Pentacam

Interpretation Guideline

Copyright by G/70700/1005/e
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Pentacam Interpretation Guideline

Foreword
We thank you for the trust you have put in this
OCULUS product. With the purchase of this
instrument, you have chosen a modern,
sophisticated product, which was manufactured
and tested according to strict quality criteria.
Our enterprise has been doing business for over
100 years. Today OCULUS is a medium-sized
enterprise concentrating completely on helping
ophthalmologists, optometrists and opticians to
carry out their responsible work by supplying an
optimal range of instruments for examinations
and surgery on the eye.
The Pentacam is the newest product in the
Oculus line. It is based on the Scheimpflug
principle, which generates precise, sharp images
of the anterior eye segment. Our painstaking
product development has produced an
instrument that takes extremely accurate
measurements and is easy to use.
If you have questions or desire further
information on this product, call, fax or email us.
Our service team will be glad to help you.
OCULUS Optikgeräte
Managing director and management team

OCULUS has been certified according to DIN EN

ISO 9001:2000 and 13485:2003 and therefore
sets high quality standards in the development,
production, quality assurance and servicing of its
entire product range.

Pentacam Instruction Manual
Introduction
This guideline should help all Pentacam users to
interpret the results and screens the Pentacam
provides.
We may not have covered everything which
might be of kind of interest. Therefore we ask
each Pentacam user for help to improve this
guideline step by step. Please forward your
special cases to us and we will be happy to
implant them.
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Of course, this guideline cannot replace the
years of experience and the medical studies, but
it will be a help in questionable cases as well as
be a help for beginners. The personal
experience and impression from each of you and
the cross connection of the results from different
instruments linked with the individual patient’s
history may sometimes lead to different results
as shown in this guideline.
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Pentacam Interpretation Guideline

Table of Contents

Introduction.....................................................................................................................................................3
Table of Contents ...........................................................................................................................................4
1. Description of unit and general remarks..............................................................................................5
2. Corneal INTACS ..................................................................................................................................6
2.1. Case 1, INTACS after PRK, Alain-Nicolas Gilg, MD........................................................................6
3. Orthokeratology ...................................................................................................................................9
3.1. Case 1, General Screening, Alain-Nicolas Gilg, MD .......................................................................9
4. Corneal Ectasia .................................................................................................................................11
4.1. Case 1, Ectasia after RK, Renato Ambrósio, MD ..........................................................................11
4.2. Case 2, Ectasia after LASIK?, Prof. Michael Belin ........................................................................12
5. Glaucoma ..........................................................................................................................................15
5.1. Case 2, General screening, Tobias Neuhann, MD ........................................................................15
5.2. Case 1, YAG Laser Iridectomy, Eduardo Viteri, MD......................................................................16
5.2.1. Comments...............................................................................................................................18
6. Keratoconus.......................................................................................................................................19
6.1. Case 1, Locating the cone, Prof. Michael Belin .............................................................................19
6.2. Keratoconus detection, Prof. Michael Belin ...................................................................................20
6.2.1. Case 2, Keratoconus, OD & OS?, Prof. Michael Belin ...........................................................20
6.2.2. Case 3, INTACS implantation, Prof. Michael Belin.................................................................22
6.2.3. Case 4, Form Fruste Keratoconus?, Prof. Michael Belin .......................................................24
6.3. Proposed Screening Parameters, Prof. Michael Belin...................................................................26
6.4. Case 5, Unilateral Keratoconus?, Renato Ambrósio, MD..............................................................27
6.4.1. Conclusion ..............................................................................................................................28
7. IOL-calculation after corneal laser refractive surgery........................................................................29
7.1. Holladay Report .............................................................................................................................29
7.2. Case 1, Tobias Neuhann, MD........................................................................................................30
8. PIOL, pre-op and post-op evaluation, Eduardo Viteri, MD ................................................................31
8.1. Evaluation in Artisan Phakic IOL....................................................................................................31
8.1.1. Preoperative evaluation ..........................................................................................................31
8.1.2. Postoperative evaluation ........................................................................................................32
9. Cataract .............................................................................................................................................33
9.1. Case 1, Cortical Cataract, Tobias Neuhann, MD...........................................................................33
10. Corneal transplant .............................................................................................................................34
10.1. Case 1, Removing the sutures?, Tobias Neuhann, MD.............................................................34
11. What would you recommend? ...........................................................................................................35
11.1. Case 1, Keratoconus and Cataract, Tobias Neuhann, MD........................................................35
12. Other cases .......................................................................................................................................36
12.1. Case 1, Corneal Infiltrate, Renato Ambrósio, MD ......................................................................36
12.2. Case 2, Incisional Edema, Renato Ambrósio, MD .....................................................................37
12.3. Case 3, Corneal Thinning after Herpetic Keratitis, Renato Ambrósio, MD ................................38
12.4. Case 4, Epithelial Ingrowth after Keratomileusis in situ, Renato Ambrósio, MD .......................39
13. Recommended Settings and Color Maps..........................................................................................40
13.1. Recommended Settings .............................................................................................................40
13.2. Recommended Color Maps........................................................................................................40
13.2.1. Screening for LASIK, PRK etc. ...........................................................................................40
13.2.2. Screening for PIOL implantation .........................................................................................41
13.2.3. Glaucoma Screening...........................................................................................................41
13.2.4. IOL Calculation for Treated and Untreated Corneas ..........................................................41
13.2.5. Screening for Keratoconus and Ectasia..............................................................................42
14. References and Contact Addresses..................................................................................................43

