10/31/24, 10:37 AM How to interpret corneal topography: 5 clinical uses - EyeGuru

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HowEyeGuru
to interpret corneal
topography: 5 clinical uses
Angela Chen, B.S., Benjamin Lin, M.D., Shawn Lin, M.D.

*Note:* Technically, topography and tomography are different

imaging modalities (explained below). However, both are
colloquially referred to as topography. Except for our section
differentiating between them, we will also refer to both as
topography.

In this article, we will review what corneal topography and

tomography are, why they are useful, and how to interpret a
normal Pentacam scan. We will also review 5 clinical uses for
topography that will prepare you well for cornea clinic.

Topography vs. Tomography

This is the technical distinction between topography and
tomography:

1) Corneal topography is a non-invasive imaging technique for

mapping the surface curvature and shape of the anterior corneal
surface.

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10/31/24, 10:37 AM How to interpret corneal topography: 5 clinical uses - EyeGuru

How it’s done:

Placido disc (topography): Evaluates the cornea based
on the reflection of concentric rings (mires).
Widely spaced rings = flatter
Closely spaced rings = steeper
Devices: Orbscan, Atlas, NIDEK OPD

2) Corneal tomography computes a 3-D image of the cornea and

assesses the entire cornea, anterior and posterior surfaces.
Nowadays, tomography is most commonly used.

How it’s done:

Scheimpflug imaging (tomography): Evaluates the cornea
using a camera that captures cross-sections of the
cornea as it rotates
Devices: Pentacam, Galilei, Sirius

Utility
Management of astigmatism in cataract surgery and after
corneal transplant
Screening candidates for refractive surgery by identifying
irregular astigmatism and helping estimate postoperative
ectasia risk
Detection of ectatic disorders such as keratoconus, pellucid
marginal degeneration and post-LASIK ectasia

Determining visual significance of corneal and conjunctival

lesions, such as pterygia and Salzmann’s nodular
degeneration

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Guiding suture removal and placement of corneal relaxing

incisions

Basic Principles
Colored Maps: You will see a rainbow of colors on every
topographic map. These range from warm colors (red, orange,
yellow), to neutrals (green) to cool colors (blue, purple). On our
representative Pentacam images below, you will see four different
types of maps.

1) Axial map (top left)

Useful for assessing irregularity of astigmatism and
planning suture removal after PK
Warm colors = steep (think “steeping warm tea”)
Cool colors = flat
2) Corneal thickness, aka pachymetry map (bottom left)
Displays distribution of corneal thicknesses across the
entire measured area.
Warm colors = thin (think “in the heat wear thinner
layers”)
Cool colors = thick (think “in the cold wear thicker
layers”)
3) Anterior elevation map (top right)
Useful for assessing regularity of astigmatism, location of
astigmatism and surgical planning for AK, toric planning

Warmer colors indicate where the cornea is elevated

above the best fit sphere; cooler colors indicate where
the cornea is depressed below the best fit sphere

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4) Posterior elevation map (bottom right)

Useful for identifying forme fruste keratoconus
Warmer colors indicate where the cornea is elevated
above the best fit sphere; cooler colors indicate where
the cornea is depressed below the best fit sphere

Normal Cornea
Expected topography: Progressive flattening from center to the
periphery by 2-4D, with the nasal area flattening more than the
temporal area.

Interpreting Pentacam Values1

A) Anterior corneal values

K1, K2, Km: The two major meridians (K1, K2), determined

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using the 3mm ring, are 90 degrees from each other. Red
corresponds with the steep meridian whereas blue
corresponds with the flat meridian. Km is the average of K1
and K2
Rf, Rs, Rm: Radii corresponding with K1, K2, and Km,
respectively
QS: Quality score (I.e. “OK,” “Data gaps,” “Fix,” “Model”) may
alert the technician to retake the exam due to suspect quality
Q-val: Describes the corneal shape factor, or eccentricity of
the cornea. The ideal value is -0.26.
More negative values may suggest keratoconus or
hyperopic correction whereas positive values may
suggest myopic correction.
Axis: The meridian that requires no cylinder power to correct
astigmatism
Astig: The central corneal astigmatism
Rper: Average radius of curvature between the 6mm and 9mm
zone center
Rmin: Smallest radius of curvature in entire field measurement
Rmin may be elevated in keratoconus

B) Posterior corneal values

The same variables described for the front of the cornea are
used to characterize the back of the cornea.

C) Pupil center: Calculated by finding the center point based on

edge detection on the iris then the distance is calculated in mm

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Pachy apex: Corneal thickness at the apex

Thinnest Location: Thinnest point over anterior corneal
surface
K Max (Front): Steepest point over anterior corneal surface

D) Values used in IOL calculations (out of scope of this article)

5 Clinical Uses
1) Keratoconus

Topographic diagnosis of keratoconus is suggested by:

1. High central corneal power

2. Large difference between the power of the corneal apex and
periphery
3. Differences in steepness between the two corneas of a given
patient.

