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SURVEY OF OPHTHALMOLOGY VOLUME 55  NUMBER 5  SEPTEMBER–OCTOBER 2010

HISTORY OF OPHTHALMOLOGY
MICHAEL MARMOR, EDITOR

Origins of the Keratometer and its Evolving Role


in Ophthalmology
Ron Gutmark, MD,1 and David L. Guyton, MD2

1
The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA; and 2The Wilmer Eye Institute, The Johns
Hopkins Hospital, Baltimore, Maryland, USA

Abstract. The keratometer, or ophthalmometer as it was originally known, had its origins in the
attempt to discover the seat of accommodation in the eye. Since that early beginning, it has been re-
invented a number of times, with improvements and modifications made in the original principles of
its design for new applications that arose as ophthalmology advanced. The cornea is not only
responsible for the majority of the refraction in the eye, but is also readily accessible for measurement
and modification. The keratometer’s ability to measure the cornea has allowed it to play a central role
in critical advances in ophthalmic history. This review describes the origins and principles of this
instrument, the novel applications that led to the keratometer’s continued resurgences over its nearly
250-year history, and the modern devices that have borrowed its basic principles and are beginning to
replace it in common clinical practice. (Surv Ophthalmol 55:481--497, 2010. Ó 2010 Elsevier Inc. All
rights reserved.)

Key words. astigmatism  contact lens  cornea  doubling mechanism  history  IOL
power calculation  keratometer  ophthalmic devices  ophthalmometer  refractive
surgery

Keratometer Development and Origins accommodation.68 Eventually, they concluded that


As early as the late 1700s, scientists attempted to no significant changes occurred, but maintained
develop techniques of measuring the cornea’s this notion as one of three mechanisms acting
curvature because of their interest in determining concurrently to allow accommodation of the eye:
the mechanism of visual accommodation. Jesse (1) change in the cornea’s radius, (2) change in the
Ramsden and Everard Home were among those distance between the crystalline lens and the retina,
who proposed that accommodation occurred pri- and (3) change in the shape of the crystalline lens.68
marily from changes in the cornea. To prove their In 1801, Thomas Young described experiments
theory, Ramsden and Home attempted to measure that he conducted on himself in an attempt to
its curvature. In 1779, after trying several designs, clarify which of the three mechanisms was actually
they settled on one that consisted of a telescope that occurring during accommodation. He wrote:
examined a doubled, reflected image in the I shall take the range of my own eye, as being
cornea.88 This enabled them to measure whether probably about the medium, and inquire what
the curvature of the cornea changed during changes will be necessary in order to produce

481
Ó 2010 by Elsevier Inc. 0039-6257/$ - see front matter
All rights reserved. doi:10.1016/j.survophthal.2010.03.001
482 Surv Ophthalmol 55 (5) September--October 2010 GUTMARK AND GUYTON

it [accommodation]; whether we suppose the


radius of the cornea to be diminished, or the
distance of the lens from the retina to be
increased, or these two causes to act conjointly,
or the figure of the lens itself to undergo an
alteration.126

Basic Principles and Early Designs


Early attempts at measuring the cornea relied on
rulers and compasses,122,126 but the accuracy of
these methods was not sufficient. The first impor-
tant step that led to the creation of the modern
keratometer was the realization that reflections of
objects in the eye could be utilized as an accurate
way to measure the corneal curvature. By treating
the cornea as a spherical convex mirror, one can
easily determine the radius of curvature of this
‘‘mirror’’ by employing the laws that govern re-
flections and the geometric relations of similar
triangles (Details in Appendix A).
The first task in designing the keratometer was to
measure the size of the reflected image of the object
on the cornea. This issue had already been addressed
by astronomers attempting to measure the sizes of
celestial bodies, such as the sun, and the distances
between stars by the use of two threads of a spider web Fig. 1. von Helmholtz’s original ophthalmometer. (a)
placed in the image plane of an astronomical von Helmholtz’s sketches of his ophthalmometer. (b)
telescope. These threads were then aligned with two Drawings of enclosure for glass plates used to double
points whose distance was being measured. In the image (vertical and horizontal cross sections).120 (c)
Sketch of the mires of the von Helmholtz ophthalmom-
mid-1800s, Kohlrausch and Senff119 applied this eter, illuminated from behind by candles.118
technique to the cornea; however, accurate measure-
ments were still difficult because of the constant (Fig. 2b and 2c). Because the doubled images move
movements of the eye and head. together, head or eye movements have an equal effect
The inaccuracies caused by these small movements on both and do not affect the measurement.
were addressed by optically doubling the image. This Therefore, the first keratometer was created on
idea was first employed in 1753 by Savary106 in the foundation of two fundamental principles: (1)
developing a heliometer to measure the apparent Assuming the cornea to be a spherical reflecting
diameter of the sun in apogee and perigee. To surface, the radius of curvature of the cornea can be
accomplish this, Savary adjusted the magnified, calculated from measuring the image produced by
doubled images of the sun in perigee (closest to the reflection in the cornea of an object of known
earth, larger image) so they touched, and later size and distance from the cornea. (2) An accurate
measured the distance needed to cause the images measurement of the image size, even with some
to touch when the sun was in apogee (farthest from movement of the eye, can be determined using the
the earth, smaller image). Ramsden88 borrowed this image-doubling concept. Following von Helmholtz,
concept to develop a keratometer in 1779. Seventy- others sought to improve upon it, but the basic
four years later, in 1853, Hermann von principles remained the same. Among subsequent
Helmholtz118,119 used the ideas of the astronomer designers, Louis Émile Javal and Hjalmar August
Clausen12 to create a keratometer that doubled Schiøtz deserve special mention. In 1881, they
images with two glass plates instead of prisms. In converted von Helmholtz’s original design, which
von Helmholtz’s design (Fig. 1), the two images are was primarily useful as a laboratory instrument, into
displaced from one another by tilting two movable a device that could be more easily used in clinical
glass plates (Fig. 2a) in opposite directions until the practice (Fig. 3).56 Their instrument included mires
extremities of the images touch one another. This illuminated from the front by candles, rather than
amount of displacement equals the size of the image trans-illuminated from behind, to create the
ORIGINS OF THE KERATOMETER 483