Pentacam Instruction Manual
1. Description of unit and general remarks
The OCULUS Pentacam is a rotating
Scheimpflug camera. The rotational measuring
procedure generates Scheimpflug images in
three dimensions, with the dot matrix fine-
meshed in the center due to the rotation. It takes
a maximum of 2 seconds to generate a complete
image of the anterior eye segment. Any eye
movement is detected by a second camera and
corrected for in the process. The Pentacam
calculates a 3-dimensional model of the anterior
eye segment from as many as 25,000 true
elevation points.
The topography and pachymetry of the entire
anterior and posterior surface of the cornea from
limbus to limbus are calculated and depicted.
The analysis of the anterior eye segment
includes a calculation of the chamber angle,
chamber volume and chamber height and a
manual measuring function at any location in the
anterior chamber of the eye. In a moveable
virtual eye, images of the anterior and posterior
surface of the cornea, the iris and the anterior
and posterior surface of the lens are generated.
The densitometry of the lens is automatically
quantified.
The Scheimpflug images taken during the
examination are digitalized in the main unit and
all image data are transferred to the PC.
When the examination is finished, the PC
calculates a 3D virtual model of the anterior eye
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segment, from which all additional information is
derived.
OCULUS Optikgeräte GmbH emphasizes that
the user bears the full responsibility for the
correctness of data measured, calculated or
displayed using the Pentacam. The
manufacturer will not accept claims based on
erroneous data and wrong interpretation.
This interpretation guideline has to be
understood as a help only to interpret the
examination data the Pentacam provides.
The doctors and physicians have to consider
all medical information which can be
collected by using other diagnostic
instruments e.g. slit lamp examination,
ultrasound biomicroscopy, etc. to make the
diagnosis. The results of the different
diagnostic instruments have to be compared
and closely scrutinized.
This interpretation guideline has to be
understood as a completion to the operator’s
manual. The current version of the operator’s
manual is stored on every Pentacam software
CD-ROM.
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Pentacam Interpretation Guideline

2. Corneal INTACS

2.1. Case 1, INTACS after PRK, Alain-Nicolas Gilg, MD

A female, 45 years-old, had PRK in both eyes 7
years before.
The visual acuity before the laser surgery was
• OD sph. -7.50, cyl. -0.50 @170°,
• OS sph. -6.75, cyl. -1.00 @10°.
She was referred for blurred vision, photophobia,
and poor intermediate VA.
The Zernike analysis confirmed the functional
disorders of the vision due to abnormal spherical
and high order aberrations, |Z|40 (spherical),
|Z|53.(trefoil 5th order) |Z|62 (astigmatism 6th order)
(Figure 1).

Figure 1

Pentacam Instruction Manual
The Keratoconus menu of the Pentacam
identifies this cornea as an oblate postoperative
cornea, note the negative eccentricity and
display an abnormal high aberration coefficient
due to the high order aberrations (Figure 2). The
Pachymetry map shows a smooth progression
with a thick area for the implantation of the
Figure 2
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INTACS in the 7mm zone. Though, she was a
good candidate for INTACS implantation.
The visual acuity before the implantation of the
corneal INTACS was:
• OD 0.9; sph. -1.25, cyl. -0.50 @175°
• OS 0.6; sph. -1.50, cyl. -0.50 @55°.
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Pentacam Interpretation Guideline

The visual acuity after implantation of the The Scheimpflug image shows a successful fit of
INTACS: the implanted INTACS (Figure 3).
• OS 1.0; sph. +0.50, cyl. -1.25 @30°.

Figure 3
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Pentacam Instruction Manual

3. Orthokeratology

3.1. Case 1, General Screening, Alain-Nicolas Gilg, MD

A male, 34 years old, referred for changing his
soft contact lenses because of a progressive
intolerance during the day.
The subjective refraction results in visual acuity
• OD sph. -2.5,
• OS sph. -1.0.
The Pentacam “Show 2 examinations screen”
displays an optimal eccentricity on the 30° of
both eyes, OD 0.50, OS 0.49 which permits us to
propose the orthokeratology treatment to this
patient (Figure 1).
After fitting the lenses, prior to midday
examinations revealed a good visual acuity on
day 1, VA: 0.8, day 8 and 28 VA: 1.0.

Figure 1
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Pentacam Interpretation Guideline

The patient was examined 4 times within 2 maps comparison screen confirmed the efficacy
months to view the corneal progression. The 4 of the treatment (Figure 2).

