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 The optical quality
of the cornea Antonio Calossi

T
he cornea is a relatively complex structure, consisting of a num-
ber of layers: the epithelium, the Bowman, the stroma, the
Descemet membrane and the endothelium[1-3]. The stroma occu-
pies 90% of the corneal thickness, which is about 530 m at the center
and 700 m at the periphery. The stroma consists of layers of lamella
consisting of bundles of collagen fibrils arranged in parallel and
crossed-over in an approximately orthogonal arrangement between one
lamella and the next. The arrangement of the fibrils is extremely im-
portant. Each fibril has a diameter of about 25-33 nm and their structure
and their arrangement are the reason behind these refractive properties,
while the regularity and uniformity of the dimension and the separa-
tion are crucial for the transparency of the cornea. The fibrils form a fair-
ly regular substance, even though there is light dispersion due to the
difference in the refractive index between the fibrils and the interstitial
material. This lack of optical homogeneity creates the Tyndall effect,
that is, dispersion of light inside the cornea, which permits the obser-
vation of this tissue in an optical section under the slit lamp. The light
diffused by the stromal substance creates a destructive interference in
all directions, except the direction of the incident light, which con-
tributes to maintaining good corneal transparency[4-10]. For as long as
the fibrils maintain this regular structure, the cornea will be transpar-
ent, otherwise, opacities will form that degrade the retinal image be-
cause of the light diffusion that reduces the contrast and the clarity of
the image.
On the basis of Rayleighs principle, an optical surface can be consid-
ered perfect when it produces a wave-front with aberrations that do
not exceed one-quarter of the wave-length[11]. The visible spectrum
ranges from 380 to 760 nm with a maximum of photopic sensitivity at
around 555 nm (0.555 m); in this way the irregularities of the corneal
surface have an insignificant optic effect only when they produce a

Antonio Calossi 1
 wave aberration of less than 0.14 m, which approximately corre-
sponds to a surface irregularity of 0.4 m (see appendix). The small ir-
regularities in the external surface of the cornea due to microfolds and
micro-villi of the corneal epithelium are smoothed by the tear film. One
of the functions of the tear film is the maintenance of the smoothness
of the optical surface. The mean central thickness of the tear film is
about 10 m[12]. If the tear film is distributed over the corneal epitheli-
um in a uniform manner, the dioptric effect is zero because it behaves
as a afocal flat lamina. In reality, in the time span between one blinking
action and the next, there are irregularities of thickness of the various
components of the tear film, in the order of the light wave length,
which can influence the quality of the retinal image[13-15].
The front surface of the cornea supplies the largest individual contri-
bution to the overall dioptric power of the eye, because of the large
jump in refractive index between air and the cornea. As a result, the
shape is extremely important in the determination of the aberration of
the retinal image. In Gullstrands schematic eye[16], which have an over-
all power of 60D, the anterior surface of the cornea has power of ap-
proximately +49 D (about 80% of the entire system) while the posteri-
or face has a power of 6D. This means that the total dioptric power of
the cornea is +43D. The paraxial power (P) of a dioptric surface de-
pends on the radius of curvature (r), and the difference in the refractive
index of the two media separated by this surface:
n n
P= 2 1
r
the greater the difference in this index, the greater the dioptric power
of that surface. The difference in refractive index between air and the
cornea is nine and a half times greater that the difference between the
cornea and aqueous; small variations in the shape of the anterior sur-
face are sufficient to create a significant dioptric variation. Each change
in radius curvature equal to 4/100 of a millimeter corresponds to a
dioptric variation of 0.25D. In this way, it is obvious that the careful
study of the corneal surface is particularly important in optical terms.
The modern techniques of computerized video-keratography consent
accurate quantitative measurements of thousands of points on the
corneal surface. In order to analyze the optical quality of the cornea, we
examined some video-keratographic indices that we have defined as
kerato-refractive indices[17]. These indices have been devised to provide
a simple method for quantity, with just a few yet significant numerical
values how much the surface of the optical zone of the cornea in ex-
amination differs from the ideal cornea. Before we describe these in-
dices, we should take a look at how an ideal cornea should appear.
The area of the cornea that contributes to the formation of the foveal
image is called the optical zone. This area of the cornea covers the en-
trance pupil. What we see when we observe an eye from the outside are
not the real pupil and iris, but the virtual image of these structures cre-
ated by the cornea. The virtual image of the pupil, back on the object

2 The optical quality of the cornea


Figure 1. The incident light rays are refracted by
the cornea and pass through the real pupil. The
only area of the cornea that is useful for the for-
mation of the foveal image is the area of the
cornea that covers the entrance pupil diameter
because the light rays that are refracted from
other parts of the cornea and directed towards
the fovea are screened by the iris.

space, is called the entrance pupil. In Gullstrands schematic eye, the en-
trance pupil is about 14% larger than the real pupil[18]. The light rays di-
rected towards the pupil are refracted by the cornea and pass through the
real pupil (Figure 1). The only portion of the cornea useful for the creation
of the foveal image is the area of the cornea that covers the entrance pupil
because the light rays which are refracted by other portions of the cornea
and directed towards the fovea are screened by the iris. More peripheral
portions of the cornea contribute to the formation of images in the pe-
ripheral field, in a retinal zone outside the foveal area. The more one shifts
away from the foveal area, the greater the width of the retinal receptive
fields. This causes a rapid degradation of the resolution power of the pe-
ripheral retina[19,20]; in this way, the clarity of the images in the peripheral
visual field has little effect on the general visual performance[21].
The diameter of the pupil determines the width of the useful optical
zone, which varies as a function of the pupillary dynamics. For a con-
stantly good retinal image, there should be no aberrations within the en-
trance pupil under conditions of maximum physiological mydriasis.
Nevertheless, it should be remembered that under Stiles-Crawford Effect
(SCE) of the first kind[22-24] the portion of the cornea that covers the more
central area of the pupil supplies a brighter image that formed by the
cornea which covers the peripheral area of the entrance pupil: if a light
ray that passes through the center of the pupil is perceived with 100%
brilliance, a light ray that passes through the pupil at a distance of 1 mm,
will be perceived as 93% brilliance, at 2 mm 71%, and at 3 mm from the
center of the pupil, only 41% of brilliance will be perceived due to this
effect. The aberrations in the central optical zone have a greater effect
than those closer to the edge. From an optical point of view, the ideal
cornea must have an optical zone consisting of an elliptical surface, with
an adequate shape factor (asphericity), it must be perfectly smooth and
have the apex centered on the visual axis. There will be spherical aber-
ration if the shape factor is not adequate; if the apex is not centered, there
will be a prismatic effect, astigmatism from oblique incidence and coma;
if the surface is irregular, there will be high order aberrations.

