ORIGINAL ARTICLE

ARCH SOC ESP OFTALMOL 2008; 83: 183-192

DIURNAL VARIATIONS OF CENTRAL AND

PARACENTRAL CORNEAL THICKNESS AND CURVATURE
VARIACIONES DIURNAS DE ESPESOR Y CURVATURA CORNEAL
CENTRAL Y PARACENTRAL
GIRLDEZ-FERNNDEZ MJ1, DAZ-REY A2, GARCA-RESUA C1, YEBRA-PIMENTEL-VILAR E3

ABSTRACT

RESUMEN

Objective: Corneal topography and thickness has

clinical importance in contact lens fitting and
refractive surgery, however repeated measurement
of corneal thickness and curvature is complicated
by the natural phenomenon of diurnal variation.
Our aim was determine diurnal variations of central
and paracentral corneal thickness and curvature
over a period of ten hours.
Materials and methods: Corneal thickness and
curvature of 10 right eyes of 10 young healthy men
were determined by Orbscan Topography System
and EyeSys videokeratoscope respectively. Both
parameters were determined for central and paracentral regions 1 mm and 2 mm from the centre of
the cornea at 2-hour internals for ten hours.
Results: The cornea was thickest and flattest on
awakening. There was a difference in corneal thickness (ANOVA, Schffc method p< 0.05) and curvature (ANOVA, Tamhane method p< 0.05) over time
for all the corneal locations studied, with greater
changes observed in the peripheral corneal data.
The minimum value was 10 and 8 hours after eye
opening for central and paracentral zones, respectively. Change in central and paracentral corneal

Objetivo: La topografa y espesor de la crnea tienen una gran importancia clnica en la adaptacin
de lentes de contacto y en ciruga refractiva. Sin
embargo, la repetibilidad en las medidas de estos
parmetros se ve comprometida por el fenmeno
natural de las variaciones diurnas. Nuestro objetivo
es determinar las variaciones diurnas de espesor y
curvatura corneal central y paracentral durante un
periodo de 10 horas.
Material y mtodo: Se determin la curvatura y
espesor corneal en los ojos derechos de 10 varones
jvenes mediante Orbscan y videoqueratoscopio
respectivamente. Ambos parmetros fueron determinados para la zona central y paracentral a 1 y 2
mm del centro de la crnea, cada dos horas durante
un periodo de 10 horas.
Resultados: La crnea presentaba su espesor mximo y curvatura mnima al abrir el ojo. Se observ
una variacin estadsticamente significativa de
espesor (ANOVA, mtodo de Scheffc p< 0,05) y
de curvatura (ANOVA, mtodo de Tamhane p <
0,05) a lo largo del da en todas las localizaciones
estudiadas, si bien la variacin y los rangos de valores en la zona paracentral eran mayores. Los valo-

Received: Jan. 29, 2007. Accepted: Feb. 15, 2008.

Santiago de Compostela University. Santiago de Compostela. Spain.
1 Graduate in Optics and Optometry.
2 Graduate in Medicine. Ophthalmologist. Minho University. Braga. Portugal.
3 Ph.D. in Pharmacy.
Correspondence:
Eva Yebra-Pimentel Vilar
Escuela Universitaria de ptica y Optometra
Universidad de Santiago de Compostela. Campus Sur
15782 Santiago de Compostela
Spain
E-mail: eyebra@usc.es

GIRLDEZ-FERNNDEZ MJ, et al.

thickness was strongly correlated with corneal curvature, except for the 2 mm nasal and superior
semi-meridians.
Conclusions: These data indicate a shift in corneal
thickness and curvature that can be of clinical relevance as individual changes vary greatly (Arch Soc
Esp Oftalmol 2008; 83: 183-192).
Key words: Cornea, corneal thickness, corneal curvature, pachymetry, diurnal variation.

res mnimos para ambos parmetros se observaron

a las 10 y 8 horas despus de abrir los ojos para las
zonas central y paracentral respectivamente. Las
variaciones de espesor y curvatura estaban altamente correlacionadas excepto para la localizacin
nasal y superior a 2 mm del centro.
Conclusiones: Estos datos evidencian un cambio
en espesor y curvatura que pueden ser de relevancia
clnica atendiendo a la variacin individual encontrada.
Palabras clave: Crnea, espesor corneal, curvatura
corneal, paquimetra, variacin diurna.