Figure 2

On day 28, the patient complained of fluctuations
during the day of his visual acuity. The Patient
was examined in the morning after wearing the
lens over night and in the late afternoon. The
Pentacam confirmed using the “Compare 2
Exams” screen that the effect of the ortho-K lens
was reversible during the day which leads to the
diagnosis to fit a more effective ortho-K lens to
this patient (Figure 3).

Figure 3
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Pentacam Instruction Manual

4. Corneal Ectasia

4.1. Case 1, Ectasia after RK, Renato Ambrósio, MD

A 28 years old male patient had RK in 1995 for
myopic astigmatism with RK enhancement three
years later in OS. Corneal topography was not
performed prior to surgery according to patient
information.
Uncorrected VA was 20/30 in OD and 20/200 in
OS. Patient refers severe glare and starburst all
day, mainly at night.
Refraction is –0.25 –3.00 x 156, giving 20/20 in
OD and –5.00 –2.25 x 39, giving 20/30 in OS.
Patient was fit with a RGPCL with significant
improvement of the symptoms in both eyes.
The Pentacam Quad map demonstrates corneal
Ectasia in both eyes, more advanced in OS
(Figure 1, 2). In OD, the patient has a central
cornea with less distortion than OS, which
enables relatively good uncorrected vision.
However, the patient refers quality of vision was
terrible in both eyes.

Figure 1 Figure 2

Figure 3 Figure 4

The pachymetric progression is abrupt in both and tomography would have performed and well
eyes as an important sign of Ectasia (Figure 3, interpreted. This case would have been
4). Probably mild Ectasia could have been considered as a bad candidate for RK.
diagnosed prior to surgery if corneal topography
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Pentacam Interpretation Guideline

4.2. Case 2, Ectasia after LASIK?, Prof. Michael Belin

A 46 year old female had previous LASIK 2 The referring surgeon was concerned about Post
years prior. She presented interested in an LASIK Ectasia based on OrbScan topography.
enhancement to her dominant right eye. BSCVA OrbScan topography shows significant posterior
was 20/20+ with – 1.25 D. elevation (Figure 1).

Figure 1

Pentacam Instruction Manual
Evaluation with the OCULUS Pentacam reveals
no posterior elevation abnormality and no
evidence of post-operative Ectasia (Figure 2).
Figure 2
DISCUSSION - This case demonstrates one of
the limitations with the current version of the B&L
OrbScan. The OrbScan routinely fails to correctly
identify the posterior corneal surface in post-
operative patients leading to underestimates of
residual bed thickness and frequent incorrect
diagnosis of Post LASIK Ectasia.
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Patient underwent a routine LASIK enhancement
without incident.
Here the OrbScan incorrectly reads the corneal
thickness 37µm thinner than the Pentacam and
shows an incorrect Ectasia (Figure 3).
The Pentacam shows a normal post-operative
appearance (Figure 3).
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Pentacam Interpretation Guideline

Orbscan 37 µm thinner
Figure 3
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Pentacam Instruction Manual

5. Glaucoma

5.1. Case 2, General screening, Tobias Neuhann, MD

A 48 year old white male patient wants to have a medical treatment. His ophthalmologist
second opinion about his glaucoma treatment. recommends now a second medication. We
His father and grandfather have had glaucoma. measured 24mmHG with Goldmann applanation
He himself has had ten years of glaucoma tonometer.

Figure 1

After taking a Pentacam examination, looking to
the 4 maps display (Figure 1) we put the
24mmHg in the Dresdner scale and the
corrected IOD was displayed with 11mmHg
because of a corneal thickness of about 728µm
in the apex. The additional examination on HRT
resulted in a healthy optic nerve and we
recommend the patient to stop his medication.
His IOP today is during daytime between 19 and
22mmHg.We still see him 4 times a year for IOD
and HRT check Figure 2, 3).

Figure 2 Figure 3
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Pentacam Interpretation Guideline

5.2. Case 1, YAG Laser Iridectomy, Eduardo Viteri, MD

This is a 64 year old female patient who was
complaining of episodes of blurred vision and
tearing. The IOP was 18 mm Hg in both eyes.
Anterior chamber was shallow on slit lamp
examination and optic nerve had a C/D ratio of
0.6 in both eyes. The lens was clear and
gonioscopy exam revealed a narrow angle in
both eyes (grade I-II).
The anterior segment exam with the Pentacam
(Figure 1) documented an irido-corneal angle of
22.5 degrees with an ACD (epithelial) of 2.43
mm. The patient was reluctant to have YAG
laser Iridectomy until she was able to compare
her anterior segment biometry with that of other
normal patients.

Figure 1: Pentacam exam previous to YAG laser Iridectomy.

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Pentacam Instruction Manual

After YAG Laser Iridectomy was performed, changed (Figure 2). This is quite evident in the
several of her anterior segment measurements differential display (Figure 3)

Figure 2: Pentacam exam, 10 days after YAG Laser Iridectomy.