Fig. 2. (a) Diagram of von Helmholtz’s double-plate


setup, where a is the near plate, b is the far plate, c is the
image of the of the mire on the cornea, and c1 and c2 are
the doubled images of c, that the observer would see. (b)
Explanation of doubling principle: The displacement
required to move the second images so that it just touches
the primary image (x), is equal to the size of image (x). (c)
Representation of the doubling principle using mires of
the Bausch & Lomb Keratometer.

reflections from the cornea. This allowed the device


to be rotated around its axis to enable measure-
ments in multiple meridians.22
The creation of the von Helmholtz ophthalmom- Fig. 3. Javal-Schiøtz ophthalmometers. (a) Original Javal-
eter (keratometer) and the improvements thereaf- Schiøtz ophthalmometer using two candles to front-
illuminate two movable mires.8 (b) Later design of the
ter allowed ophthalmologists and scientists to use Javal-Schiøtz ophthalmometer using electric lamps for
the device for various applications, particularly the illumination of a printed protractor mire.16
quantitative measurement of corneal astigmatism,
which Thomas Young had described half a century
earlier. radius of curvature of both the anterior and posterior
faces (see Appendix B).
Mathematical methods exist for accurately calcu-
lating the refractive dioptric power of an optical
Keratometric Refractive Index system such as the cornea with two refractive
The keratometer provides the information neces- surfaces.30 However, the keratometer measures only
sary to determine the radius of curvature of the the radius of curvature of anterior surface of the
external surface of the cornea (see equation A.1 in cornea. Thus, calculations based only on the re-
Appendix A). Although this is a useful quantity for fractive index of the cornea and that of air will lead
the characterization of the shape of the cornea—and to over-estimation of the corneal power, as they will
has its applications, as we will see—ophthalmologists not consider the negative refractive power of the
were more interested in determining the power of the posterior corneal surface. Direct measurements of
cornea. To this end, it is necessary to convert radius of the corneal posterior surface are difficult, so in
curvature to power. This conversion can be per- order to correct for this error, it is necessary to
formed easily for a single spherical refracting surface, estimate the posterior corneal curvature based on
given the radius of curvature of the surface and the the curvature of the anterior surface. This is done by
indices of refraction on either side of the surface. assuming that the anterior and posterior surfaces of
Performing this conversion for a two-sided refracting the cornea relate to each other by a constant
element such as the cornea requires knowledge of the factor.23,24,78,79 This assumption has been shown to
484 Surv Ophthalmol 55 (5) September--October 2010 GUTMARK AND GUYTON

be accurate in the majority of eyes.30 Once the keratometers use the original 1.3375, American
constant factor is determined, the value of Optical chose 1.336, and Zeiss chose 1.332.78,79
the radius of curvature of the posterior surface of Others attempted to offer more accurate estima-
the cornea can be easily computed. The mathemat- tions of the keratometric index based on various
ical relationships for an optical system with two methods of calculation. Some of these values, and
refractive surfaces can be used to calculate the the methods of calculation, are summarized in
correct power, or alternatively, a ‘‘compensated’’ Table 1.
index of refraction for the cornea can be used,
which takes into account the constant relationship
between the two surfaces. This ‘‘compensated’’
index of refraction is known as the keratometric Improvements in the Design of the
index of refraction. Keratometer
The true index of refraction of the corneal stroma Over the years numerous additions and modifi-
is approximately 1.376.78,79 In order to account for cations have been made to the keratometer. The
the --5.00 to --7.00 diopter refractive power of the differences among most early keratometers were in
posterior surface of the cornea,21,65 there have the method of doubling and the method by which
historically been a number of different values of the images of the mire(s) were aligned with one
the keratometric index used. Based on the reduced another.114
schematic eye of Listing,67 von Helmholtz consid- There are two basic ways of adjusting the
ered ‘‘the whole corneal system . . . as a lens like alignment of the mire images:
a watch-crystal surrounded by aqueous humor on
both sides,’’ and ‘‘consequently, we may just as well 1. Doubling apparatus remains fixed and mire
consider the aqueous humor as extending clear out location is varied.
to the anterior surface of the cornea.’’118,119 He 2. Doubling apparatus is variable and mire loca-
went on to say that, ‘‘this assumption is . . . almost tion is fixed.
necessary for the reason that, while the measure- Since the introduction of the first keratometers,
ments of the outer surface of the cornea are basic keratometer designs have employed variations
accurate enough, the data with respect to the inner on one of these two principles. The original von
surface are not sufficiently reliable.’’118,119 von Helmholtz model employed variable doubling
Helmholtz used the value of 1.3365118,119 as the where the position of the two mire images is
keratometric index. Later, Javal and Schiøtz used adjusted by changing the position of the doubling
1.337, which they ascribe to a value determined by device, while the mires remain stationary.
Ludwig Mauthner.52 Subsequently, Javal used a value When it was introduced, the Javal-Schiøtz oph-
of 1.3375 because, according to Marius Tscherning thalmometer incorporated a fixed doubling device,
(who worked in the same laboratory as Javal), it in which the doubling device is stationary, while the
allowed for an expedient calculation of 45 D, given mire separation is adjusted. In order to adjust the
a radius of curvature of 7.5 mm (see equation B.1 in alignment of the images in a fixed doubling device,
Appendix B).116,117 the size of the object must be changed. This can be
Although this was the original proposed kerato- done in a number of ways such as by moving the
metric index, other values were proposed later by keratometer mires laterally (Javal-Schiøtz ophthal-
various clinicians and scientists and by the manu- mometer)55 or by employing an iris diaphragm in
facturers of different keratometers. For example, the plane of the object to reduce the object size
whereas the Haag-Streit and Bausch & Lomb (Reid portable ophthalmometer).90,114