Antonio Calossi 3

Figure 2. Baker's equation: p indicates how rap-
idly the cornea flattens or curves as we move
further from the apex, so it represents the degree
to which the aspheric surfaces differ from the
spherical form.
* One number is sufficient for the definition of a circle
or a sphere: the radius of curvature; in order to de-
fine a conic or a conicoid two numbers suffice: the
apical radius and the shape factor. In actual fact, in
order to define a circle univocally, we also need to
know the position of its center with respect to the
reference system. In a similar manner, for the defini-
tion of a conic in an equivocal manner, in addition
to the apical radius and the shape factor, we also
need to know the position of the apex and the di-
rection of axis of symmetry.
4 The optical quality of the cornea
Corneal asphericity
and spherical aberration
Conics
The expression aspheric surface simply means a surface that is not
spherical. However, this expression is commonly used to indicate the
surfaces that can be described by the equation of a conic. The conic
curves have been given this name because they are generated by the sec-
tion of a cone with a plane more or less tilted with respect to the base,
and these are: the circle, the ellipse, the parabola and the hyperbole. Each
of these curves, if rotated on its axis of symmetry creates respectively a
sphere, and elipsoid, a paraboloid and a hyperboloid. These solid figures
are called conicoids. The typical corneal section is a prolate ellipse, con-
sisting of a more curved central part, the apex, with a progressive flat-
tening towards the periphery. The asphericity of the cornea is usually de-
fined by determining the asphericity of the conicoid which best fits the
portion of cornea to be studied. If we accept this first approximation, the
profile of a meridian can be defined with two values*: the apical radius
(which is on the vertex of the conic), which can be expressed in terms of
a circle with the same degree of curvature, and a shape factor, which rep-
resents the variation in curvature from the apex towards the periphery
and which defines the degree of asphericity (Figure 2). This ultimate pa-
rameter can be defined in a number of different ways[25]. There are four
different coefficients for expressing the shape factor of a conic, each one
of which is used in a different way to quantify the same thing: the shape
factors p and SF, the eccentricity e, and the coefficient of asphericity Q. If
one of these indices is known, others can be calculated using the con-
version formulas reported in Table 2.
Any conic can be represented by the following equation[26]:
y2 = 2r0 x px2 (1)
where y is the semi-chord, or rather the distance of a point on the curve
from the axis of symmetry; if the conic represents the section of an as-
pheric optical surface, the value y is the distance of a point on the sur-
face from its optical axis, x is the sagitta of the section, r0 is the apical
radius, while p indicates the rapidity of flattening or curving as we
move away from the apex.
In an ellipse, if a is the major semi-axis and b the minor semi-axis, the
value p indicates the following proportion:
b2
p= (2)
a2
The equation (2) shows that in the circle, which is the limit case of the
ellipse, b = a and therefore p = 1 The parabola is another limit case,
where a tends to infinity and therefore p = 0.
The prolate ellipses are a family of curves where the major axis coin-
cides with the x axis, b is less than a and therefore p varies between 0

p Q e SF (= e2)
Table 1. Different types of conical section with
Hyperbole <0 < -1 >1 >1 the corresponding values of the various coeffi-
Parabola 0 -1 1 1 cients of asphericity.
Prolate ellipse 0 < p <1 -1 < Q < 0 0 < e <1 0 < SF <1
Circle 1 0 0 0
Oblate ellipse >1 >0 <0 <0
Average/normal cornea 0.8 -0.2 0.45 0.2

p Q e SF
Table 2. Formulas of conversion between the
p= 1+Q 1 e2 1 SF various shape factors of a cone.
Q= p1 e2 SF
e= 1 p Q SF
SF = 1p Q e2

and 1. The closer p is to 1, the less elongated the shape will be. In an
oblate ellipse p is greater than 1. In this case, the minor axis will be
found along the x axis and therefore the surface will be progressively
more curved as we move away from the apex. In a hyperbole, p < 0.
The shape factor p is a value that indicates how much a curve differs to
a parabola instead of a circle. For this reason, a commonly used term for
defining the asphericity is Q, which is related to p by the equation
Q=p1 (3)
If Q = 0 the curve is a circle; if Q lies between 1 and 0 the curve is a
prolate ellipse; if Q = 1 it is a parabola; if Q < 1 a hyperbole; if Q > 0
the curve is an oblate ellipse.
It is likely that the term Q is not highly intuitive because the normal pro-
late corneas, are expressed as negative numbers. An alternative way of
expressing the degree of flattening of a conic is to use the term eccen-
tricity (e). The relationship between e and p is the following:
p = 1 e2 (4)
and therefore
e=1p (5)
If e = 0 the curve is a circle; if it lies between 0 and 1 the curve is an el-
lipse; if e=1, the curve is a parabola; if e > 1 the curve is a hyperbole.
The main problem that emerges when eccentricity (e) is used to express
the shape of a conic is that sometimes p can have a value greater than
1, so in these cases e2 is negative, and e no longer makes sense because
it equals the square root of a negative number. Negative values of e are
purely conventional and, for the oblate ellipse, they can be expressed in
the following way:
if p > 1 then e = p 1
With this convention, if e < 0 the curve is oblate.
The second problem with the parameter e is that the relationship be-
tween the variations of eccentricity and the variations of peripheral flat-

Antonio Calossi 5
 p e Q e2 LSA 3 mm LSA 5 mm LSA 7 mm
3.00 -1.41 2.00 -2.00 +2.43 +7.90 +21.35
2.90 -1.38 1.90 -1.90 +2.33 +7.51 +19.89
2.80 -1.34 1.80 -1.80 +2.23 +7.13 +18.53
2.70 -1.30 1.70 -1.70 +2.12 +6.76 +17.24
2.60 -1.26 1.60 -1.60 +2.02 +6.39 +16.03
2.50 -1.22 1.50 -1.50 +1.92 +6.03 +14.88
2.40 -1.18 1.40 -1.40 +1.82 +5.68 +13.79
2.30 -1.14 1.30 -1.30 +1.72 +5.33 +12.76
2.20 -1.10 1.20 -1.20 +1.62 +4.99 +11.78
2.10 -1.05 1.10 -1.10 +1.52 +4.66 +10.85
2.00 -1.00 1.00 -1.00 +1.43 +4.34 +9.96
1.90 -0.95 0.90 -0.90 +1.33 +4.01 +9.11
1.80 -0.89 0.80 -0.80 +1.23 +3.70 +8.29
1.70 -0.84 0.70 -0.70 +1.14 +3.39 +7.51
1.60 -0.77 0.60 -0.60 +1.04 +3.09 +6.76
1.50 -0.71 0.50 -0.50 +0.95 +2.79 +6.04
1.40 -0.63 0.40 -0.40 +0.85 +2.50 +5.35
1.30 -0.55 0.30 -0.30 +0.76 +2.21 +4.69
1.20 -0.45 0.20 -0.20 +0.66 +1.93 +4.05
1.10 -0.32 0.10 -0.10 +0.57 +1.65 +3.43
1.00 0.00 0.00 0.00 +0.48 +1.37 +2.83
0.90 0.32 -0.10 0.10 +0.39 +1.10 +2.26
0.80 0.45 -0.20 0.20 +0.30 +0.84 +1.70
0.70 0.55 -0.30 0.30 +0.21 +0.58 +1.16
0.60 0.63 -0.40 0.40 +0.11 +0.32 +0.64
0.50 0.71 -0.50 0.50 +0.03 +0.07 +0.14
0.40 0.77 -0.60 0.60 -0.06 -0.18 -0.35
0.30 0.84 -0.70 0.70 -0.15 -0.42 -0.82
0.20 0.89 -0.80 0.80 -0.24 -0.66 -1.28
0.10 0.95 -0.90 0.90 -0.33 -0.90 -1.73
0.00 1.00 -1.00 1.00 -0.18 -0.48 -1.85
-0.10 1.05 -1.10 1.10 -0.50 -1.37 -2.59
-0.20 1.10 -1.20 1.20 -0.59 -1.59 -3.00
-0.30 1.14 -1.30 1.30 -0.68 -1.82 -3.40
-0.40 1.18 -1.40 1.40 -0.76 -2.04 -3.79
-0.50 1.22 -1.50 1.50 -0.85 -2.25 -4.17
-0.60 1.26 -1.60 1.60 -0.93 -2.47 -4.54
-0.70 1.30 -1.70 1.70 -1.01 -2.68 -4.90
-0.80 1.34 -1.80 1.80 -1.10 -2.89 -5.25
-0.90 1.38 -1.90 1.90 -1.18 -3.09 -5.59
-1.00 1.41 -2.00 2.00 -1.26 -3.30 -5.93
-1.10 1.45 -2.10 2.10 -1.35 -3.50 -6.25
-1.20 1.48 -2.20 2.20 -1.43 -3.69 -6.57
-1.30 1.52 -2.30 2.30 -1.51 -3.89 -6.89
-1.40 1.55 -2.40 2.40 -1.59 -4.08 -7.19
-1.50 1.58 -2.50 2.50 -1.67 -4.27 -7.49
-1.60 1.61 -2.60 2.60 -1.75 -4.46 -7.78
-1.70 1.64 -2.70 2.70 -1.83 -4.64 -8.07
-1.80 1.67 -2.80 2.80 -1.91 -4.83 -8.35
-1.90 1.70 -2.90 2.90 -1.99 -5.01 -8.62
-2.00 1.73 -3.00 3.00 -2.07 -5.18 -8.89
-2.10 1.76 -3.10 3.10 -2.15 -5.36 -9.15
-2.20 1.79 -3.20 3.20 -2.22 -5.53 -9.41
-2.30 1.82 -3.30 3.30 -2.30 -5.71 -9.66
-2.40 1.84 -3.40 3.40 -2.38 -5.88 -9.91
-2.50 1.87 -3.50 3.50 -2.45 -6.04 -10.16
-2.60 1.90 -3.60 3.60 -2.53 -6.21 -10.39
-2.70 1.92 -3.70 3.70 -2.61 -6.37 -10.63
-2.80 1.95 -3.80 3.80 -2.68 -6.53 -10.86
-2.90 1.97 -3.90 3.90 -2.76 -6.69 -11.08
-3.00 2.00 -4.00 4.00 -2.83 -6.85 -11.30