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Pentacam Interpretation Guideline

Figure 3: Differential display after YAG Laser Iridectomy.

The irido-corneal angle is 4º wider, and, although where you can see changes ranging from 0.19
the ACD only deepened 0.09 mm centrally, the mm to 0.30 mm. This was enough to increase
main difference is evident in the periphery, the AC volume from 64 to 92 mm3.

5.2.1. Comments

In narrow angle Glaucoma, the Pentacam is
quite useful in measuring the irido-corneal angle,
although this may be difficult in 360º because of
the eyelid interference. We can obtain more
consistent data when measuring peripheral ACD
and AC volume. The exam has been of great
help also in educating the patient about this
disease, and making evident the effect of the
treatment.
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Pentacam Instruction Manual

6. Keratoconus

6.1. Case 1, Locating the cone, Prof. Michael Belin

Most clinicians have characterized Keratoconus
based on the appearance on curvature maps.
This leads to inaccurate placement of the cone
and a high incidence of pseudo “Pellucid
Marginal Degeneration” which is a relatively rare
occurrence. Elevation and Pachymetry maps are
more reliable in locating the apex of the cone.
The example below shows such a case. While
looking to the sagittal curvature map you would
expect the cone between 6 and 7 o clock. The
elevation maps of the anterior and posterior
corneal surface shows the real position (Figure
1).

Figure 1
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Pentacam Interpretation Guideline

6.2. Keratoconus detection, Prof. Michael Belin

Placido derived curvature maps will often miss Elevation maps are a more reliable method to
early keratoconus and frequently miss diagnose detect early keratoconus
a “normal” cornea with a off-centered apex as
keratoconus

6.2.1. Case 2, Keratoconus, OD & OS?, Prof. Michael Belin

The case shown below explains the difference (Figure 1) shows the left and right eye but gives
between suspicious and significant elevation no unequivocal statement if it is a keratoconus or
maps and numbers. The topographic map not.

Figure 1

The right eye seems to be ok as well as the left
eye, may be a little bit steeper as the mean
population. The Pentacam 4 maps screen
answers clearly the question.
The right eye (Figure 2) has a regular corneal
thickness but the elevation maps of the anterior
and posterior surface indicates this cornea as a
suspicious cornea. Both sides show inferior
position of the cone with suspicious elevations.
The left eye (Figure 3) indicates an inferior
thinning but a smooth anterior elevation map.
The reason for the thinning in the Pachymetry
map gives the posterior elevation map where we
have significant elevations, more than 30µm.
Note, the position of the thinning in the
Pachymetry map and the highest spot in the
posterior elevation map is exact at the same
position.
This is an excellent example to document that
only topography or anterior elevation does not
answer the important questions of today,
Keratoconus or not!
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Pentacam Instruction Manual

suspicious elevation

Figure 2

significant elevation
Figure 3
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Pentacam Interpretation Guideline

6.2.2. Case 3, INTACS implantation, Prof. Michael Belin

27 year old female referred by his optometrist

because of poor vision OD secondary to
keratoconus. Her visual acuity BSCVA was
20/200 OD and with RGP over-refraction 20/30.
Patient complained of poor contact lens
tolerance with less than 3 hours of daily wearing
time. The patient was being considered for
INTACS. Anterior Corneal Curvature analysis
revealed the following (Figure 1).
Anterior Corneal Curvature analysis reveals
significant inferior cone displacement, maximum
steepness of > 50D, with the steepest part of the
cone well below the pupillary margin. A
presumptive diagnosis of Pellucid Marginal
Degeneration (PMD) was made. Initial surgical
planning included dissimilar INTAC segments to
treat PMD.
Figure 1
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Pentacam Instruction Manual

Complete Pentacam Anterior Segment Analysis Both the anterior and posterior elevation map, as
reveals the shortcomings of cone location and well as the pachymetry map locates the cone
Keratoconus classification based solely on just at the inferior pupillary border with a picture
anterior curvature. classic for traditional Keratoconus (Figure 2).

Figure 2

Surgical planning included identifying the steep

axis for the incision and looking at the
pachymetry over the incision location to
determine the incision depth (Figure 3).
Surgical planning included:
ƒ 0.35 INTACS
ƒ Incision at axis 155
ƒ Incision depth 440 microns.