TABLE 1
Estimations of the Keratometric Index of Refraction
Estimated
Source Keratometric Index Source of Calculation
45
Ho et al 1.3281 Rotating Scheimpflug camera (Pentacam, Oculus) (221 subjects)
Dunne et al23 1.3283 Purkinje image reflection from anterior and posterior corneal surfaces
(80 subjects)
Dubbelman et al21 1.329 Scheimpflug imaging of anterior and posterior curvature (114 subjects)
Edmund24 1.3300 Photokeratoscopy and pachymetry
Olsen et al79 1.3315 Gullstrand’s exact schematic eye
Fam et al30 1.33273 Orbscan II (Bausch & Lomb) measurements of anterior and posterior
curvature (2429 subjects)
ORIGINS OF THE KERATOMETER 485

The manner in which doubling is accomplished The other method of adjusting the alignment of
was also an important distinction between early the mire images in a fixed-doubling ophthalmom-
ophthalmometers. The Javal-Schiøtz ophthalmome- eter is to employ an adjustable iris diaphragm as the
ter, for instance, was the first to incorporate object. Thomas Reid devised a portable ophthal-
a Wollaston prism for doubling. This prism’s mometer based on this principle (Fig. 5). This
birefringence properties create two equally intense portable ophthalmometer was positioned so that the
diverging light paths, differing only in their iris diaphragm (D) was directed toward an external
polarization.56,87 light source. This light passing through the iris
Among the first to produce a Javal-Schiøtz style diaphragm was directed toward the patient’s eye by
ophthalmometer were Pfister and Streit (later to a beam splitter prism (P), and would be seen as
become Haag-Streit, who have since produced a disk reflected from the patient’s cornea, whose
a number of Javal-Schiøtz style ophthalmometers) image was doubled with a Wollaston prism (BP).90
(Fig. 4a,c,e). At approximately the same time Ophthalmometers employing variable doubling
(1888), Leroy and Dubois devised an ophthalmom- were developed in parallel to the fixed doubling
eter that was a hybrid of the Helmholtz and Javal- instruments described earlier. In 1899, the
Schiøtz instruments (Fig. 4b). This ophthalmometer Chambers-Inskeep ophthalmometer was introdu-
used two glass plates to create the doubling effect as ced.E It was based on the von Helmholtz model
in von Helmholtz’s device, but was a fixed doubling design with stationary mires and varied doubling by
instrument with movable mires like the Javal-Schiøtz moving the doubling apparatus (prisms) longitudi-
device. This device was said to be more accurate nally (Fig. 6). Doubling in this ophthalmometer was
than the original Javal-Schiøtz device and was also achieved using two weak prisms with their apices in
‘‘considerably cheaper.’’4 Subsequent models of the opposite directions, as proposed by Landolt
Javal-Schiøtz style ophthalmometer maintained the (Fig. 6b).29 This ophthalmometer was the fore-
fixed doubling principle and have remained largely runner of the American Optical ophthalmometers.
unchanged, even retaining the same mire design Soon after Chambers and Inskeep introduced
(Fig. 4c--e). their ophthalmometer, John Sutcliffe devised an

Fig. 4. Javal-Schiøtz--style ophthalmometers. (a) Pfister-Streit (1894). (Haag-Streit Company Archive, Koeniz, Switzer-
land). (b) Leroy-Dubois (1888).66 (c) Haag-Streit (1950). (Haag-Streit Company Archive, Koeniz, Switzerland). (d ) Topcon
OMTE-1. (www.rimc.net). (e) Haag-Streit OM-900 (1997). (Haag-Streit Company Archive, Koeniz, Switzerland).
486 Surv Ophthalmol 55 (5) September--October 2010 GUTMARK AND GUYTON