Table 3. Conversion table for the different notations of asphericity with the corresponding longitiudinal spherical aberration (LSA) (calculated
for n = 1.376, r = 7.80 mm).

6 The optical quality of the cornea

tening coefficients is not linear. The variation in curvature which corre-
sponds to 0.1 units of e is difference in the transition from 0.1 to 0.2
compared to the transition from 1.1 to 1.2 in the first instance the two
curves are almost the same, in the second case, they differ considerably.
For this reason, sometimes the shape factor of a cornea is indicated in
terms of e2. Originally, this was chosen for the Wesley-Jessen[27,28]
Photoelectronic Keratoscope (PEK), where the term e 2 was replaced by SF
(shape factor). As a result
SF = e2 (4)
and
SF = 1 p (5)
As for p, SF was introduced in an attempt to produce a definition for
the oblate forms as well, that steepem from the apex towards the pe-
riphery. If e2= 0 the curve is a circle if e2 lies between 0 and 1, the curve
is a prolate ellipse; if e2= 1 the curve is a parabola; if e2> 1 the curve is
a hyperbole; if e2< 0 the curve is an oblate ellipse.
We would like to point out that if we use SF (or e2) to describe the shape
of the cornea, the terms negative and positive asphericity mean the op-
posite to Q, given that 0 < SF < 1 for a prolate ellipse and SF < 0 for an
oblate ellipse. This may cause some confusion, given that the same sur-
face can be described by a positive or negative number, depending on
whether SF or Q have been used. Table 1 summarizes the various types
of conic section with the corresponding values of the different shape
factors; table 2 summarizes the equations of conversion between the
various coefficients, while table 3 reports the various values of as-
phericity in different notations.
In the more recent publications of optometric literature, the value p is
reported frequently while the coefficient Q is used more frequently in
the ophthalmology journals; in publications relative to contact lenses,
the common term is eccentricity (e). Personally, we prefer the index e2,
which we prefer to define as asphericity (e2), instead of SF, because for
a sphere the value is zero. Contrary to Q, in the prolate surfaces, as in
a physiological cornea, the value e2 is positive and increases with an in-
crease in the degree of asphericity. In oblate corneas which have a re-
verse shape with respect to the physiological cornea, asphericity (e2) has
a value of less than zero; the negative value is greater the more the
geometry is reverse, or rather the more the cornea is oblate. The index
e2 lacks the limits of eccentricity (e) in that it is linear and easily con-
sents the representation of the oblate surfaces.
If the index of asphericity (e2) is used, the equation of a conic (1) be-
comes:
y 2 = 2r 0x (1 e 2)x 2 (6)
while in the three-dimensional version of the conic, that is a conicoid
with the axis of revolution Z, can be expressed in the following form:
x 2 + y 2 + (1 e 2)z 2 2zr 0 = 0 (7)

Antonio Calossi 7

Distribution of the frequency of the corneal asphericity (e2)
on a diameter of 8 mm in a sample of 1030 normal eyes
(continuos line represent the normal distribution)
Distribution of the frequency of the corneal asphericity (e2)
on a diameter of 4.5 mm in a sample of 1030 normal eyes
(continuos line represent the normal distribution)
that the apex coincides with the vertex and with the geometrical center of
Figure 3
The real cornea and the elliptical model
Approximating the corneal profile to a conic is useful from a mathematical
point of view, because as we mentioned already, this permits the straight-
forward description of its shape, using just two parameters: the apical ra-
dius and an index that expresses how much the curve differs from the cir-
cumference described by the apical radius. In the field of eye optics, this ap-
proach is useful for examining the spherical aberration.[29] Generally-speak-
ing, it is possible to closely approximate the profile of each meridian and
semi-meridian of the cornea to an elliptical curve. The direct evolution of
the elliptical model is the ellipso-toric model[30], that is, a surface where
every meridian has a different apical radius; a meridian of maximum and
minimum curvature can be identified and the difference between these two
produces the corneal astigmatism, and along each meridian, from the cen-
ter to the periphery, the curvature flattens with elliptical progression.[31]
In actual fact the cornea differs from the mono-elliptical progression in
the more peripheral areas, where the flattening is more accentuated and
the asphericity is greater than at the center. However, in many cases,
the ellipse is still a valid model for the optical zone of the cornea. Table
4 and figure 3 report the mean values of asphericity of the anterior sur-
faces of the cornea for a diameter of 8 mm, in addition to an optical
zone of 4.5 mm in a sample of 1030 normal eyes of 515 patients (282 fe-
males and 233 males, aged between 14 and 82 years (mean 38.9, SD
14.6), measured using the Eye Top CSO topograph (Florence, Italy).
The conic model includes some approximations and, in particular, assumes
the cornea, and that the corneal surface is symmetrical in relation to the line
of sight. In actual fact, this model is excessively simplified, because each
cornea has a specific profile, like a finger-print[32], and in some cases, par-
ticularly in the presence of pathologies, trauma, or resulting from surgery,
the profile of the cornea is completely different to the one described above.
In order to define corneal asphericity, the best-fit asphero-toric surface
can be calculated, or rather, the profile that minimizes the difference in
curvature between the surface and the portion of cornea that is repre-
sented. The degree with which this surface reflects the cornea may be
defined by an index, RMS (root mean square) which means how far the
surface measured differs on average from the best-fit. The RMS, or the
standard deviation, of the instantaneous curvature can be used as an index
of surface irregularity because it indicates how far the corneal surface dif-

p 8 mm e 8 mm e2 8 mm Q 8 mm p 4.5 mm e 4.5 mm e2 4.5 mm Q 4.5 mm

Mean 0.72 0.51 0.28 0.28 0.86 0.31 0.14 0.14
Std. Dev. 0.13 0.14 0.13 0.13 0.12 0.24 0.12 0.12
Minimum 0.14 0.22 0.05 0.86 0.47 0.46 0.21 0.53
Maximum 1.05 0.93 0.86 0.05 1.21 0.73 0.53 0.21

Table 4. Mean values, standard deviation and range of asphericity, expressed in the various notations, relative to the anterior surface of the cornea
on a diameter of 8 mm and an optical zone of 4.5 mm in a sample of 1030 normal eyes in 515 subjects, measured with the CSO topograph.

8 The optical quality of the cornea

fers from a perfectly smooth asphero-toric surface[17]. In the sample of 1030
normal eyes that we described above, for an area of pupil of 4.5 mm, the
mean value of this irregularity index was 0.44 D (SD 0.11) (Tab. 5).