Figure 3
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Pentacam Interpretation Guideline

6.2.3. Case 4, Form Fruste Keratoconus?, Prof. Michael Belin

A 47 year old female was presented for a second a BSCVA 20/20+ OU, Slit Lamp and external
opinion. She was previously told she was not a examination WNL, Placido Topography (Figure
candidate for refractive surgery and that she had 1).
“Form Fruste” Keratoconus. Her exam revealed

Figure 1

Pentacam anterior segment analysis reveals analyze a shape abnormality. Curvature is a

normal pachymetry (normal distribution & central
thickness > 650 microns). The anterior &
posterior elevation reveals a slightly decentered
apex leading to a “False Positive” inferior
steepening on a curvature map. Custom LASIK
was performed without incident (FIG 2a&b).
DISCUSSION - This case illustrates the
limitation on curvature analysis in trying to
reference based measurement and in this case
inaccurately reflects shape information. Elevation
is independent of axis or orientation and does
not have the false positive rate commonly seen
with curvature maps.
 Page 25
Pentacam Instruction Manual

Decentered
apex, no
keratoconus

Figure 2a

Decentered
apex, no
keratoconus

Figure 2b
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Pentacam Interpretation Guideline
6.3. Proposed Screening Parameters, Prof. Michael Belin
The following are my guidelines for pre-operative
refractive surgery screening for keratoconus:
o Look at anterior elevation first,
o BFS fitted in float,
o +/- 75µm scale;
o Look at posterior elevation
o BFS fitted in float
o +/- 75 µm scale
o Look at the Pachymetry and thickness
distribution;
o off center distribution of corneal
thickness is highly suspicious
o Look at the symmetry of both eyes;
o if one eye is abnormal, usually
both eyes are abnormal;
o Look at curvature last.
The following screening parameters are related
to the OCULUS Pentacam elevation maps, using
a Best Fit Sphere (BFS), fitted in float with an
automatic calculation of the optimal diameter for
the BFS (Settings, Miscellaneous Settings in the
Pentacam menu).
ƒ I prefer the Intuitive scale as more
reliable. The American just mimics the
Orbscan which is probably not the best
thing to do.
ƒ In the anterior elevation map differences
between the BFS and the corneal
contour
o less than +12µm are considered
normal,
o between +12µm and +15µm are
suspicious,
o more than +15µm are typically
indicative of keratoconus.
Similar numbers about 5µm higher apply to
posterior elevation maps.
 Page 27
Pentacam Instruction Manual

6.4. Case 5, Unilateral Keratoconus?, Renato Ambrósio, MD

A 26 years old male patient with history of
unilateral keratoconus was referred for second
opinion about laser vision correction. Both eyes
had myopic astigmatism with BSCVA better than
20/20. He does not adapt to contact lens use
because of allergy!
The Pentacam exam is extremely useful for
detecting mild changes in OD. The comparison
of both eyes of the front sagittal and pachymetry
maps clearly illustrates the asymmetry between
OD and OS (Figure 1).

Figure 1

However, in OD the corneal thickness

progression detects a suspect abnormal abrupt
increase of the thickness values from the
thinnest point (485 micron, located 0.52 micron
temporally and 0.45 micron inferiorly) towards
the limbus. Note the current corneal thickness
progression graph shown in red is very close to
the limit. The artificial intelligence indices for
8mm zone from the anterior cornea are all
normal (Figure 2).

Figure 2
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Pentacam Interpretation Guideline
The Sagittal Front map detects an asymmetric
“Eight – 8” in OD with higher curvature values
inferiorly, but the higher keratometric powers are
lower than 44.5D (Figure 3). Please note the
different scale of the topometric map. In OS, a
typical abrupt increase in the pachymetric values
is seen from the thinnest
Figure 3
6.4.1.
Interestingly, corneal hysteresis, measured with
the ORA (Ocular Response Analyzer from
Reichert) was low in both eyes, 9.8mmHg in OD
and 9.1mmHg in OS.
The diagnosis is truly mild or early or form fruste
keratoconus in both eyes with asymmetry (OS
more advanced than OD), since early changes
are detected in OD.
The changes are not detectable by corneal
topography (Placido) in OD.
spot (449 micron, located 0.29 micron temporally
and 0.93 micron inferiorly) towards the limbus.
The artificial intelligence indices for 8mm zone
from the anterior cornea detect keratoconus,
grading 2 (Figure 4).
Figure 4
Conclusion
This patient was oriented about the risk or
keratoconus progression and not to rub his eyes.
LASIK is totally contra indicated for both eyes. It
was also discussed that custom surface ablation
could be an option if the cornea and wavefront
measurements are stable over one year. In this
case, the patient needs to understand and
accept the risk of Ectasia progression that could
occur with, without (or even despite) of surgery.
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Pentacam Instruction Manual

7. IOL-calculation after corneal laser refractive surgery

7.1. Holladay Report

This new program was developed together with
Dr. Jack T. Holladay to improve the calculation of
IOL's for patients which have undergone corneal
surgery. This problem is well known and several
methods have been tried to get proper K-
readings for the calculation of the IOL but no
method was precise enough. All those methods
which have been in use so far are assumptions
and approximations.
Placido based topographers calculate the
refractive power of the cornea with the
approximation that the ratio between back/front
power of the cornea is 82% which leads to an
overall corneal refractive index of 1.3375.
A Placido based topographer has a blind spot in
the center and this area is interpolated, but it is
essential the center has an accurate corneal
measurement especially for the K-readings. In
the “Holladay Report” the ratio between back
and front power of the cornea is calculated for
the current examination as well as the
“Equivalent K-Readings” of this cornea.
The calculation of the EKR’s is based on a study
done by Jack T. Holladay, MD.
These “Equivalent K-Readings” can be
implanted into the IOL calculation formulas to get
the correct IOL calculated for all patients,
including those with abnormal corneas.
The two examples below shows the difference
between an untreated cornea (Figure 1) and a
post LASIK treatment Figure 2). As you can see
the difference between the SimK readings and
the EKR’s is up to 1.5dpt.