INTRODUCTION
The determination of corneal thickness has gained relevance in recent years, party due to the growing interest in the continued use of contact lenses
(1,2) and refractive surgery (3-5). Corneal thickness
provides valid information about its physiological
condition and possible changes associated to diseases, traumas and hypoxia.
The diurnal variations of corneal thickness are an
obstacle for repeated pachymetric measurements.
The pattern of this variation is that the cornea
attains maximum thickness upon awakening after
night sleep (6-8). Optical and ultrasound pachymetry have been utilized to measure corneal thickness in periods of 12-48 hours (7-10). Utilizing the
Haag-Streit optical pachymeter, Kiely et al (7)
found a diurnal variation of 10 m for the central
thickness and 20 m in the periphery at 40.
The corneal curvature has also been considered
in relation to refractive surgery, the adaptation of
contact lenses and others. Several authors have studied the daytime change of the central corneal curvature which show that the cornea is flatter upon
awakening, with a slight but statistically significant
increase in curvature throughout the day (6,10,11).
More significant variations are observed in the
superior and inferior hemi-meridians (12), in addition to gender differences (13).
Kiely et al (7) studied the relationship between
the curvature and corneal thickness and found a significant correlation between the diurnal thickness
and curvature variations in the horizontal meridian.
On the other hand, Rom et al (14) did not find a
relationship between the variations of corneal thickness and topography.

184

This study determined the central and para-central

corneal thickness and curvature values (at 1 and 2
mm from the centre) during a 10-hour period, with
measurements being taken at 2 hour intervals. The
aim was to determine the daytime corneal thickness
and curvature values in the central and para-central
locations as well as to study the relationship between the thickness and curvature variations.

SUBJECTS, MATERIAL AND

METHOD
Ten young men took part in the study, having no
history of contact lens use, ocular or systemic pathology or receiving at the time any type of topical or
systemic medication. Women were not included in
the study sample in order to avoid the effects of hormonal activity on the corneal thickness and curvature
(15). After explaining the procedures to the patients,
they were asked to sign the informed consent.
Immediately upon awakening and with the purpose of eliminating the effect of tear evaporation on
the size of the cornea (8), each subject covered his
right eye with a patch up to the first measurement.
The thickness and curvature values of the right eye
cornea were determined with the Orbscan Topography System (Orbscan II version 3.0) and with
the EyeSys videokeratoscope (EyeSys Corneal
Analysis System 2000. version 3.1; EyeSys, INC,
Houston, TX), respectively.
Although previous studies have demonstrated
that Orbscan yields higher values than the optical
and ultrasonic pachymeters (16,17), its usefulness
has been proved for measuring corneal thickness in
investigation and in clinical practice with a preci-

ARCH SOC ESP OFTALMOL 2008; 83: 183-192

Diurnal variation in corneal thickness and curvature

sion in relation to gauge spheres of 2 m (range,

1.2 m in the centre to 3.2 m in the periphery)
(10,16). Repeated measurements on individuals
produced a mean standard deviation of 9.08 m in
the central 7 mm of the cornea (10). However, the
repetitiveness and reproducibility of the Orbscan is
low when measuring corneal curvature (18), for
which reason the curvature values were determined
by videokeratoscopy. Previous studies have shown
a high repetitiveness in measurements taken with
the videokeratoscope, with a standard deviation of
0.01 mm in humans and gauge spheres (19.20).
The thickness and curvature measures were taken
in nine corneal locations: central and at 1 and 2 mm
from the centre in the nasal, temporal, superior and
inferior half-meridians. The first measurements
were taken immediately after withdrawing the eye
patch and at 2 hour intervals for a 10-hour period.
The statistical analysis was made utilizing SPSS
6.1 (SPSS Inc., Chicago, Illinois, USA). For comparing the daytime thickness and curvature variations in said locations an ANOVA test was applied
with an Univariant General Linear Model. The corneal thickness and curvature were considered as
dependent variables whereas the central location, at
1 and 2 mm from the centre, meridians and the measurement time were considered as factors. As Levenes test for equalizing variances was statistically
significant for the thickness but not for the curvatu-

re, the Sheffec and Tamhane methods were utilized

for thickness and curvature, respectively. The relationship between the thickness and curvature measurements were assessed by means of linear regression analysis.