Corneal aberrations
following refractive surgery

The conventional procedures of photoablative or incisional refractive sur- Figure 4. Spherical aberration.
gery, normally make a significant improvement to the low order refrac-
tive defects (defocus and regular astigmatism) but produce higher order
corneal aberrations which were not observed prior to surgery.[33-35] There
is usually only an increase of spherical aberration (Figure 4), while in cases
which are complicated by decentering, surface irregularities, regression
and ectasias, more invalidating aberrations, such as coma, may appear
(Figure 5) in addition to other high order aberrations (Figure 6).
The spherical aberration is symmetrical and the light rays that pass
through the paraxial zone of the pupil focus at a different distance that

the rays that pass through the marginal pupil. By convention, the Figure 5. Coma.
spherical aberration is positive when the marginal rays focus ahead of
the paraxial rays, whereas it is negative when the opposite is true. The
difference in diopters between the marginal and paraxial focal points is
called the Longitudinal Spherical Aberration (LSA). In general, a single
dioptric surface that separates two homogeneous media can be made
free from spherical aberration for a given pair of conjugate axial points
(i.e. for an object point placed on the optical axis at a determinate dis-
tance) of its section os a perfect Cartesian oval[36,37]. This is a curve of

the fourth degree, not an ellipse but a true oval. For certain special pairs
of conjugates, the curve degenerates into various conic sections includ- Figure 6. High order aberration.

ing a circle, hence the aplanatic point of a sphere.

Unfortunately, a surface free from spherical aberration for a specified
pair of conjugates will exhibit some aberration for all other pairs.
If, as in the case of the cornea, the medium that gives origin to the light rays
is air and the object is placed at infinity, the perfect oval has the shape of a
prolate ellipsoid where the asphericity (e2) is given by the following equation:
1
e2 = 2
n
where n is the refractive index of the medium that refracts the rays. For
corneal tissue n is 1.376 and in this case e2 should be 0.5282 (e = 0.7268;
p = 0.4718; Q = 0.5282).
In a normal eye, it is unlikely that the cornea will have this value of as-
phericity. There is normally a certain quantity of positive spherical
aberration that we can consider physiological[38-40]. As for all the mono-
chromatic aberrations, the value of the spherical aberration increases
with an increase in pupil diameter. If the value of asphericity remains

constant, LSA will increase with the square of the pupil diameter Figure 7. Spherical aberration as a function of
(Figure 7). If the pupil diameter remains fixed, the spherical aberration the diameter (p = 0.80, r = 7.80 mm).

Antonio Calossi 9

Following myopic photoablative treatment, the effect of reduction in the
Figure 8. Spherical aberration as a function of r
(p = 0.80; diam. 4.5 mm).
ject will consist of a disk surrounded by a diffused halo. If the overall
Figure 9. Spherical aberration as a function of p
(r = 7.80; diam. 4.5 mm).
Figure 10. Asphericity as a function of the
Surgically Induced Refractive Change (SIRC) to
obtain physiological spherical aberration.
Preop: Q = 0.2; r = 7.80 mm; LSA for 5 mm
+0.84 D (Q =-e2).
10
becomes a function of the value of asphericity, the refractive index and the
radius of curvature. If we consider the refractive index, the pupil diame-
ter and the asphericity as constant, the spherical aberration will be re-
duced if the corneal surface flattens, and increases as the cornea becomes
more curved (Figure 8). With equal curvature, the longitudinal spherical
aberration becomes negative if the surface is more prolate than Cartesian
oval shape; it will become positive if it is less prolate, spherical or oblate
(Figure 9). Table 3 reports different values of asphericity in the different no-
tations with the corresponding longitudinal spherical aberration (LSA).
Positive spherical aberration is greater the more the cornea is oblate.
spherical aberration due to flattening is normally not sufficient to com-
pensate for the increase in spherical aberration due to the substantial vari-
ation in shape obtained with the majority of the current ablation profiles.
This effect is even greater in the incisional operations of radial keratoto-
my, where with equal dioptric correction, the cornea becomes even more
oblate. The opposite occurs with hypermetropic treatments, the current
ablation profiles produce a hyper-prolate cornea. This variation in shape
produces a negative spherical aberration which is normally not compen-
sated by the increase in positive from the increased curvature.
The spherical aberration of the anterior corneal surface is added to that
of the posterior surface and that of the lens. These will tend to com-
pensate if they are of opposite signs.[38-40] If all the components of spher-
ical aberrations do not mutually compensate, the image of a point-ob-
spherical aberration is not excessive, there will be a slight loss in con-
trast, with an improvement in the depth of the field.[41] The latter phe-
nomenon is due to the multifocal effect of the spherical aberration. This
is the reason why, in the event of residual ametropia, th eyes operated
by corneal refractive surgery have a better unaided visual acuity that
would be expected on the basis of the residual refractive error.[42,43] A
slight residue of spherical aberration may also prove useful in the event
of presbyopia. This is the principle of some type of multifocal contact
lenses with simultaneous vision and the multi-focal intraocular lenses,
The optical quality of the cornea
which have been created in such a way as to produce a certain degree
of spherical aberration. With these lenses, if the spherical aberration is
positive (as in a myopic treatment), the center of the pupil is used for
distance vision and the peripheral zones for near; vice-versa, if the
spherical aberration is negative (as in a hypermetropic photoablative
treatment), the center is for near vision and the periphery for distance.
If the spherical aberration becomes excessive, there can be a significant loss
in contrast and blurring of the images that can be irritating and invalidat-
ing particularly under conditions of low light intensity, when the increase
of the pupil diameter causes an increase in the value of spherical aberration.
It is not easy to define a threshold for spherical aberration that can be tol-
erated or that might be useful, as the subjective responses to the loss of con-
trast sensitivity and tolerance to blurring are extremely variable. In the cases
of refractive surgery treatments on virgin corneas, it is a good rule to leave
the same value of spherical aberration. The graph in Figure 10 reports the
values of asphericity necessary to maintain the physiological value of the
corneas spherical aberration (the mean value of an un-operated eye) in
function of the spherical equivalent corrected with photoablative surgery.
However, when the surgeon intentionally aims for a certain degree of
spherical aberration, it is possible to simulate different values of spheri-
cal aberration using contact lenses with appropriate eccentricity in order
to choose the one that produces the most satisfactory visual results.
Even when an optic system is correct in terms of spherical aberration
and focuses all the rays perfectly on the optical axis, the quality of the
images of the points which are just off the axis will not be perfect, un-
less the system is also corrected for coma. The coma aberration takes
its name from the fact that the image of a luminous dot which is posi-
tioned just slightly off the axis of a lens appears like a comet, with a
central nucleus, where the greatest quantity of light energy is concen-
trated, in addition to a tail that is laterally blurred. This phenomenon
derives from the fact that the linear magnification of a lens is a func-
tion of the height with which the rays are incident on it.
If the magnification of the rays that pass more externally through the lens
is greater than that of the central rays, we say that the coma is positive;
if the opposite is true, the coma is negative. In a real eye, the foveal image
is affected by coma due to the loss in symmetry of the eye in relation to
an appropriate axis. Coma is probably the worst type of aberration due
to the asymmetrical blurring which produces very ugly image.

Keratorefractive indices
(Calossi, Vinciguerra)
The peculiarities of the shape of a specific cornea which determine the
optical propertys we mentioned before can be quantified using some nu-
merical indices (Figure 11) and compared with those of an ideal cornea
or with a range of normality. We will now describe our proposal[17] which

Antonio Calossi 11
 was implemented in the eye top CSO topograph (Florence, Italy). We
have already mentioned that the portion of the cornea useful for the
creation of the foveal image is the area that covers the entrance pupil;
each eye has its pupil diameter that changes with the various light con-
ditions; however, in order to compare the different cases, for each eye
we selected a fixed entrance pupil. The numerical values of our indices
represent the following parameters.