axis of the instrument, instead of the perpendicular


cylindrical lenses being decentered transverse to the
axis that Sutcliffe used, in order to create the
variable doubling effect in perpendicular directions.
This keratometer (Fig. 8a), also borrowed an optical
arrangement used in the Sutcliffe ophthalmometer,
known as the Scheiner disc principle, to improve
focusing accuracy and thus improve the adjustment
Fig. 5. Reid’s portable ophthalmometer. The illuminated of the testing distance. The Scheiner disc arrange-
aperture itself in the iris diaphragm (D) serves as the mire. ment creates a slightly doubled central image of the
The object size is thus varied by adjusting the iris mire when the instrument is at the wrong distance
diaphragm.90 from the cornea and is not focused appropriately.87
Although the keratometer’s general design and
ophthalmometer that would allow measurements of principles remained the same, a number of
both perpendicular meridians of the cornea simul- variations on the original concept emerged over
taneously. The Sutcliffe ophthalmometer (Fig. 7a), the years. Some variations were made to address
invented in 1906,114,A introduced a novel method of difficulties in focusing the keratometer mires,
doubling the image of the mire using two movable which led to error in the proper distance of the
perpendicular cylindrical lenses, each flanked by mires from the eye. The Bausch & Lomb keratom-
two stationary cylindrical lenses. Prism effect could eter, for example, as noted earlier, employs the
then be introduced independently in perpendicular Scheiner disk principle to improve focusing accu-
directions by decentering the respective movable racy and thus improve the adjustment of the testing
cylindrical lenses (Fig. 7b). This type of ophthal- distance.87 Another method to reduce focusing
mometer is referred to as a ‘‘one-position ophthal- error is the use of collimated mires, as employed in
mometer’’ because it does not have to be rotated the Zeiss telecentric ophthalmometer, which elim-
between measurements of the two principal merid- inates the change in magnification that would
ians. The mire design and one-position principle otherwise accompany errors in testing distance
were subsequently adopted for the Bausch & Lomb-- from the eye.B
style keratometers (Fig. 8b). Other design variations improved the keratome-
The Bausch & Lomb--style keratometers employ ter’s ease of use, particularly for pediatric applica-
horizontal and vertical prisms that move along the tions. Performing keratometric measurements in
pediatric patients can be difficult because of the
requirement that the patient remain relatively still at
a fixed distance from the device. Automated
keratometers increase the speed with which accurate
measurements can be taken.77 Hand-held keratom-
eters eliminate the need for head fixation and can
be operated by only one hand.125 Hand-held
keratometers also facilitate measurements in the
operating room,2 useful in children who are un-
willing to cooperate in the office124 or for ongoing
assessment of corneal astigmatism during cataract or
corneal surgery.3,70,74,105

Utilization of the Keratometer during the


Major Eras in Ophthalmology
THE ERA OF OPTICS AND REFRACTION, AND
ASTIGMATISM
Fig. 6. Chambers-Inskeep ophthalmometer. (a) Patient In addition to examining the mechanisms of
and examiner views of the Chambers-Inskeep ophthal-
mometer (1899).32 (b) Detail of eye-piece (10) and accommodation, Young’s experiments in 1801 also
doubling prisms (h) of the Chambers-Inskeep led to the discovery of astigmatism of the eye. He
ophthalmometer.E described that particular experiment as follows:
ORIGINS OF THE KERATOMETER 487

Fig. 7. Sutcliffe ophthalmometer. (a) Drawing of Sutcliffe ophthalmometer.114 (b) Mire design of Sutcliffe
ophthalmometer (Sutcliffe reports borrowing this mire design from Rudyard Kipling’s monogram).114

I take.a double convex lens. fixed in him to conclude that his astigmatism must have
a socket one-fifth of an inch in depth.I drop been located primarily in his crystalline lens.126
into it a little water.till it is three-fourths full, Soon after Young’s discovery, others described
and apply it to my eye, so that the cornea.is corneal astigmatism, including Gerson, Wilde, and
everywhere in contact with the water. My eye Jones, but their descriptions were not based on any
immediately becomes presbyopic, and the ophthalmometric measurements.8 It was not until
refractive power of the lens.is not sufficient 1846 when Senff made measurements of the cornea
to supply the place of the cornea, rendered with a spider web apparatus, as described previously,
inefficacious by the intervention of the water; that corneal astigmatism was proven quantitatively.
but the addition of another lens.restores my Upon measuring the cornea for the first time, it was
eye to its natural state, and somewhat more.I immediately apparent to Senff that the cornea was
find the same inequality in the horizontal and not spherical in cross section as the keratometric
vertical refractions as without the water.126 equations had assumed.18,118,119 Rather, it was an
ellipsoid. Following Senff, others such as Knapp and
His experiment showed that immersion in water,
Donders18 made further measurements and showed
which neutralized the refraction of his cornea, did
that the cornea was indeed an ellipsoid with an
not correct his astigmatism (i.e., the difference in
elongated horizontal meridian. Also, their measure-
the horizontal and vertical refractions), which led

Fig. 8. ‘‘One--position’’ keratometer. (a) Bausch & Lomb keratometer. (www.pemed.com). (b) Mire design of Bausch &
Lomb keratometer.
488 Surv Ophthalmol 55 (5) September--October 2010 GUTMARK AND GUYTON