RESULTS
Figure 1 and 2 show the corneal thickness and
curvature measurements taken at the central and
nasal, temporal, superior and inferior areas at 1 and
2 mm of the centre. The statistical analysis showed
statistically significant corneal thickness variations
in all the locations and period of the study (ANOVA, Schffc method, p < 0.05). The cornea exhibited its maximum thickness upon opening the eye
after night sleep, which then reduced during the day
in all the locations. The mean diurnal variation in
central corneal thickness was of 14 m (1.95%),
with individual values in the range of 9-22 m, and
with the minimum value after 10 hours of said initial opening. The mean gradient of the pachymetric
descent in the centre of the cornea was of -0.686.
The thickness variations corresponding to the nasal,
temporal, superior and inferior at 1 and 2 mm of the
centre are shown in tables I and II, the minimum
value being approximately 8 hours after opening
the eye. The mean gradient of the pachymetric des-

Fig. 1: Mean value of central and nasal, temporal, superior and inferior corneal thickness immediately after opening the
eye and at 2-hour intervals in a 10-hour period: a) at 1 mm from the centre; b) at 2 mm from the centre of the cornea.
ARCH SOC ESP OFTALMOL 2008; 83: 183-192

185

GIRLDEZ-FERNNDEZ MJ, et al.

Fig. 2: Mean value of central and nasal, temporal, superior and inferior corneal curvature immediately after opening the
eye and at 2-hour intervals in a 10-hour period: a) at 1 mm from the centre; b) at 2 mm from the centre of the cornea.

cent for 1 and 2 mm measurements in the meridians

are shown in table III, where the values corresponding to the nasal, temporal, inferior and superior
locations at 2 mm from the centre indicate a larger
pachymetric reduction than in the centre of the cornea (0.686). In the case of the superior meridian, it
can be seen that the mean gradient of the thickness
Table I. Percentage of maximum corneal thickness
diurnal variation at 1 and 2 mm of the cornea
centre in the nasal, temporal, superior and
inferior hemi-meridians
Location
from the centre

Nasal

Temporal

1 mm (%)
2 mm (%)

2.23
2.97

2.57
2.80

Superior Inferior
2.13
2.66

2.70
3.14

variation 1 mm from the centre is slightly smaller

than the central one, and the value obtained at 2
mm, even though it is bigger, fits in better with the
pachymetric variation in the centre of the cornea.
The smallest curvature was observed with the first
opening of the eye after sleep, with a statistically
significant difference when compared with the
values obtained throughout the day (ANOVA, method of Tamhane p < 0.05). After an initial increase
of the corneal curvature, it remains virtually stable
through the day in all the locations of the study.
The mean variation of central curvature observed
in the period of the study was of 0.07 mm, with the
smallest value being at 2 hours after opening the
eyes. Table IV shows the values of the para-central
measurements of the study.
No statistically significant differences were
found between the thickness variations (ANOVA,

Table II. Variations in corneal thickness at 1 and 2 mm of

the cornea centre in the nasal, temporal,
superior and inferior hemi-meridians during a
10-hour period after opening the eyes (mean
values and range)

Table III. Mean gradient of pachymetric descent in

paracentral location at 1 and 2 mm of the
cornea centre in the nasal, temporal, superior
and inferior hemi-meridians

Location
from the centre

Location
from the centre

Nasal

Temporal

1 mm (m)
2 mm (m)

-0.994
-1.250

-0.784
-1.247

1 mm (m)
2 mm (m)

186

Nasal

Temporal Superior

Inferior

22 (7-32) 22 (13-31) 24 (12-27) 20 (8-26)

19 (10-40) 19 (12-47) 23 (12-36) 16 (13-44)