Astigmatism
Figure 11. Calossi-Vinciguerra keratorefractive 3 mm: corneal toricity expressed in diopters in an area of cornea of
indices. diameter 3 mm, centered on the corneal vertex;
5 mm: corneal toricity expressed in diopters in an area of cornea of
diameter 5 mm, centered on the corneal vertex.
For the two diameters, these two values represent the degree and the
axis of the regular astigmatic component of the cornea. A difference
in the axis or power between the two diameters indicates the pres-
ence of irregular astigmatism, which cannot be efficaciously correct-
ed with an spectacle lens.
Mean pupillary power
This is the mean axial curvature, expressed in diopters, for an entire
portion of cornea of diameter 3 mm centered on the entrance pupil,
taking the Stiles-Crawford effect into consideration; that is, giving
greater importance to the central points. This parameter represents
the spherical equivalent of the cornea within a pupillary zone of di-
ameter 3 mm. This parameter is useful for the definition of the mean
central curvature in irregular corneas, for example in keratoconus,
perforating keratoplasty, trauma etc. or extremely aspherical corneas,
for example after refractive surgery.
Asphericity
This is the mean asphericity of an area of cornea of diameter 4.5 mm,
centered on the center of the pupil. It is a coefficient the degree to
which the optical zone of the cornea is prolate or oblate. It can be ex-
pressed as any of the four parameters we described above.
Spherical aberration
Longitudinal spherical aberration (LSA) expressed in diopters of an
area of cornea of diameter 4.5 mm, centered on the center of the pupil.
It expresses the difference between the marginal and the paraxial
power. It is calculated by applying a procedure called ray tracing to
the best-fit conic on a pupillary zone of 4.5 mm.

Mean Std. Dev. Mean 2SD Mean + 2SD Mean 3SD Mean + 3SD Minimum Maximum
Asphericity (p) +0.86 +0.12 +0.62 +1.10 +0.50 +1.22 +0.47 +1.21
Long. spher. aberration LSA (D) +0.82 +0.25 +0.32 +1.32 +0.07 +1.57 0.00 +1.69
Irregularity of curvature RMS (D) +0.44 +0.11 +0.22 +0.66 +0.11 +0.77 +0.22 +1.06
Surface asymmetry SAI (D) +0.27 +0.16 0.00 +0.59 0.00 +0.75 +0.04 +1.18
Table 5. Kerato-refractive indices in a sample of 1030 normal eyes. These four indices have been calculated on an area of cornea of di-
ameter 4.5 mm centered on the center of the pupil.

12 The optical quality of the cornea

 Irregularity of curvature
Standard deviation (or Root Mean Square RMS) of the instanta-
neous curvature with respect to a best fit aspherical surface, calcu-
lated for an area of cornea of diameter 4.5 mm centered on the
pupil and expressed in diopters. A zero index of irregularity indi-
cates a perfectly smooth surface that can be approximated to as-
pheric-toric.
Surface asymmetry
SAI (Surface Asymmetry Index) is the index of surface asymmetry
of the area of cornea of diameter 4.5 mm, centered on the center of
the pupil, calculated as the mean difference between the instanta-
neous curvature along two opposite semi-meridians on each merid-
ian. A cornea with a perfectly symmetrical optical zone has a SAI
value of zero.
In the event of asymmetry, the mean instantaneous curvature of the
flattest corneal hemisphere of the area of the cornea of diameter 4.5
mm, centered on the center of the pupil, is indicated in blue, while
red indicates the mean curvature of the corneal hemisphere of
greater curvature.
In order to facilitate the clinical interpretation of these indices, the val-
ues of asphericity, spherical aberration, irregularity of curvature and
asymmetry (SAI), are compared with the values measured in a sample
of normal eyes.
The values that lie between two standard deviations from the
means of the normal population are considered to be the physio-
logical values and are indicated in green; the values that lie be-
tween two and three standard deviations from the mean of the nor-
mal population are considered to be suspect and are indicated in
yellow. The values that lie beyond three standard deviations from
the mean for the normal population are considered to be abnormal
and are indicated in red.
Table 5 reports the mean values and the standard deviations of a sam-
ple of 1030 normal eyes, that we have described and that we can con-
sider as physiological intervals of the shape defects of the corneas op-

tical zone.
Figure 12. Distribution of the frequency of the
Figure 12 reports the distribution of the frequencies. Calossi-Vinciguerra keratorefractive indices for a
We will now present some examples where the keratorefractive indices sample of 1030 normal eyes. The asphericity,
which in this case has been expressed in rela-
contribute to quantifying the optical quality of the corneal surface. In tion to p, has a normal distribution (shown by
order to make a direct comparison, all the maps of curvature have been the continuous curve). The same applies to the
spherical aberration (LSA). Corneal irregularity
reported on an absolute scale. (RMS) and surface asymmetry (SAI) have an
asymmetrical distribution (skewness RMS =
1.07; skewness SAI = 1.48) due to the fact that
Normal cornea the minimum possible value of these two in-
dices is ZERO; as a result the distribution tail of
Figure 13 reports the maps of axial curvature of a normal cornea with the frequencies can only develop in the direc-
tion of position values; the distribution of SAI is
slight physiological with-the-rule astigmatism (Sim-K: 41.59/42.81 ax leptocartic (kurtosis = 3.23), that is, with a peak
10), Figure 14 reports the map of the instantaneous curvatures. The of the frequency superior to that expected of
normal distribution, with a mode of 0.15 and a
profiles of instantaneous curvature (Figure 15) highlight the regular median of 0.23 D.

Antonio Calossi 13


Figure 13. Map of the axial curvature for a normal cornea with mild Figure 14. Map of the instantaneous curvature of a normal cornea
with-the-rule physiological astigmatism. with mild with-the rule physiological astigmatism.

Figure 15. Profiles of instantaneous curvature of the principal meridi- Figure 16. Keratorefractive indices: the green numbers for asphericity,
ans of a normal cornea with mild physiological with-the-rule astig- spherical aberration, irregular curvature and asymmetry indicate that
matism. The red line indicates the meridian of greatest curvature, in the values in this case lie between the two standard deviations of the
this case 100, while the blue line indicates the meridian of flattest mean for a normal population.
curvature, in this case 10, the green line (dK) indicates the difference
between the two meridians, or the corneal toricity at different dis-
tances from the center, which in this case tends to be fairly constant.

form of the cornea with a slightly prolate central zone and mild torici-
ty which is constant on the entire surfaces. The kerato-refractive indices
in this case (Figure 16) are all within normal limits: corneal astigmatism
is 1.30 D ax 8 at 3 mm and 1.14 D ax 11 at 5 mm. The slightly pro-
late asphericity (e2 = 0.21, e = 0.46) with a mean pupillary curvature of
42.27 D at 4.5 mm produce a slight physiological spherical aberration
of +0.61 D; slight curvature irregularity (0.32 D) as with the slight sur-
face asymmetry (0.33) are compatible with normal limits.

Herpetic keratitis
In this case, irregularity of the corneal surface can be observed due to
scars from herpetic keratitis. The effects of this can be examined in the

14 The optical quality of the cornea

axial map (Figure 17), in the map of the instantaneous curvature (Figure
18) and in the profiles of the extremely irregular curvature (Figure 19).
The keratorefractive indices (Figure 20) indicate substantial irregularity
in the keratometric astigmatism which is 2.72 D at 3 mm and becomes
1.02 D at 5 mm, the axis shifts from 26 for 3 mm to 69 at 5 mm; the
irregularity of curvature has a value of 1.61 D which is significantly out-
side normal limits; asphericity that is greater than normal levels (e =
0.90, e2 = 0.81) produces slight negative spherical aberration of 0.58 D
which is of minor significance; the same applies to the surface asym-
metry of 0.84 D which is slightly greater than normal levels.

LASIK, small optical zone

This case of LASIK for myopia had a very poor qualitative outcome.
The axial map (Figure 21) highlights large-scale asymmetric multi-fo-
cality; the map of the instantaneous curvature (Figure 22) indicates an
excessively small zone of 4 mm and that the center of ablation is de-

Figure 17. Axial map of a cornea scarred by herpetic keratitis. Figure 18. Map of instantaneous curvature relative to the previous case.

Figure 19. Profiles of instantaneous curvature relative to the previous case. Figure 20. Keratorefractive indices relative to the previous case.