ments demonstrated that astigmatism primarily, but ments. At the time, it was thought by some that the
not exclusively, arose in the cornea, contrary to what reason for this was that the patient could not
Young had initially described.126 tolerate seeing so clearly. In reality, one of the
In 1827, shortly after Young’s discoveries, a British reasons for this discrepancy, alluded to ealier, is that
astronomer, George Airy, detected his own astigma- the keratometer measures the amount of astigma-
tism after noticing that he often did not use his left tism at the corneal plane. Therefore, the vertex
eye, but when he did, circular objects appeared oval distance of spectacle lenses would need to be
to him. He determined that a spherocylindrical lens accounted for. For example, in an aphakic eye,
would correct this defect and commissioned the 2.00 diopters of astigmatism at the cornea is
production of such a lens.1 properly corrected by a cylinder of approxi-
Because it was now known that astigmatism mately1.50 diopters of power in the spectacle plane.
primarily arose in the cornea, it was not a far leap Additionally, the keratometer uses only small areas
for ophthalmologists to begin using the keratometer of the cornea for the measurement, smaller than the
to aid in refraction by determining the correction average pupil. The measurements obtained, there-
needed for astigmatism. The idea of using the fore, may not be representative of the average
keratometer to measure the necessary correction for refraction across the pupil. Other reasons for the
astigmatism was incorporated into the design of difference between the keratometrically measured
Javal and Schiøtz’s keratometer. The mires on their astigmatism and the subjective refraction include
keratometer (Fig. 9) constitute two rectangles, one error due to the contribution of the posterior
divided in the middle by a line and the second surface of the cornea, as well as the presence of
having staggered steps removed from one edge. lenticular astigmatism.3
Javal and Schiøtz designed their instrument so Different ‘‘rules’’ were proposed to adjust the
that each step was 5 mm wide, which when amount of astigmatism measured by a keratometer
calculated with the parameters of their keratometer to best correlate with values obtained by subjective
is the width that corresponds to 1 diopter of corneal refraction.55,3,29 The best known of these rules is
astigmatism. By properly aligning the mire images in Javal’s rule,55 shown in equation 1.3,26
each principal meridian, the amount of corneal
AstigmatismTotal 5 pðAstigmatismCorneal Þ þ k ð1Þ
astigmatism could be read directly from the number
of steps of overlap of the mire images. It is
Javal chose p to equal 1.25 to adjust for the vertex
important to note that as Weiland points out, Javal
distance of the spectacle lenses, and k to equal 0.50
and Schiøtz’s calculation of a 5 mm step size to
D (against the rule) to account for a supposed
correlate with 1 diopter of corrective cylinder is
average lenticular astigmatism.26 Javal’s rule has
misleading, as it is valid only when the corrective
many exceptions. For example, the p value of 1.25 is
spectacle lens is placed in contact with the eye,
more appropriate for astigmatism accompanying
which at the time was not possible.122
myopia than accompanying hyperopia.
Ophthalmologists quickly realized that because
Despite the accuracy and ease with which the
the majority of astigmatism arose in the cornea, the
keratometer was able to measure the curvature of
keratometer would be a powerful tool in refraction
the cornea, it could not be depended upon solely,
by determining the orientation and power of
and subjective refraction with an optometer and/or
astigmatism, thus yielding the cylinder and axis
trial lenses remained necessary for best accuracy.122
portions of the refraction. In spite of these facts,
Edward Jackson wrote about the use of the
there were several features of the keratometer that
keratometer for refraction. He stated that the
would lead to patients rejecting correcting cylinders
keratometer approximated the corneal astigmatism
that were based directly on keratometry measure-
and:
in the majority of cases the ’approximation’ is
not so close as may be rightfully demanded of
the ophthalmic surgeon . . . and that in
exceptional cases . . . the difference between
the corneal and total astigmatism is so great
that the former can hardly be regarded as in
any proper sense a guide to the latter . . . What
it does, then, places it clearly among the
Fig. 9. Stepped and solid mires of Javal and Schiøtz approximate tests. But among such tests the
ophthalmometer.15 Each step on the stepped mire was definiteness with which it indicates what it
designed to represent 1 diopter of astigmatism. does indicate, the fact that its indications are
ORIGINS OF THE KERATOMETER 489

entirely objective, and the rapidity with which a ‘‘contact lens’’ was an enlarged model of the eye
they may be obtained, all give it high rank . . .52 that was filled with water. He would place his eye in
the model as part of his experiments in an attempt
As mentioned previously, lenticular astigmatism
to explain why the world was not seen upside-down
was considered to be a problem, as it could not be
as expected based on the optics of the eye. There is
accounted for with this device. This disadvantage for
no evidence, however, that Leonardo had intended
the normal eye, though, was not present with the
to create a contact lens.27 René Descartes was the
aphakic eye. Because the crystalline lens was no
first to propose a device that had contact with the
longer present, any astigmatism in the aphakic eye
eye to correct refractive errors.17,28 His ‘‘contact
could be attributed to the cornea. This, as Weiland
lens’’ consisted of a tube, open at one end with
remarks, led to ‘‘the ideal field for keratometry.’’122
a lens mounted at the other end, which was to be
Jackson wrote of ‘‘the scientific value of the simple
filled with water and placed in contact with the eye.
determination of the corneal astigmatism, and of its
Herschel in 183043 and Fick in 1888 were the first to
practical value in the determination of astigmatism
describe afocal contact shells.34 August Müller was
in the aphakic eye, either of which amply justify its
the first to describe a powered contact lens in
routine use.’’52
1889.81 With the introduction of modern-type
Despite this theoretical advantage of keratometry
plastic corneal contact lenses by Tuohy in 1950,C
in the aphakic eye, the other inaccuracies remain,
contact lenses ‘‘evolved from an optical curiosity
and one in particular—the vertex distance
into a widely accepted visual aid.’’110
problem—is significant.
Early in the development of glass contact lenses
As a plus corrective lens is moved away from the
there appeared to be a major problem: contact
eye, less plus power is needed to maintain the same
lenses that were ground, as those described by
correction. In other words, changing the spectacle
August Müller, were uncomfortable and could not
vertex distance can have a substantial effect on the
be worn for an extended period of time,14,75,81
effective power of a correcting lens. Equation 2, an
whereas contact lenses that were blown, as those
approximation, illustrates this point.
produced by F. A. Müller, were comfortable and
D z D2d ð2Þ could be worn continuously for extended periods of
time. But the latter were of unknown power. Fitting
Where D is the change in power due to vertex was generally done with trial sets or by making
distance change, D is the power of the lens, and molds of the eye.14 Joseph Dallos was a major
d the distance the lens moves (in meters). As can be proponent of fitting contact lenses by taking molds
deduced from this formula, aphakic eyes, which of the eye, and he perfected this technique.14 As
require very high power lenses (large D), will be contact lenses gained popularity and acceptance,
even more susceptible to error due to a change in the keratometer gained a new application. By 1936,
the vertex distance of the spectacle lens. When in his textbook Visual Optics, Emsley had already
astigmatism is present accompanying aphakia, the written that ‘‘when fitting some contact glasses.the
refraction in the two principal meridians changes by keratometer is definitely necessary.’’27
different amounts with changes in vertex distance, The keratometer found a number of different
leading to significant changes in the power of roles in contact lens management. These included
correcting cylinder needed. It became common the fitting of the contact lens, monitoring changes
wisdom to reduce the power of the cylinder for an (of the cornea and of the contact lens), and
aphakic eye, as determined by the keratometer, by ensuring accurate parameters of the finished con-
one-fourth to one-third, before prescribing it, so tact lens.104
that the patient could ‘‘tolerate’’ it. In actuality, the The fitting of contact lenses requires the de-
power decrease was necessary to provide the correct termination of several parameters to ensure an
cylinder at the spectacle vertex distance! effective lens and comfortable fit. These parameters
This vertex distance problem was eventually un- include the base curve and diameter of the contact
derstood. By that time, however, the lens could be lens, as well as the refraction and the amount of
placed directly in contact with the eye. Corneal corneal astigmatism.35 Base curve refers to the
contact lenses had been invented. radius of the spherical back surface of the contact
lens. Because the keratometer measures the curva-
THE ERA OF CONTACT LENSES ture of the anterior corneal surface, which is the
Numerous versions of ‘‘contact lenses’’ were surface that will be adjacent to the posterior lens
proposed since the 15th century. Leonardo da Vinci surface, it is perfectly suited for determining the
is often credited with describing the first contact proper base curve. The appropriate lens diameter
lens.14,75,81,110 What is referred to as his design for can also be estimated from the keratometric
490 Surv Ophthalmol 55 (5) September--October 2010 GUTMARK AND GUYTON