Figure 1 Figure 2

For more information concerning the Holladay the homepage from Jack T. Holladay MD
Report and the Holladay IOL formula please visit www.docholladay.com.
Page 30
Pentacam Interpretation Guideline

7.2. Case 1, Tobias Neuhann, MD

There is still no ideal formula available for a
reliable IOL calculation. I can recommend a
simple way to meet both patient and surgeon’s
expectation:
Just use the central measured power of the
Pentacam (true net power) and fill this number
into K1 and K2 into your preferred IOL formula.
Use also several other formulas to get a better
idea where you will end up.
This way is not the final solution but for today the
best what I can recommend.
The BSCVA pre op of the patient shown below
was 20/200 with a myopic maculopathy. The
central power in the True net Power Map (Figure
1) of the cornea was 22.3 D after PRK for –14 D
myopia! This power result is very low. More than
20 D lower than a normal cornea. We only had
this information for the cataract surgery and we
ended –1.5 D off the intended refraction which
was emmetropia with a BSCVA of 20/40
because of the myopic maculopathy. The patient
is now very happy and wants absolutely no IOL
exchange.

Figure 1
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Pentacam Instruction Manual

8. PIOL, pre-op and post-op evaluation, Eduardo Viteri, MD

8.1. Evaluation in Artisan Phakic IOL

8.1.1. Preoperative evaluation

A well known high myopic 20 years old patient
enters the office, refraction data:
OD: -12.00 (-1.50 x180),
OS: -12.50 (-1.50 x 10).
She complained of poor contact lens tolerance
with less than 4 hours of daily wearing time. We
discussed about several treatments and finally
about the possibility to implant a PIOL.
The Pentacam allows us to measure very easy
and accurately the anterior chamber, in order to
determine if there is enough space to implant an
iris fixation Artisan Phakic IOL. You can measure
not only the distance from the endothelium to the
anterior surface of the crystalline lens, but also
you can determine the available space at the
point where the claws will grasp the iris (Figure
1). Most important are minimum distances which
are in most of the cases not perpendicular to the
iris but diagonal.

Figure 1 Scheimpflug image with pre-op measurements

The Pentacam examination for the pre-operative is enough space for the ARTISAN PIOL
planning of the surgery shows with the taken implantation.
central and periphery measurements that there
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Pentacam Interpretation Guideline

8.1.2. Postoperative evaluation

The Scheimpflug image shown below displays distance to the iris and to the crystalline lens.
the same case after the successful Artisan PIOL Her post-op refraction:
implantation. It is quite evident space from the OD: +0.25 (-1.00 X 180),
anterior PIOL surface to the endothelium OS: +0.50 (-1.00 X 180).
centrally and at the periphery (Figure. 2). The We had a good pre-op planning and a happy
posterior of the PIOL presents also enough post-op patient.

Figure 2: Scheimpflug image after Artisan IOL implantation.

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Pentacam Instruction Manual

9. Cataract

9.1. Case 1, Cortical Cataract, Tobias Neuhann, MD

A 23 year old -12.5 D myopic white female have
had a fundus examination in a local eye
department. Best spectacle corrected visual
acuity (BSCVA) was 20/30. Best corrected visual
acuity with contact lenses (BCLCVA) was not
documented. She was told having cataract
surgery would be the only option to enhance
visual acuity. Now she appeared in our clinic for
a second opinion. Scheimpflug image (Figure 1)
could perfectly document the peripheral cortical
density (yellow arrow).
The cause for the reduced spectacle best
corrected vision was corneal warpage caused by
the contact lenses which slightly changed in two
weeks (second table).

Figure 1

Figure 2
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Pentacam Interpretation Guideline

10. Corneal transplant

10.1. Case 1, Removing the sutures?, Tobias Neuhann, MD

A 22 year old white male had corneal transplant
due to keratoconus 12 months earlier. The first
suture was already removed. The examination
with the Pentacam shows a small corneal
astigmatism (Figure 1) but a peripheral hot spot
(white arrow). The BSCVA was 20/25 after
removing the first sutures. I have no idea what
happens after removing the second sutures.
WHAT WOULD YOU RECOMMEND
Question is now: REMOVE THE SECOND
SUTURES YES or NO

Figure 1

We recommended no suture removal because of astigmatism. The patient only wears his glasses
the „hotspot“ temporal of the center and the low for driving at night.
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Pentacam Instruction Manual

11. What would you recommend?

11.1. Case 1, Keratoconus and Cataract, Tobias Neuhann, MD

A 54 year old male asks for glasses. BSCVA is with undetected keratoconus (Figure 1 & 3), left
on both eyes 20/80 .The Pentacam gives in 2 eye no cataract but undetected keratoconus
seconds the solution why: Right eye cataract (Figure 2 & 4).