Antonio Calossi 15


Figure 21. LASIK for myopia, excessively small optical zone exces- Figure 22. Map of instantaneous curvature relative to the previous case.
sively prolate and decentered. The axial map highlights the asym-
metrical multi-focal properties of the pupillary zone (the yellow ring
represents the pupil diameter in this case under photopic condi-
tions, the small yellow cross is the center of the pupil, the large
white cross represents the main meridians of the sim-K. The meet-
ing point corresponds to the corneal vertex).

Figure 23.Profiles of instantaneous curvature relative to the previous case. Figure 24. Keratorefractive indices relative to the previous case.

centered by 0.5 mm in an infero-nasal direction. The profiles of instanta-

neous curvature (Figure 23) highlight that the optical zone is extremely
oblate and has an irregular surface. From the kerato-refractive indices
(Figure 24) we can observe a strong spherical aberration which with the
pupil of 4.5 mm is +4.84 D, caused by excessive negative eccentricity (e
= 1.6, e2 = 2.57); the index of surface irregularity is significantly outside
normal levels (1.77 D); the same applies to values of asymmetry (1.36 D).

Asymmetric PRK
In this case, a decentered treatment was further complicated by epithe-
lial hyperplasia in the upper zone which produced a strong asymmetry
of the optical zone of this cornea. The instantaneous map (Figure 25)

16 The optical quality of the cornea



Figure 25. Map of instantaneous curvature relative to the decentered Figure 26. Map of instantaneous curvature relative to the previous case.
PRK treatment, further complicated by epithelial hyperplasia in the
superior zone.

Figure 27. Profiles of instantaneous curvature highlight the asymme- Figure 28. Keratorefractive indices relative to the previous case.
try of the vertical meridian represented by the red line.

highlights the morphological aspects of the treatment that, as can be

seen from the axial map (Figure 26), has produced a very poor optical
result. The profiles of instantaneous curvature (Figure 27) show strong
vertical asymmetry. The keratorefractive indices (Figure 28) show a
mild spherical aberration (LSA +1.61 D), which despite being outside
normal limits, is of little importance. However, the asymmetrical com-
ponent is important (SAI 2.00 D), as is the surface irregularity (2.06 D).

Excellent PRK
The map of axial curvature (Figure 29), and the map of instantaneous
curvature (Figure 30), show the excellent outcome of a PRK treatment
for a myopic defect of6.00. The profiles of curvature (Figure 31) high-
light the extreme regularity due to the excellent smoothing of the sur-
face treated. The indices (Figure 32) indicate a fairly flat pupillary area

Antonio Calossi 17


Figure 29. Map of axial curvature in a perfect case of PRK treatment Figure 30. Map of instantaneous curvature relative to the previous case.
for myopia of 6.00 D.

Figure 31. The profiles of istantaneous curvature underline that the Figure 32. The keratorefractive indices underline the good quality of
optical zone is almost spherical and extremely regular. the surface in the cornea.

(39.35 D), a minimally-oblate optical zone (e = 0.41, e2 = 0.17), and

spherical aberration within normal limits (+1.14 D). Astigmatism lies
with physiological levels at 3 mm (0.77 D ax 9) and at 5 mm (0.46 D
ax 5). The indices of irregularity (0.40 D) and of asymmetry (0.11 D)
are excellent.

Zernikes analysis of the corneal surface

An even more detailed examination of the optical quality of the corneal
surface and the wave-front generated by the anterior surface of the
cornea can be obtained using Zernikes analysis. This is a sophisticated
analytical method ideal for representing surfaces of any shape. It is
based on a set of orthonormal polynomials developed in the Thirties by

18 The optical quality of the cornea

Frits Zernike,[44] a brilliant scientist who won the Nobel Prize for
Physics in 1952 for his invention of the contrast-phase microscope. In
the field of optics, Zernikes polynomials are widely used in the inter-
ferometric tests, to describe the quality of the surfaces in an optic in-
strument and in the aberrometric measurements, where wave-front
sensors are used. Using Zernike's analysis, any surface can be described
as the weighted sum of typical shapes represented by the polynomials.
The series of polynomials is of increasing order and potentially infinite.
Obviously, the greater the number of polynomials used, the more de-
tailed the surface representation. The more the surface is complex, the
greater the number of polynomials used. As we said before, this math-
ematical procedure is particularly suitable for providing the analytical
description of both the optical surfaces and the wave-fronts. The es-
sential advantage of Zernike's polynomials is that they allow the de-
composition of any surface, even the most complex, into a series of ba-
sically independent components. The components chosen by Zernike
are those specific for the wave aberrations. The ortho-normal charac-
teristic of Zernike's polynomials permits the analysis of the individual
components of the different aberrations independently of each other, to
quantify the importance of any single component and to classify them
by order or group. In this way, for example, in a complex aberration,
we can quantify the prismatic component, the component of defocus,
the degree of regular astigmatism, the spherical aberration, coma and
so on. Or alternately we can group together all the spherical-like (of
even-number order) or coma-like aberrations (of odd-number order);
similarly we can differentiate the degree of aberration that can be cor-
rected with spectacles, that is the entire second order (defocus and pri-
mary astigmatism), from the component that cannot be corrected with
an ophthalmic lens, that is from the third order onwards; we can also
distinguish the primary aberrations from the secondary and the terti-
ary etc. The various aberrations or groups or aberrations can therefore
be quantified as a number or in graphical form.
In optic terms, what is of interest is the description of the deformation
of a surface, that is any modification of the form that makes it different
to the desired shape. Normally the surface is not analyzed directly with
Zernike's method, but the operator observes the different between the
surface measured - irrespective of whether it is an optical surface or a
wave-front - and what the desired surface should be. In this context, the
evaluation of perfection of a surface does not refer to a specific absolute
shape, but to the shape the surface was scheduled to have. A given op-
tical surface, viewed singularly, can transform the perfect wave front
(spherical or plane) into a strongly deformed wave-front. If this action
corresponds to the expected action, the aberration is of no account be-
cause in the final analysis it will be compensated by those introduced
by the others and the surface can be considered perfect for its final pur-
pose. On the contrary, any modification of the surface shape that re-
moves it from the desired shape, can be considered to be a deformation.

Antonio Calossi 19
 The error of the wave-front associated with this deformation will prop-
agate unchanged through the entire system and can be observed as the
wave aberration that the system produced without any deformations.
Moreover, the errors of the wave-front are directly additive, so the over-
all aberration is the algebraic sum of the contribution of aberration of
all the components of the optical system.
We have already mentioned that in order to describe any shape of sur-
face exactly, it is necessary to have an infinite number of polynomials.
In practice, with a finite number of components, we can normally de-
scribe even complex optic surfaces and wave-fronts in an extremely
valid manner.[45]
What remains after what has been described by a set of selected poly-
nomials is the residue which can be quantified numerically or present-
ed as a graph as the difference between the geometrical surfaces de-
scribed by the set of polynomials and the real surface. The quantity that
remains is a group of all the aberrations of higher order than those de-
scribed by the selected set of polynomials. For example, with 36 poly-
nomials, 7 orders can be represented, in this case the residue is the
group of aberrations that are higher than the seventh order.

