astigmatism

 Principal meridians lie between:

o 30° and 60°
o 120° and 150°

Irregular Anterior Corneal Surface

 Characterized by:
o Irregular mires
o Doubling of mires

Keratoconus

 Characterized by:
o Inclination and jumping of mires while attempting to adjust them
 When attempting to superimpose the plus mires, they jump
above and below each other (pulsating mires)
o Minification of mires in advanced keratoconus (K > 52 D) due to
increased myopia
o Oval mires seen due to large astigmatism
o Irregular, wavy and distorted mires also indicate advanced keratoconus

JAVAL–SCHIOTZ KERATOMETER

Principle:

 The working of Javal-Schiotz keratometer is based on the principle of:

o Variable object size
 o Constant image size

Optical System and Parts:

1. Object (Mires):
o Consists of two mires (A and B)
o Mounted on an arc, allowing synchronous movement (Figs 6.11 and
6.12)
o Together they form the object — variable size is attained by their
movement
o One mire:
 Stepped
 Has a green filter
o Other mire:
 Rectangular
 Has a red filter
o The mires are divided horizontally through the centre (Fig. 6.13)
o Illuminated by small lamps
o The image formed by the patient’s cornea (first Purkinje image) acts as
an object for the rest of the optical system
2. Objective Lens and Doubling Prism:
o These form the doubled image of the new object (i.e., the corneal
image of the mires)
o Doubling prism used is of the Wollaston type
 Produces fixed image doubling by birefringent (double
refracting) property of the material
3. Eyepiece Lens:
o Enables the examiner to observe a magnified view of the doubled
image

Procedure of Keratometry

1. Instrument Adjustment

 A white paper is held in front of the objective piece, and a black line is focused
on it.
 Then the instrument is calibrated to make it ready for use.

2. Patient Adjustment

 The patient is seated in front of the keratometer with:

o Chin on the chin rest
o Forehead against the forehead rest
  The chin rest is adjusted to bring the eye at the level of the telescope (T) of
the instrument (Fig. 6.12).
 The eye not being examined is covered with an occluder provided with the
instrument.

3. Adjustment of Mires

 The mires are adjusted so they are focused in the centre of the patient’s
cornea.
 Figure 6.13: Shows the patient’s view of the mires.
 Figure 6.14: Shows the doubled mire image as seen by the examiner through
the eyepiece.

4. Recording of Keratometric Readings

 Only the central pair of images is used for measurements.

 By changing the separation of mires, the separation of these two images is
changed.
 When the two control images just meet:
o The scales associated with mire separation indicate the correct corneal
radius and dioptric power of the cornea.

Measurement in Two Meridians

 The radius of curvature is first found in one meridian.

 Then the entire optical system is rotated by 90 degrees about its central axis.
 The second meridian, perpendicular to the first, is measured in the same way.

Astigmatism Detection

 If corneal astigmatism is present:

o There may be overlapping of the mires (Fig. 6.15)
o Or, they may move further apart
 Since:
o Stepped mire (staircase pattern) is green
o Rectangular mire is red
o The area of overlap appears whitish
 Each step of the mire = 1 D of corneal power
 So, number of steps overlapped gives approximate degree of astigmatism

Oblique Astigmatism

 When oblique astigmatism is present and mires are horizontal:

o The central bisecting lines of the images are not aligned (Fig. 6.16A)
 The instrument is rotated until the control lines are aligned (Fig. 6.16B)
  A scale associated with rotation:
o Indicates, in degrees, one meridian of oblique astigmatism
 Corneal radius or power is then measured in:
o This meridian
o And in the meridian 90° to it, as usual

SURGICAL / OPERATING KERATOMETER

 The surgical keratometer is attached to the operating microscope.

 It is helpful in monitoring astigmatism during corneal/limbal surgery.

Limitations of Accuracy

The accuracy of the surgical keratometer is limited due to the following factors:

 Difficulty in aligning the patient’s visual axis and the keratometer’s optical axis
 Keratometers are calibrated for a fixed distance from the anterior cornea
o Different microscope objective lenses have different focal lengths
o This results in different working distances
 Air in the anterior chamber results in a second target reflection
 External pressure on the globe causes a change in corneal curvature

AUTOMATED KERATOMETER

 Essentially, an autokeratometer is similar to manual keratometer.