Figure 1 Figure 2

Figure 3 Figure 4

Our recommendation is:
1. cataract surgery on the right eye,
2a. deep lamellar keratoplasty left eye
2b. toric IOL implantation left eye after suture
removal.
There is still one question open for the right eye!
Which K reading shall we use for the IOL
calculation?
The Pentacam gives us the true and real
measured central power of the cornea!
We used 42.9 for both K1 and K2.
Postoperative refraction is +0.5 D of the intended
refraction!
NOTE: The Pentacam measures the true power
of the central cornea while topographers have to
extrapolate the central power of the cornea
because of the blind spot in its center where the
camera is located!
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Pentacam Interpretation Guideline

12. Other cases

12.1. Case 1, Corneal Infiltrate, Renato Ambrósio, MD

A 33 year old female referred for evaluation of
corneal infiltrate. Patient refers having used tap
water for cleaning the soft contact lens overnight
two days ago and started symptoms after 6
hours using the lens in OS. She woke up with
moderate secretion. She complains about
photophobia and blurred vision in OS with
glasses. Pentacam was performed in both eyes
and the infiltrate could be documented with
clinical correlation with slit lamp biomicroscopy
(Figure 1, 2).

Figure 1 Figure 2

She herself prescribed topical drop of
combination of neomycin, polymixin B and
dexametasone, using 4 times since last night
and referred mild improvement. Patient was
advised to discontinue contact lens use in both
eyes and asked to stop the medication. We
decided to empirically start 4th generation
Fluoroquinolones every hour around the clock,
having initiated with attack dose of one drop
every ten minutes during the first hour. One day
later she referred improvement in the symptoms
and vision.

Figure 3 Figure 4

Pentacam was repeated in day 3. The infiltrate Scheimpflug images and slit lamp biomicroscopy
has importantly decreased as seen in the
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Pentacam Instruction Manual

(Figure 3, 4). She noted improvement in BSCVA in OS.

12.2. Case 2, Incisional Edema, Renato Ambrósio, MD

A 76 year old female patient referred with Endothelial morphology demonstrates large cells
incisional edema 12 months after phaco that with pleomorfism and polymegatism. Central cell
improved with discontinuation of topical carbonic count was 1.079 cells/mm2.
anydrase inhibitor use.

Figure 1 Figure 2 Incisional edema

Slit lamp exam (Figure 1) can be correlated with Interestingly the Scheimpflug image
the Pentacam exam (Figure 2). The central demonstrates the “U shape” sign or “Camel sign”
cornea was clear with no edema. The peripheral on the densitometry over the edematous area.
cornea at the incision location was edematous This is the high reflectivity of the posterior layer
with small bullae formation on the surface. The of the cornea at the incision level.
pachymetric map correlates with this finding.
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Pentacam Interpretation Guideline

12.3. Case 3, Corneal Thinning after Herpetic Keratitis, Renato Ambrósio, MD

A 68 years old female patient enters the office

with a long history of several episodes of HSV
(Herpes-simplex-Virus) stromal keratitis. The
careful slit lamp examination (Figure 1) reveals a
sub-epithelial scarring of the central cornea
consistent with “ghost scarring” of HSV.

Thinnest spot

Figure 2

Pentacam exam is useful to document corneal examination (Figure 2). Patient was kept on
thickness. The thinnest spot is displayed in the prophylactic Acyclovir 800 mg per day, omega 3
Pachymetry map and can be seen in the essential fatty acid supplementation (Flaxseed
Scheimpflug images which serve for follow up oil, 1g BID) and topical artificial tears.
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Pentacam Instruction Manual

12.4. Case 4, Epithelial Ingrowth after Keratomileusis in situ,

Renato Ambrósio, MD

A 41 years old male patient with history of in situ

Keratomileusis in 1991 and one re-treatment for
removal of epithelial ingrowth.
The Slit lamp examination (Figure 1) reveals
epithelial ingrowth under a moderately deep cap
in OD, reaching the center of the pupil area.

With the Pentacam the ingrowth can be easily

seen in the tomography (Figure 2). The
Pachymetry map in the four map screen (Figure
3) shows this effect too just while having an
opaque cornea. The Pentacam was useful for
evaluating corneal elevation, curvature,
thickness and opacity.
Figure 1

ingrowth

Figure 2 Figure 3
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Pentacam Interpretation Guideline

13. Recommended Settings and Color Maps

During many talks with doctors who are starting
to work with the Pentacam we often got the
question concerning the settings and step width
of the color scale, to which maps and values
should we look before doing LASIK, PRK, RK or
before doing an implantation of an phakic IOL,
for detecting keratoconus etc.
In the following chapter we give some
recommendations while knowing we will not
cover everything but hopefully most of the cases.
We know that each doctor is used to work with
his individual maps and settings for many years.
Therefore please understand the following
chapter as recommendations only, but perhaps
some new and interesting points are mentioned.