readings by employing a nomogram created by Dyer, correction near the anterior focal point. Soon
based on the measurements of a large series of additional formulas were derived, some based on
patients.3 Measurement of the shape or toricity of optical theory (e.g., Haigis, Holladay I, Hoffer Q),
the corneal surface is also achieved by the kera- whereas others were empirically based regression
tometer and is vital in choosing a properly fitting formulas (e.g., SRK/I, SRK/II, Binkhorst),112 and
contact lens. Depending on the toricity of the still others applied empirical data to theoretically
cornea, different lens designs may be selected derived formulas (e.g., SRK/T).92
(e.g., spheric, aspheric, bitoric).25 A precise determination of corneal radius is of
As contact lenses became more popular and the vital importance for the accuracy of the IOL power
technology improved, it became more and more formulas. Of the relevant optical variables, an error
important to obtain accurate measurements of in corneal radius can have a tremendous effect on
a larger area of the cornea. The keratometer in its postoperative refractive error, as seen in Table 2.
original configuration could only measure approx- Following corneal refractive surgery, the measure-
imately 2.5 mm of the central cornea.113 As contact ment of corneal radius and the calculation of
lens diameters extended beyond this range, clini- desired IOL power are complicated by additional
cians became interested in ways to extend the factors.
capability of the keratometer. Several methods of As discussed previously, the accuracy of the
measuring the periphery of the cornea were pro- keratometer relies on several assumptions regarding
posed, thus allowing further study of the cornea as the normal cornea. These assumptions, although
well as affording the ability to construct a crude not entirely accurate, had usually been sufficient for
topographical map of the entire cornea. Some clinical purposes. Once the cornea becomes abnor-
clinicians made peripheral measurements of the mal by disease or surgical intervention, however,
cornea with the ordinary keratometer by altering these assumptions become even less applicable, and
the fixation of the subject, with eccentric fixation errors in measurement increase. Because calcula-
targets in the plane of the mires.123 Others created tions of IOL power require knowledge of the
devices with small single mires6 or reduced mire corneal power, accurate keratometric measurements
separation69,104 that could allow for examination of are essential. As discussed previously, calculations of
small areas on the peripheral corneal surface when corneal power are based on the radius of curvature
combined with fixation targets that guided the of the cornea. Without direct measurement of the
subject to look to the side. However, these small- posterior corneal surface, the conversion from
mire keratometers suffered from decreased pre- radius of curvature to a dioptric power relies on
cision because the decreased movement of the mires estimations and adjustments that are necessary
reduced the precision of measurements.20 because only the anterior corneal curvature is
measured. Because these corrections are based on
a normal corneal shape and on a normal ratio
THE ERA OF INTRAOCULAR LENS IMPLANTATION between the anterior and posterior corneal surfaces,
AND REFRACTIVE SURGERY any alteration in this configuration can introduce
With the advent of intraocular lens (IOL) error into the calculations. Refractive surgeries such
implantation and later refractive surgery, keratom- as radial keratotomy (RK), photorefractive keratec-
etry found new applications and new challenges. tomy (PRK), and laser-assisted in situ keratomileusis
When IOL implantation surgery was initially (LASIK) alter the form of the normal cornea to
introduced, surgeons implanted IOLs of a standard achieve specific refractive outcomes. Because of
power. It was soon realized that IOL power should these changes, measurement of the cornea with
be calculated in order to obtain more precise post- keratometry and other corneal biometry techniques
surgical results. Various formulas were presented by such as corneal topography became problematic.
a number of clinicians and visual scientists including
Binkhorst,5 Colenbrander,13 and Le Grand.65 These TABLE 2
formulas required several ocular measurements Refractive Error as a Function of Various Ocular
such as corneal power, anterior chamber depth, Measurements
and axial length of the eye. Corneal power was
measured by the keratometer, anterior chamber Variable Error Rx error
depth was determined by a slit-lamp attachment, and Corneal radius 1.0 mm 5.7 D
axial length was measured by ultrasound. In an Axial length 1.0 mm 2.7 D
aphakic eye, measurement of the axial length could Postoperative anterior 1.0 mm 1.5 D
chamber depth
also be calculated using the keratometrically
determined corneal power and the aphakic spectacle Data from Olsen.79
ORIGINS OF THE KERATOMETER 491