 In it:
o The reflected image of the target is focused onto a photodetector.
o The image size is measured, and radius of curvature is computed.
o The target mires are illuminated with infrared light.
o An infrared photodetector is used.

Advantages of Autokeratometers:

 A compact device
 Very less time-consuming
 Comparatively easy to operate

Precision of Autokeratometry:

 Almost all studies have found exceptionally high precision with

autokeratometry.

Availability of Autokeratometers:

 Autokeratometers are available:

 o Alone
o More commonly in combination with autorefractometers as
autokeratorefractometers
 (e.g. Nidek ARK 2000-S autokeratorefractometer)

Automated Keratometry is also available in:

 IOLMaster (see page 348)

 Pentacam (see page 201)
 Orbscan (see page 199)
 Corneal topographer (see page 184)

Handheld Autokeratometers:

 PalmScan P2000
 HandyRef-K (uses synchroscan technology)

RELATIONSHIP BETWEEN RADIUS OF CURVATURE AND DIOPTRIC POWER OF

CORNEA

The following equation gives the relationship between radius of curvature and
dioptric power of the cornea:

 D = Dioptric power of the cornea

 n = Index of refraction of the cornea
 r = Radius of cornea in metres

Constant Used for Calibration:

 Since the invention of ophthalmometer by Helmholtz,

the index of refraction of the cornea has been taken as 1.3375 for calibrating the
instrument.

Therefore:

Calibration in Keratometers:

 Usually, keratometers are calibrated for:

o Radius of curvature
o And corresponding dioptres
 Otherwise, conversion can be done using the above equation
 For ready reference, a conversion table is also available

Range of Keratometer:
  36–52 D (6.5–9.38 mm)
 Lower limit can be extended up to:
o 30 D (5.6 mm)
 Upper limit can be extended up to:
o 61 D (10.9 mm)
 This is done by interposing a lens of:
o –1.0 D and +1.25 D, respectively,
o In front of the objective of the telescope

CLINICAL USES OF KERATOMETERS

The various uses of keratometer in day-to-day ophthalmic practice are as follows:
1. It helps in measurement of corneal astigmatic error.
2. It helps to estimate the radius of curvature of the anterior surface of the
cornea. So, it is of great use in contact lens fitting.
3. Keratometer is used to monitor the shape of the cornea in keratoconus and
keratoglobus.

4. We may be able to assess the refractive error in cases with hazy media

This provides a rough estimate, based on the fact that:

Normal corneal power = 43.5 D

Comparison of the two eyes in these cases is useful

[Link] has gained a special place in intraocular lens (IOL) power

calculation

 The K readings are taken with the help of a keratometer

 Along with axial length, these readings are used to calculate IOL power
 The calculation is done using the Sanders-Retzlaff-Kraff (SRK) formula.

[Link] is used to monitor pre- and post-surgical astigmatism.

[Link] is used for differential diagnosis of axial versus curvatural anisometropia.

[Link] is used to detect rigid gas-permeable lens flexure.
Limitation of Keratometry:

[Link] measurements of keratometer are based on a false assumption that:

• The cornea is a symmetrical spherical or spherocylindrical structure

• With two principal meridians separated from each other by 90 degrees

 • Whereas in reality, the cornea is aspheric

[Link] measures the refractive status of a very small central area of cornea (3-4
mm), ignoring the peripheral corneal zones.
[Link] loses its accuracy when measuring very flat (<40 D) or very steep (>50 D)
cornea.
[Link], small corneal irregularities would preclude the use of keratometer due
to irregular astigmatism.
[Link] index of refraction in radius to dioptre conversion.
[Link]-position instruments assume regular astigmatism.
[Link] to focal point is approximated by distance to image.
[Link] use of para-axial optics to calculate surface power.
[Link] cannot describe corneal asphericity.

SOURCES OF ERRORS IN KERATOMETRY

o Improper calibration
o Faulty positioning of the patient
o Improper fixation by the patient
o Accommodative fluctuation by examiner
o Localized corneal distortion
o Excessive tearing
o Abnormal lid position
o Improper focusing of the corneal image