Expected topography: inferior steepening on anterior axial map

and corresponding thinning on pachymetry map. There are many
systems to grade keratoconus. Here are some examples of
various systems, but these are not necessarily the only criteria by
which to rule in or rule out keratoconus.

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Cutoff points for Keratoconus

Normal <47.2D

F F t K t 47 2 48 7D

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Forme Fruste Keratoconus 47.2-48.7D

Central K2
Keratoconus >48.7D

Inferior-superior
>1.2D
asymmetry index

Astigmatism >2.5D

≥35µm subclinical keratoconus

Orbscan II topography
≥51µm keratoconus
posterior elevation3

≥16µm subclinical keratoconus

Orbscan II topography
≥19µm keratoconus
anterior elevation3

Normal ≤+17µm
Pentacam Scheimpflug Suspicious +18µm to +20µm
corneal tomography

posterior elevation4 Risky >+20µm

Normal ≤+12µm
Pentacam Scheimpflug Suspicious +13µm to +15µm
corneal tomography

anterior elevation3 Risky >+15µm

2) Pellucid marginal corneal degeneration

Expected topography: against-the-rule “crab claw” or

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“butterfly” pattern on axial map

3) Astigmatism

Regular astigmatism: uniform steepening along a single corneal

meridian that can be fully corrected with a cylindrical lens (BCVA
of 20/20 or better)

Expected topography: symmetric “bow-tie” along a single

meridian

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Irregular astigmatism: nonuniform steepening that cannot be

corrected by cylindrical lens (BCVA of 20/50 or worse due to
irregular astigmatism).

Expected topography: steep and flat axes less or more than

90 degrees apart

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With-the rule astigmatism: Steeper in the vertical meridian

Against-the-rule astigmatism: Steeper in the horizontal meridian

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4) Refractive error

Myopia is associated with steeper central corneal curvature

Hyperopia is associated with flatter central corneal curvature

However, these are not hard and fast rules, as axial length
plays a big role in the overall myopia/hyperopia of the eye.

5) Refractive surgery

Preoperative assessment should be performed to rule out

ectactic (e.g. irregular) patterns, which occur in disorders like
keratoconus and pellucid marginal degeneration. If an ectactic

disorder is suspected, LASIK is not recommended.

Refractive surgery itself can induce corneal ectasia. In

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preoperative planning, percent tissue altered (PTA) is used to

estimate the risk of inducing a cornea ectasia. Generally, a
PTA < 40% is accepted as a lower risk in a normal eye.5

PTA = (FT + AD)/CCT

PTA: percent tissue altered; FT: flap thickness; AD: ablation

depth; CCT: preoperative central corneal thickness

Postoperative assessment is performed to evaluate any

dioptric changes at the corneal level and to rule out
decentered or incomplete ablation, ectasia or other changes.

Quick Tips for Clinic

Choose which post-keratoplasty suture to remove based on
the steep axis of astigmatism on topography. Removing
sutures along the steep axis leads to corneal flattening.
Candidates for Toric IOL will have regular symmetrical
astigmatism, appearing as a “bowtie” or “figure-eight” pattern
on topography (can be with or against-the-rule)
Keratoconus or pellucid eyes will have an irregular
astigmatism, often with inferior steepening and corneal
thinning,

Review Questions
1) Based on this patient’s topography, are they a candidate
for Toric IOL?

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for Toric IOL?

Answer: No, the topography shows irregular astigmatism.

Only patients with regular astigmatism are good
candidates for Toric IOLs.

2) Based on this patient’s topography post-LASIK, what

refractive error did they have prior to LASIK?

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Answer: This post-LASIK topography demonstrates central

corneal steepening (“steeping warm tea” reminds us that
warmer colors correspond with steeper corneal curvature).
Therefore, the patient was being corrected for hyperopia.

References:

1. Agarwal A, Agarwal A, Jacob S. Dr. Agarwal’s Textbook on

Corneal Topography (Including Pentacam and Anterior
Segment OCT), 2/E. Second ed. New Delhi, India: Jaypee
Brothers Medical Publishers (P) Ltd; 2010.
2. Rabinowitz YS. Videokeratographic indices to aid in screening
for keratoconus. J Refract Surg. 1995;11(5):371-9.
3. Jafarinasab MR, Shirzadeh E, Feizi S, Karimian F, Akaberi A,
Hasanpour H. Sensitivity and specificity of posterior and
anterior corneal elevation measured by orbscan in diagnosis
of clinical and subclinical keratoconus. J Ophthalmic Vis Res.
2015;10(1):10-15.
4. Tanuj D NM, Tarun A. New Investigations in Ophthalmology;

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10/31/24, 10:37 AM How to interpret corneal topography: 5 clinical uses - EyeGuru

2017.
5. Santhiago MR, Smadja D, Gomes BF, Mello GR, Monteiro
ML, Wilson SE, et al. Association between the percent tissue
altered and post-laser in situ keratomileusis ectasia in eyes
with normal preoperative topography. Am J Ophthalmol.
2014;158(1):87-95.e1.