With RK, radial slits are made in the mid-peripheral This method is accurate,47,48,49,101,111 but requires
cornea. Normal intraocular pressure causes these the availability of precise pre-surgical keratometry
weakened areas to bulge, resulting in a flattening of and refractive error.57 A number of other methods
the central cornea (Fig. 10a). Errors in RK result that require a variety of pre- and post-refractive
because standard keratometric measurements co- surgery data have been proposed.31,39,53,64,100,102,111
incide with the location of the newly formed Other methods that require knowledge of clinical
transition zone, where the flat central cornea begins history aimed at adjusting the index of refraction to
its transition into the peripheral cornea. As this area is make it more accurate following refractive sur-
steeper than the central cornea, keratometric mea- gery.10,54,62,63,96,99,101,102 When preoperative mea-
surement is unreliable.112 Although RK results in surements are not available, or when it is uncertain
changes to the shape of the cornea, this procedure whether they were accurate and stable, methods not
does not significantly alter the thickness of the central requiring knowledge of clinical history are needed. A
cornea, nor the ratio of the anterior surface to number of such methods have been proposed,
posterior surface radii of curvature.41 In PRK and including the contact lens method,94,109 methods
LASIK, on the other hand, both the thickness of the that employ post-operative topography or keratom-
cornea and the ratio of the anterior to posterior radii etry data,33,38,60,95,98,103,107 a method that relies on
of the cornea change (Fig. 10b).44,76,112,121 These postoperative pachymetry,36 and methods relying on
changes in the cornea result in overestimation of new ocular scanning devices such as the Pentacam
corneal power in RK, PRK, and LASIK, which leads to (Oculus, Inc., Wetzlar, Germany)7 or Orbscan II
undercorrection with subsequent cataract and IOL (Orbtek, Bausch and Lomb, Salt Lake City, UT,
surgery.89,96,100,101,102,112 To overcome these inaccur- USA).11,85
acies with keratometry after refractive surgery, various
methods have been devised to estimate corneal power
(see Hoffer46 for a more complete review). These
methods include: (1) performing calculations based Transition to Modern Techniques of
on known dioptric power values (such as pre- or post- Keratography
operative refraction), thereby circumventing the Although devices to measure corneal power and
need to convert the radius of curvature of the cornea corneal topography have only recently become
to a dioptric power value; (2) adjusting the conver- commonplace in ophthalmology clinics, the origin
sion factor (index of refraction) by estimating the for many of these dates back to the late 1800s. Many
change that will occur between the anterior and of these new devices are based on the Placido disk
posterior corneal surfaces; and (3) taking direct principle. In 1880, Antonio Placido described the
measurements of the posterior corneal surface.57 use of a disk painted with alternating black and
The first such method, often referred to as the white rings, with a hole in the center equipped with
spherical equivalent change method112 or clinical a plus lens for the examiner to look through
history method,47 was published by Guyton37 and (Fig. 11).83,84
Holladay50 in 1989 and was initially intended for eyes The reflection of these rings from the front
after RK. It proposed subtracting the change in the surface of the patient’s cornea gave the examiner
spherical equivalent due to the refractive surgery a qualitative assessment of the contour of the
from the power measured by the keratometer pre-RK. cornea. Placido employed this technique, took

Fig. 10. Changes in cornea induced by RK and PRK/LASIK. (a) Removal of corneal tissue in PRK and LASIK results in
decreased corneal thickness and change in ratio of anterior to posterior corneal radii of curvature. (b) Bulging of mid-
peripheral cornea in RK results in flattening of central cornea, with no change in corneal thickness or ratio of anterior to
posterior corneal radius of curvature.
492 Surv Ophthalmol 55 (5) September--October 2010 GUTMARK AND GUYTON