ARCH SOC ESP OFTALMOL 2008; 83: 183-192

Superior Inferior
-0.603
-0.726

-1.100
-1.426

Diurnal variation in corneal thickness and curvature

Scheffc method, p > 0.05) or curvature variations

(ANOVA, Tamhane method p > 0.05) observed in
the centre of the cornea and at 1 and 2 mm from the
centre in all the hemi-meridians measured. Similarly, no statistically significant differences were
found between the thickness variations (ANOVA,
Scheffc method p > 0.05) or between the curvature variations (ANOVA, Tamhane method p > 0.05)
which were measured in the hemi-meridians of the
study. The nasal, temporal, superior and inferior
thickness and curvature variations at 1 and 2 mm
from the center are shown in figures 3 and 4 respectively.
Table IV shows the results of the statistical analysis comparing the daytime variations in thickness
and curvature in the corneal locations of the study.
A high degree of correlation was observed between
the variations in the center of the cornea (r= 0.983,
r2 = 0.967, p < 0.001) and in the other locations,
excepting the nasal and superior areas at 2 mm from
the center.

DISCUSSION
The purpose of this study is to contribute to the
knowledge about the effect of time on the corneal
thickness and curvature in the course of the day. By
establishing said changes in the central and paracentral areas of the cornea, it would be possible to
Table V. Correlation between the diurnal thickness and
curvature variations in each location of the
study

Nasal
Temporal
Superior
Inferior

1 mm
2 mm
1 mm
2 mm
1 mm
2 mm
1 mm
2 mm

r2

0.933
0.604
0.968
0.848
0.991
0.797
0.817
0.927

0.870
0.365
0.937
0.719
0.982
0.635
0.667
0.859

0.007
0.204
0.002
0.033
0.000
0.058
0.047
0.008

determine the time in which basal measurements

should be taken.
The relevance and implications of knowing the
diurnal variations of corneal thickness are particularly important in the clinical evaluation of PRK
patients and in candidates for other keratorefractive
surgeries. In fact, the most common contraindication
for LASIK surgery is reduced central corneal thickness, which is also an important factor in the characteristics of the flap made during the intervention
(21,22). Corneal curvature has also been considered
in relation to refractive surgery due to its relationship with the thickness and diameter of the flap (23).
In this study, the maximum corneal thickness for
all locations was measured immediately after opening the eyes in the morning. This finding matches
those of other studies (5-10).
The reduced oxygen supply during sleep leads to
anaerobic metabolism which causes and increase in
lactic acid production, in turn leading to an increase
in osmotic pressure which facilitates the diffusion of
water from the aqueous humor to the stroma. This
increases the corneal thickness (24). When comparing the corneal thickness obtained during a 10-hour
process, we observe a statistically significant variation in all the locations of the study. Even though the
mean daytime variation of the observed central corneal thickness (14 m) was similar to that found by
other authors (7,10,25), individual variations could
be clinically relevant (range of 9-22 m).
As can be seen in table III, the magnitude of
thickness change and the range of values is larger in
para-central data. This fact is also observed when
comparing the mean gradient values of the central
pachymetric reduction (-0.686) with the values of
the nasal, temporal, inferior and superior paracentral data at 2 mm (table III). In the case of the superior meridian, it can be seen that the mean gradient
of the thickness variation at 1 mm from the centre is
slightly smaller than the central variation, and even
when the value obtained at 2 mm is larger, it most
closely matches the central value. This can be due
to the fact that the superior cornea, both in eye clo-

Table IV. Mean variation and value range of central and para-central curvature at 1 and 2 mm from the centre of the
nasal, temporal, superior and inferior hemi-meridians (mm)
Central
0.07 (0.05-0.1)

Location

Nasal

Temporal

Superior

Inferior

1 mm
2 mm

0.05 (0.01-0.10)
0.07 (0.02-0.12)

0.06 (0.03-0.11)
0.07 (0.02-0.16)

0.07 (0.03-0.11)
0.06 (0.03-0.20)

0.06 (0.03-0.12)
0.07 (0.05-0.13)

ARCH SOC ESP OFTALMOL 2008; 83: 183-192

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GIRLDEZ-FERNNDEZ MJ, et al.