The CSO program

We applied Zernike's a analysis to altimetric data of the anterior surface
of the cornea measured by the Eye Top CSO topograph. Moreover, from
the instantaneous curvatures of the corneal surfaces measured using
the same instrument, we can trace the normals of this surface.
Then by applying Snell's law of refraction to every point measured, it
is possible to calculate the wave-front that is generated by the corneal
surface. The wave-front calculated is then analyzed by Zernike's
method. In this way it is possible to decide whether to display the aber-
rations of the corneal surface or alternately, the aberrations of the wave-
front generated by the anterior surface of the cornea.[46]
The optical quality of the human eye is determined by the optical prop-
erties of both the cornea and the lens, their optical density and the dis-
tribution of their refractive index, their relative alignment, the position
of the fovea and the position of the pupil. For this reason, the meas-
urement of the overall optic aberrations consents the most complete de-
scription of the properties of formation of the image by the eye; while
the combination of the information supplied by corneal topography,
with the information on the ocular aberration, if expressed in the same
language, provides information the individual optical properties of the
single ocular components.[39,40,47,48]
In the specific case of the analysis of the aberrations of the corneal sur-
face, as we are not aware of the contribution of the other ocular struc-
tures, we presume that the internal aberrations have no influence and
we analyze the aberrations by comparing the eye with an ideal cornea
that produces a spherical wave-front.
Zernike's analysis model can be found in the CSO topograph from ver-

20 The optical quality of the cornea

sion 6.0 onwards. For the analysis of the various components of the
total aberration, a set of 36 Zernike's polynomials. The results of the
analysis are reported in a summary using numerical indices and graph-
ical representations. In this summary (Figure 33), the aberrations are
displayed together and split into their various components. In the top
left part of the screen, there is the map of the 'Total Aberration' which
corresponds to the sum of all the components of aberration with the ex-
ception of tilt and defocus, to the 36th polynomial which corresponds to
Zernike's 7th order. Below the map, the RMS of the total aberration
which consents the numerical quantification of how much the surface
in examination differs from the perfect reference surface. When the sur-
face aberration is analyzed, the reference surface is Cartesian oval, that
is, the ideal surface that produces a perfectly spherical wave-front.
When the aberration of the wave-front is analyzed, the reference sur-
face is a spherical wave-front, that is completely free from aberrations.
The wave aberration is represented in terms of OPD (optical path dif-
ference). The color scale to the side of the map is expressed in microns
and is the same for the five maps presented in the summary. An ab-
solute scale was chosen with a step that filters the physiological aber-
rations for a mean pupil diameter of 5 mm. The scale is 1.5 m for the
corneal surface and 0.5 m for the wave-front. In the lower left part,
there is a histogram of the expansion coefficients for Zernike's polyno-
mials where each bar represents the weight of each polynomial.
In the right of the screen, there are two panels where the different com-
ponents of the aberrations are classified according to two different cri-
teria. The panel Seidel shows the third order aberrations of
Seidel,[49,50] which correspond to the primary aberrations: regular astig-
matism (that is, primary), which reports the map, the degree expressed
in diopters (D), the axis and the RMS; the spherical aberration with

Figure 33. Summary of the Zernike analysis, of the wave-front gen- Figure 34. The same case as the previous figure. In this image, the
erated by the corneal surface of a keratoconus on an entrance pupil spherical-like and coma-like components group together the even and
of 5 mm (for further details, refer to the description in the text). odd orders.

Antonio Calossi 21
 map, quantity in diopters (D) for the longitudinal spherical aberration
(LSA) and RMS; coma with RMS and direction; the high order aberrations
which groups together all the components of aberrations of higher order
that the primary; tilt, with the value expressed in prismatic diopters (Dp),
direction and RMS; and finally, the power that represents the sum be-
tween the dioptric power of the reference surface and the defocus com-
ponent, the power is expressed in diopters (D) and millimeters (mm) (the
conversion is made using the refractive index of the stroma = 1.376).
The panel radial orders (Figure 34) presents: regular astigmatism with
the map, the degree, expressed in diopters (D), the axis and RMS; the
group of the spherical-like aberrations (even aberrations) with the map
and RMS; the group of the coma-like aberrations (odd aberrations) with
the map and the RMS; the residue of aberration beyond Zernike's 7th
order; tilt, with the value in prismatic diopters (Dp), direction and RMS;
and finally the power which represents the sum of the dioptric power
of the reference surfaces and the defocus component, the power is ex-
pressed in diopters (D) and millimeters (mm) (the conversion is made
using the refractive index of the stroma = 1.376).
Using these aberrometric data of the corneal wave-front, it is possible
to calculate other parameters to quantify directly the optical quality of
the retinal image that a specific cornea is in a position to produce. The
first step is to perform a mathematical operation called autocorrelation
on the aberrometric map of the corneal wave-front, which supplies the
optic transfer function (OTF). The second step is to perform the math-
ematical operation called a Fourier transform on the OTF, to obtain the
point-spread function (PSF), which represents the energetic distribution
on the retina of the light originating from a point light source. The third
step is to reproduce the PSF for each point of the object. This corre-
sponds to the mathematical operation called convolution, that pro-
duces the simulation of a retinal image for any large object, in our case,
we chose a table of high contrast EDTRS ottotypes and another at 10%
contrast. All these findings, reported numerically and graphically are

Figure 35. Summary of the visual quality relative

to the previous case.

22 The optical quality of the cornea

displayed in a summary (Figure 35) that we have called summary of
the visual quality. In the top left part of the window, there is a map of
the total aberration of the corneal wave front in terms of OPD. Above
this, the corresponding values of RMS. Below, for a more detailed ana-
lytical picture, the expansion of all Zernike's coefficients in a pyramid-
like graph with gray scale shading. In this case a pyramidal display of
radial order on the ordinate and angular frequency on the abscissa was
used to display the value of the Zernike coefficient on a third axis. The
way to display such a graph is as an image in which the gray-scale lu-
minance is used to encode the Zernike coefficient value[51]. The second
graph below reports the spot diagram, which indicates the aberration
of the rays that pass through the pupil without any diffraction; each
point represents the impact zone of each single ray on the retina; the
spot domain (which in this example is 83 m) represents the size of a
zone on the retina where all the rays are distributed. The second graph
above shows the PSF with its domain and its maximum peak; different
to the spot diagram, PSF also takes diffraction into account. The con-
volution of the high and low contrast ottotypes have been reported in
order to provide an immediate qualitative evaluation.
Figure 35 represents the corneal aberration of a keratoconus on a entrance
pupil of 5 mm. The major coma component greatly degrades the visual
quality of this eye with asymmetrical defocus of the images which is
translated into almost total illegibility of the low contrast ottotypes.

RMS corneal wave-front (micron) RMS corneal surface (micron)

Mean Std. Mean Mean Min Max Mean Std. Mean Mean Min Max
Dev. + 2SD + 3 SD Dev. + 2 SD + 3 SD
Sph Ab 3 mm 0,04 0,03 0,10 0,13 0,0000 0,12 0,11 0,08 0,27 0,35 0,0001 0,32
Coma 3 mm 0,05 0,03 0,11 0,14 0,0005 0,17 0,13 0,08 0,29 0,37 0,0014 0,45
High Horder 3 mm 0,10 0,03 0,16 0,19 0,0400 0,28 0,27 0,08 0,43 0,51 0,1064 0,74
Sph Like 3 mm 0,07 0,02 0,11 0,13 0,0300 0,21 0,19 0,05 0,29 0,35 0,0798 0,56
Coma Like 3 mm 0,09 0,03 0,15 0,18 0,0300 0,26 0,24 0,08 0,40 0,48 0,0798 0,69
Sph Ab 5 mm 0,15 0,05 0,25 0,30 0,0028 0,31 0,40 0,13 0,66 0,80 0,0076 0,82
Coma 5 mm 0,14 0,08 0,30 0,38 0,0100 0,48 0,37 0,21 0,80 1,01 0,0266 1,28
High Horder 5 mm 0,16 0,06 0,28 0,34 0,0500 0,52 0,43 0,16 0,74 0,90 0,1330 1,38
Sph Like 5 mm 0,18 0,05 0,28 0,33 0,0600 0,43 0,48 0,13 0,74 0,88 0,1596 1,14
Coma Like 5 mm 0,20 0,08 0,36 0,44 0,0400 0,60 0,53 0,21 0,96 1,17 0,1064 1,60
Sph Ab 7 mm 0,52 0,17 0,86 1,03 0,0200 1,07 1,38 0,45 2,29 2,74 0,0532 2,85
Coma 7 mm 0,42 0,23 0,88 1,11 0,0100 1,49 1,12 0,61 2,34 2,95 0,0266 3,96
High Horder 7 mm 0,35 0,17 0,69 0,86 0,0900 1,34 0,93 0,45 1,84 2,29 0,2394 3,56
Sph Like 7 mm 0,57 0,16 0,89 1,05 0,1400 1,25 1,52 0,43 2,37 2,79 0,3723 3,32
Coma Like 7 mm 0,52 0,22 0,96 1,18 0,0900 1,50 1,38 0,59 2,55 3,14 0,2394 3,99

Table 6. Calossi - Vinciguerra statistics. Medium values, standard deviations and range of corneal surface aberrations, and phase front pro-
duced by the corneal anterior surface along three different pupillary diameters have been reckoned by the Eye Top CSO topographer over
a sample of 500 subjects (1000 normal eyes). We may consider "physiological" the values included in two standard deviations from the
normal medium, while we may consider 'abnormal' those that go beyond three standard deviations.