photographs of the reflections, and later calculated other modern devices is their ability to measure the
the radius of curvature of the cornea using these posterior corneal surface accurately and directly.
images, or compared the images to images reflected The first commercially available device that
by spheres of known radius.51,120 This was a very allowed measurement of the posterior corneal
effective means of describing the corneal surface, surface was the Orbscan (originally from Orbtek,
but calculations were difficult, and comparisons Inc., currently from Bausch & Lomb).108,115 This
were time-consuming. Although other improve- device employed a scanning-slit technique for its
ments were attempted, the method employing the measurements. Optical slit-scanning uses a number
Placido disk would not allow for easy quantitative of slit light beams that scan the cornea. The two-
measurements as were available with the keratom- dimensional images of the cross-sections of the
eter. The advent of computers, however, enabled cornea illuminated by the slit beam are captured by
efficient application of the Placido disk method. a camera and processed to obtain a topographical
The first device to incorporate computer technol- map of the cornea. Newer scanning-slit systems
ogy to automate the use of the Placido disk for (Orbscan II, Bausch & Lomb) combine a Placido
performing corneal topography was the photo- disk with scanning-slit techniques to take advantage
electronic keratoscope described by Reynolds and of both technologies.9,58
Kratt in 1959.93 In 1981, the corneascope, a new, Another modern keratometric technique that
more advanced version of the photo-electronic allows for direct measurement of the posterior
keratoscope, was introduced.19,97 Automation of corneal surface is Scheimpflug photography, em-
keratoscopes allowed keratometric measurements ployed in the Pentacam (Oculus, Inc.) and GALILEI
to be taken rapidly, and this ability, combined with (Zeimer Group, Port, Switzerland).45 This relies on
the application of this technology to handheld the Scheimpflug principle, which describes the
devices40,42,61 allowed for improved measurement geometry necessary to produce focused images
of the cornea in children.42,61,77 when the planes of the image, lens, and object are
Recently, more sophisticated devices and tech- not parallel with each other (see Maus et al71 for
niques have been introduced and have the potential a complete description). An arrangement of the
of replacing the traditional keratometer in clinical three planes according to this principle results in
practice. These include videokeratography, optical a larger focal depth than can normally be achie-
coherence tomography, slit-scanning Scheimpflug ved.21,71,72,73,D This allows the camera to create
photography, and very high frequency ultrasound. a three-dimensional model of the anterior segment
The primary advantages of the newer techniques are of the eye. Using the resulting measurements of the
automation, the extended area of measurement, and thickness of the cornea, the software is able to
increased accuracy. Currently there are a number of calculate topographical and power maps of the
videokeratography devices that rely on the Placido cornea.
disk principle, use computer-based calculations, and Very high frequency ultrasound, originally used in
display color-coded maps of corneal power.59 metallurgy, has since been adapted for use in
Although the Placido-disk-based devices are use- corneal imaging.91 This technology, employed by
ful, they only measure the anterior corneal surface. Artemis (ArcScan, Inc.), allows for direct visualiza-
Therefore, in order to calculate total corneal power, tion and measurement of the posterior cornea and
various assumptions must still be made regarding the unique ability to generate 3-dimensional maps
the relationship between the anterior and posterior of individual corneal layers. This can be very useful
corneal surfaces. One of the primary advantages of in the planning of corneal refractive surgery, as well
as in the monitoring of post-surgical results.91
Comparative features of the different types of
modern keratometry devices and those of the
standard keratometer are presented in Table 3.

Conclusions
From its early origins in the study of the
mechanism of accommodation, the keratometer
has repeatedly found new applications as ophthal-
mology has advanced. Its ease of use for the
Fig. 11. Placido disk. Example of hand-held device refraction of the cornea has contributed to its
described by Placido (www.phisick.com). success in diverse applications over generations.
ORIGINS OF THE KERATOMETER
TABLE 3
Characteristics of a Selection of Corneal Biometry Techniques
Year First Described (Year first Maximum Points Measured
Technology commercially available) (typical operation may be less) Advantages Limitations
88
Keratometer 1779 4  Easy to use  Limited area of
 Inexpensive measurement
Placido disk 188084 N/A  Peripheral corneal  Extrapolates central cor-
measurement neal data
Scheimpflug photography 198572 (200486) 25,00086  Direct measurement of  Difficult to measure small
posterior corneal surface changes in central cornea
 Visualization of anterior  Image distortion due to
chamber structures Scheimpflug principle
 Large depth of focus71 must be compensated by
computer71
Very high-frequency 199080 12,288 scan linesa  Direct measurement of  Decreasing field of view
ultrasound posterior corneal surface with increasing resolution
 Mapping of individual  Requires experienced
corneal layers and anterior examiner82
chamber91
 Optical opacities do not
affect measurements82
Optical slit-scanning 1995108 (199942) 9,60058  Direct measurement of  Generation and detection
posterior corneal surface9 of sufficiently narrow slit
 Non-contact imaging for accurate measure-
 Anterior segment ments difficult to achieve
imaging58  Corneal haze affects
measurements9
a
Maley P. Artemis information [online]. E-mail from Patrick Maley, CEO Arcscan Inc, 28 July 2009.

493
494 Surv Ophthalmol 55 (5) September--October 2010 GUTMARK AND GUYTON

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ORIGINS OF THE KERATOMETER 497

Appendix A Appendix B
These laws are illustrated in Figure A.1 and are According to Gaussian optics, equation B.126 de-
described by the following equation, when d is much scribes the refracting dioptric power (P) of a spherical
larger than r, as is always the case clinically: surface of a transparent medium, given the index of
refraction of the medium (n1), the index of refraction
of the optical medium adjacent to the surface (n2), and
2dI
r5 ðA:1Þ the radius of curvature of the surface (r), in meters:
O
ðn1  n2 Þ
P5 ðB:1Þ
r
Where O is the object size, I the image size, d is the For the cornea, n1 is the refractive index of the cornea,
distance of the object from the cornea, and r is the n2 is the refractive index of air (n2 5 1.000) and r is the
radius of the front surface of the cornea. radius of curvature, in meters, as measured by the
keratometer. Equation B.1 describes the refraction at
a single refractive surface, but the cornea, having
a finite thickness, has two refractive surfaces, the
anterior surface in contact with air, and the posterior
surface, in contact with the aqueous humor. Equation
B.226 illustrates how to calculate the combined
refractive dioptric power of two refractive surfaces.
n1  n2 n0  n1
When; P1 5 and P2 5
r1 r2 ðB:2Þ
P 5P1 þ P2  nd1 P1 P2

where, in the case of the cornea, P1 is the dioptric


power of the posterior surface, P2 the dioptric power
of anterior surface, n1 and n2 are as defined above,
n0 is the refractive index of the aqueous (1.336), r1 is
the radius of curvature of the posterior surface, r2 is
Fig. A.1. Illustration of catoptric system with cornea the radius of curvature of the anterior surface, and
acting as spherical reflecting surface. d is the thickness of the central cornea.

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