12 Responses...

Michael Sibulo says:

April 16, 2020 at 7:50 am (https://eyeguru.org/essentials/corneal-
topography/#comment-1478)
Thank you doctors for creating this. I am an intern and hoping to apply for
ophtha thank you again.

Ben says:
April 18, 2020 at 2:34 pm (https://eyeguru.org/essentials/corneal-
topography/#comment-1479)
Glad you found it helpful Michael! Let us know if there are any
other topics you’d like us to cover.

Fred Feng says:

April 20, 2020 at 9:08 am
(https://eyeguru.org/essentials/corneal-
topography/#comment-1480)
Hello Ben. Thank you for this very helpful article.
Do you think if it would be possible to cover
“strabismus” in the future? Thanks!

Ben says:
May 15, 2020 at 8:30 am

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10/31/24, 10:37 AM How to interpret corneal topography: 5 clinical uses - EyeGuru

ay 5, 0 0 at 8 30 a
(https://eyeguru.org/essentials/corneal
-topography/#comment-1508)
Thanks for the feedback. Strabismus
can be extremely confusing for
beginners and is a great topic for us to
address. We’ll work on writing a
strabismus article soon!

Sheena S says:
April 20, 2020 at 10:19 am (https://eyeguru.org/essentials/corneal-
topography/#comment-1481)
Thank you, this was a great, concise summary!!

A H says:
October 20, 2020 at 7:10 am (https://eyeguru.org/essentials/corneal-
topography/#comment-1614)
Does the pentacam of Keratoconus show inferior steepening? I see a center
steepening.

Maurizio Fossarello says:

January 11, 2021 at 4:47 pm (https://eyeguru.org/essentials/corneal-
topography/#comment-1647)
Very good article! However I missed something, because I don’t understand
why steep values in sagittal map become depressed points in anterior
altitudinal map.
Intuitively, higher curvature should correspond to elevated points. Thanks for
the answer.

Aizal Manan says:

June 11, 2021 at 11:30 pm (https://eyeguru.org/essentials/corneal-
topography/#comment-1713)
Sorry for asking here 𝗜 𝗯𝗲𝗴 𝘆𝗼𝘂 𝘁𝗼 𝗮𝗻𝘀𝘄𝗲𝗿 𝗺𝗲 since I have asked a few

https://eyeguru.org/essentials/corneal-topography/ 17/20
10/31/24, 10:37 AM How to interpret corneal topography: 5 clinical uses - EyeGuru

Sorry for asking here. 𝗜 𝗯𝗲𝗴 𝘆𝗼𝘂 𝘁𝗼 𝗮𝗻𝘀𝘄𝗲𝗿 𝗺𝗲 since I have asked a few
experts in my country through online but they didn’t gave proper explanation.
Even my LASIK center ignore my question after getting my money.

I did LASIK (flap) for nearsighted. Now my SPH is 0 but CYL quite confusing.
At the LASIK center they said my CYL is 0.25 but at another eye glasses shop
they said 1.25

During the LASIK, my final package options are “Normal Full Correction” and
“Full Correction but based on area (they didnt tell me the actual term)”. The
later is more expensive but they said our eye power is actually not same on all
surface. Since your artical got the “map” image, I think my LASIK procedure
must be of of them.

After 1 month from LASIK, I still can see glare (or light streak) in dark room. I
didnt have this issue before LASIK and I believe my glasses back then is just
normal without CYL correction. The light streak quite long compare my wife
(we measure the light streak using ruler)

So could it be because I choose the more expensive procedure rather than

correct equally on all area (cheaper). Because I read astigmatism is caused
by irregular cornea shape.

Or could it be becuase its still new and I have to wait for 6 months.

But I more thing I found that my pupil is bigger than before. Even the eye
glasses shop said, “wow your eye is very clear like no cornea but your pupil is
very big”. Is there exist medicine/drop that can prevent pupil from betting too
big in dark room? I mean I want to limit the size to let say 5mm max but still
allow to shrink in light room.

Krushali Shah says:

July 19, 2021 at 7:07 am (https://eyeguru.org/essentials/corneal-
topography/#comment-1736)

hi, This is my brother’s report. What does it say? Can you please help?
This is the image link: https://ibb.co/j8JJh61 (https://ibb.co/j8JJh61)

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Lukas Mees says:

July 30, 2021 at 11:08 am (https://eyeguru.org/essentials/corneal-
topography/#comment-1740)
WOW what an article

Raul Membreno says:

May 2, 2022 at 8:39 am (https://eyeguru.org/essentials/corneal-
topography/#comment-1814)
Thank you for this article! It really helped me as I start my PGY-2
ophthalmology year.

Adibah Kaniz says:

September 23, 2022 at 6:53 am (https://eyeguru.org/essentials/corneal-
topography/#comment-1880)
Hello. Can I get the corneal topography image sample/dataset? I need those
for my project. Thank you

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