Fig. 3: Variation of corneal thickness at 1 and 2 mm of the centre of the nasal, temporal, superior and inferior hemimeridians.

sed and open conditions, is the area with the largest

hypoxic stress, which leads to a smaller thickness
reduction in open eye conditions (26-28).
The thickness increase in the periphery of the
cornea and the greater thickness variation observed
could imply changes in the regulating hydration
capacity and in the specific control thereof, indicating the presence of a lateral hydration gradient

188

extending outwardly from the apex (10). The hydration variations throughout the profile of the cornea
could be a source of errors with some refractive surgery patients because the diurnal variation in pachymetry could be greater than the amount of tissue eliminated for each dioptre. In addition, many microkeratomes generate meniscus having different
thicknesses, and therefore the corneal biomechanic

ARCH SOC ESP OFTALMOL 2008; 83: 183-192

Diurnal variation in corneal thickness and curvature

Fig. 4: Variation of corneal curvature at 1 and 2 mm of the centre in the nasal, temporal, superior and inferior hemimeridians.

stress could be compromised if in certain locations

the residual stroma is very low. If the minimum corneal thickness value is not adequately determined,
in theory the measures could yield a higher spurious
value, leading to an overestimation which could
increase the risk of developing postop kerectasia.
The central and paracentral corneal thickness
exhibited their lowest value 10 and 8 hours after

opening the eyes. Previous studies have shown that

the lowest corneal thickness values are obtained
between 5 and 12 hours after opening the eye (79,25), in some cases obtaining a corneal thinning
exceeding the base value. The differences between
studies could be due to differences in the measurement intervals and frequencies. The thinning of the
cornea beyond the base vale has already been stu-

ARCH SOC ESP OFTALMOL 2008; 83: 183-192

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GIRLDEZ-FERNNDEZ MJ, et al.

died (29), and even though its presence is proven it

is an aspect of corneal hydration dynamics for
which no explanation has yet been found. Odenthal
et al (29) suggest that the most likely possibility
that the rate of the endothelial pump is not constant
and that hypoxic stress may activate a functional
reserve in the capacity of the ionic pump delaying
its activity at a normal level. When this situation
occurs, the corneal thickness could be influenced
by other factors such as the blinking frequency, the
quality of the lachrymal film and diurnal variation
in the production of tears and intra-ocular pressure.
This could explain the increased thickness occurring after the cornea reaches its minimum thickness between 8 and 10 hours after the nightly eye
closure (29).
In what concerns curvature, our results are consistent with those found by other researchers
(7,11,13). Initially, in contrast with Kiely et al (7),
we did not observe differences in the daily variations which occur in the horizontal and vertical
meridians. Using the eyes in near focus and eyelid
pressure could play a relevant role in the daytime
changes of corneal curvature (12,30,31). For this
reason, it is likely that the results of this study will
differ from those found in other studied where the
subjects used their eyes in near focus during the
measurement period. In addition, in our study the
effect of eyelids is not very probable when the measures are taken at 1 and 2 mm from the cornea centre. Read et al (12) suggest a correlation between
the amount of work done in near focus and the curvature change values, with possible associated factors being corneal hydration, tear stability, blinking
frequency, vertical eyelid aperture and the time
elapsed between the near focus ocular activity and
the measurement. Even though statistically significant differences between meridians were not observed, Figure 4 shows a curvature increase in the
superior and inferior meridians 8 hours after opening the eyes. This finding matches agrees with
other studies, which refer an increase in the curvature of the vertical meridian at the end of the day
(11,12).
It has been suggested that diurnal corneal curvature thickness variations in normal eyes could be
related to changes in the cornea thickness (7,32).
MacRae et al (32) found that in normal eyes and in
those treated with radial keratotomy there was a
relationship between the corneal thickness and
changes in its shape. However, they observed that

190

said correlation was not statistically significant

when the sample was divided in 3 groups (8 patients
per group). In our study, the statistical analysis
shows a strong correlation between corneal thickness and curvature changes (table V). These results
can be seen graphically in the similarity existing
between figures 2 and 4, and match other studies
which include normal and radial keratotomy corneas
(32,33). On the other hand, Kwitko et al (34), did
not observe said correlation considering it was due
to the small number of subjects in their sample,
which limited statistical analysis and the detection
of statistical correlations. Surprisingly, with the
same sample size of Kwitko et al (34), we obtained
statistical significance with a similar tendency to
that found by MacRae et al (32) in which, when the
thickness of the cornea is reduced, the curvature is
increased. This relationship between thickness and
curvature could be due to the greater thickness
reduction which takes place in the para-central area
of the cornea when compared to the centre. In other
words, said difference in the thickness reduction
could be the cause of the observed curvature increase.

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