Antonio Calossi 23


Figure 36. Zernike analysis of the wave-front generated by the sur- Figure 37. Summary of the visual quality relative to the previous
face of a normal cornea with mild with-the-rule physiological astig- case.
matism on a pupil entrance of 5 mm.

Table 6 shows the RMS values range of the corneal surface aberrations
and the phase front produced by the corneal anterior surface that we
may consider as physiological intervals. The statistical analysis has
been carried out over a sample of 1000 normal eyes: 500 subjects, 277
females and 223 males, aged 14 - 80 (proportional mean 38,8 SD 14,3),
reckoned by the Eye Top CSO topographer. As follows, we will now
present Zernike's analysis of the previous examples. In order to have a
direct comparison, we will present all the cases with the same pupil di-
ameter of 5 mm, the summary of the vision quality is reported without
the effect of the lower orders, and is therefore considered to be the best
potential vision that may be corrected with spectacles.

Figure 38. Zernike's analysis of the wave-front generated by the Figure 39. Summary of the visual quality relative to the previous case.
corneal surface in a case of herpetic keratitis.

24 The optical quality of the cornea



Figure 40. Aberrometric analysis of the wave-front generated by the Figure 41. Summary of the visual quality relative to the previous case.
corneal surface in a Lasik case to treat myopia with an optical zone
that is excessively small, excessively oblated and slightly decentered.

Normal cornea
Figure 36 reports the aberrometric analysis of the wave-front generated
by the surface of a normal cornea with slight with-the-rule physiologi-
cal astigmatism as we described above. With an entrance pupil of 5
mm, the regular astigmatic component (Zernike 2nd order) is 0.47 m
with axis at 13, corresponding to 0.95 D. The other components:
spherical aberration 0.13 m, coma 0.16 m and the sum of the other
high orders 0.09 m, are of minor significance and consent good vision,
as confirmed by the summary of vision quality (Figure 37).

Herpetic keratitis
In this case (Figure 38) the spherical aberration and the low orders, with
the exception of tilt (RMS 1.31 m), are irrelevant. However, the irregu-
larity of the corneal surface caused by the scars of keratitis produce a cer-
tain degree of coma (RMS 0.52 m) and other high order aberrations
(RMS 0.72 m). As shown in the summary of the visual quality (Figure 39),
this justified the poor quality of the best vision correctable with spectacles.

LASIK, small optical zone

The aberrometric analysis of the wave-front generated by the corneal sur-
face in the case of LASIK for myopia (Figure 40) underlines the poor qual-
itative outcome due to the excessively small optical zone of 4 mm, that is
excessively oblate, with the ablation center decentered 0.5 mm in an in-
fero-nasal direction with respect to the center of the pupil. The total aber-
ration of the corneal wave-front for a 5 mm pupil entrance in this case
has an RMS of 1.96 m, the regular astigmatic component (Zernike sec-
ond order ) is 1.33 m with the axis at 174, corresponding to 2.67 D.
The excessively small and excessively oblate optical zone in this case
has produced considerable multi-focal component with a wave

Antonio Calossi 25


Figure 42. Zernike's analysis of a PRK with a decentered and asym- Figure 43. Summary of the visual quality relative to the previous case.
metric optical zone.

spherical aberration of 0.96 m, corresponding to a longitudinal spher-

ical aberration (LSA) of +7.10 D. Decentering of treatment, even to a
minimum degree, associated with considerable negative eccentricity
and tilt (RMS 3.02 m), produced a significant coma component (RMS
0.92 m in the direction of 284). The higher orders, due to irregularities
of the curvature, in this case contribute 0.40 m. The poor qualitative re-
sult is confirmed by the summary of the visual quality (Figure 41).

Asymmetric PRK
In this case (Figure 42) the decentering and the vertical asymmetry with-
in the optical zone have produced an important coma component (RMS
1.35 m), which produces considerable asymmetrical defocus of the im-
ages, as can be seen in the summary of the visual quality (Figure 43).

Figure 44. Aberrometric analysis of the wave-front generated by the Figure 45. Summary of the visual quality relative to the previous case.
corneal surface treated by PRK with an excellent optical outcome.

26 The optical quality of the cornea

Excellent PRK
The aberrometric analysis of the wave-front generated by the corneal
surface in this case (Figure 44) shows an excellent result for a PRK treat-
ment of myopia of6.00. The smoothness of the treated surface, the
good symmetry and the good shape factor of this cornea have com-
bined to cerate an excellent aberrometric quality: all the components
are compatible with those of a normal cornea. The summary of the vi-
sual quality (Figure 45) underlines the excellent optic result of this treat-
ment.

In conclusion, we can state that the keratorefractive indices permit the

immediate and straightforward interpretation of the optical qualities of
the cornea, while Zernikes analysis of the video-keratographic data
permit the detailed examination of all the components of aberration in
the corneal surface.

Acknowledgements
We would like to thank Silvano Pieri, optical analyst of Officine Galileo, and
Alessandro Foggi, engineer, for the invaluable suggestions and enthusiastic col-
laboration that permitted the development of Zernike's analysis we described in
this chapter.

Appendix
(Silvano Pieri)
Let us consider a front F which crosses a surface of separation between
two media of refractive indexes n and n', and propagate up to the front
F'. If we create a perturbation in a given zone of the wave front that will
modify the optical path along the specific trajectory, it will cause a vari-
ation in the shape of the wave-front. This modification will propagate
with the wave and its maximum value, in terms of longitudinal varia-
tion (OPD) will remain unchanged for the entire propagation.
In figure A1, let us consider a wave that propagates through an optical sur-
face. Even if in this case both the surface and the wave are plan, the line
of reasoning is completely general and can be applied to any other shape.

The picture shows a front F which meets a surface of separation be- Figure A1. OPD propagation.
tween two media of refractive index n and n' will propagate as far as
the front F'. If we consider the perfect surface, the optical pathway OP0
along a ray between a point P on F and the corresponding point Q on
F' passing through the point of impact S on the surfaces, can be ex-
pressed as:

OP = PS n + SQ n (1)

If the surface contains a deformation of depth d at point S, the im-

pact of the radius will occur at the point S; with a few approxima-

Antonio Calossi 27
 tion, we can state SS = d:

OP0 = (PS + d) n + (SQ d) n (2)

The difference in the optical pathway OPD introduced by the deforma-

tion will be:
OPD = OP OP0 = d (n n) (3)

The presence of deformation means that point Q is no longer found on

the wave-front F, which will pass through the displaced point Q. That
is, the deformation of the surfaces produces deformation on the emerg-
ing wave F, which has an approximated value given by (3). As a result,
in an approximate manner, for a given surface deformation, the corre-
sponding of the wave-front error is obtained by multiplying by the dif-
ference of the refractive indices. For n = 1, the refractive index of the air,
and n = 1.376, the refractive index of the corneal tissue, we have n n
= 0.376, so if the maximum OPD allowed is 0.14 mm, the maximum de-
formation d of the corneal surface that can be considered. According to
Rayleigh's principle, perfect is 0.14/0.376 = 0.37 mm.

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