13.1. Recommended Settings

For the correct use and interpretation of the o Q < 0 untreated cornea, normal
following chapters it is necessary to use the case,
same settings because the given values often o Q > 1 treated cornea
need defined basic settings. LASIK/PRK/RK etc.
ƒ Color scale American Style,
ƒ In the scan menu 25 images per scan o step width normal (10µm) for
and auto release; pachymetry maps;
ƒ For the elevation maps, a sphere, o step width normal (1dpt) for
fitted in float (BFS), diameter topography maps;
automatic; o step width rel. (2.5µm) minimum
ƒ Keratometer presentation for elevation maps.
Rflat/Rsteep, refractive power (dpt); ƒ Especially for the American market use
ƒ Corneal Form Factor Asphericity Q the 9mm loupe function.

13.2. Recommended Color Maps

13.2.1. Screening for LASIK, PRK etc.

We recommend using the following maps and the normal range to have information
analyzing displays: about the corneal stability.
ƒ Zernike Analysis
ƒ 4 maps refractive especially for re-treatments to see
To check pachymetry, topography and whether there are high order aberrations
the elevation maps of both corneal highlighted in red.
surfaces. ƒ Important values
ƒ Keratoconus detection and Rf and Rs, Asti and Axis, Q-value, QS,
quantification Pachymetry in the thinnest spot and in
to check whether there is a keratoconus the pupil centers, border values in the
and if corneal thickness progression is in elevation maps (ant.: < 12µm, post.:<
15µm),

Pentacam Instruction Manual
13.2.2. Screening for PIOL implantation
We recommend using use the following maps
and analyzing displays:
ƒ 4 maps Chamber
to check the anterior chamber depth,
especially in the periphery; sometimes it
is helpful to look at the large color map
of the anterior chamber depth. The
topography maps in sagittal radii as well
as the True Net Power map are
displayed, too, to check whether the
cornea was treated or if the posterior
corneal surface shows abnormalities
13.2.3.
We recommend using the following maps and
analyzing displays:
ƒ Overview screen
look to the chamber angle in the
Scheimpflug images and to the corneal
thickness. Correct the tonometrically
measured IOP with the implanted
13.2.4. IOL Calculation for Treated and Untreated Corneas
We recommend using the Holladay Report which
has the advantage of a comprehensive overview
about the cornea. The topographic maps are
displayed as well as the pachymetry map and
the anterior and posterior elevation maps. The
ACD, the simulated K-values (SimKs) are
presented as well as the Equivalent-K-Readings
Page 41
which may cause changes in refractive
power.
ƒ Scheimpflug images
to get information about the dimensions
of the anterior chamber and of the iris
curve. The chamber angle is shown also
to see whether there is an open or
closed angle.
ƒ Important values
Rf and Rs, Asti and Axis, Q-value, QS,
ACD (anterior chamber depth)
Pachymetry in the thinnest spot and in
the pupil center.
Glaucoma Screening
correction tables. The chamber depth
and chamber volume is obviously small,
usually > 100mm3 for close angle
glaucoma risk patients.
ƒ Important values
ACD, chamber volume, chamber angle,
Q-value, QS, Pachymetry, IOP-
correction.
(EKRs). The current ratio back/front power is
depicted, too. This makes it easy to check
whether the cornea has undergone any
refractive surgery or not. Based on the individual
experiences each one can decide which values
will give the best outcome for the patient, using
the EKR’s, SimK’s or the Rm.
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Pentacam Interpretation Guideline

13.2.5. Screening for Keratoconus and Ectasia

The screening for keratoconus and post LASIK
Ectasia becomes more and more a key decision
making process.
ƒ The Pentacam has the Keratoconus
detection and quantification program.
The keratoconus program considers the
anterior corneal surface only and uses
the Amsler scale for the classification.
The evaluation of the corneal thickness
progression compares the current
examination data to a normative
database.
ƒ Especially for LASIK/PRK screening the
anterior and posterior elevation data
using the settings: BFS float and
automatic diameter supports the
detection of Ectasia. As border values
the following numbers can be used: in
the anterior elevation map differences
between the BFS and the corneal
contour
o less than +12µm are considered
normal,
o between +12µm and +15µm are
suspicious,
o more than +15µm are typically
indicative of
keratoconus/Ectasia.
Similar numbers about 5µm higher apply
to posterior elevation maps.
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Pentacam Instruction Manual

14. References and Contact Addresses

Tobias H Neuhann MD Eduardo Viteri, MD.

Clinical director Humana Vision, Centro Oftalmologico
AaM Augenklinik am Marienplatz Panama 616 y Roca
Marienplatz 18/19 4759 Guayaquil
Munich 80331 Ecuador
Germany eviteri@ecuadorlaser.com
sekretariat@a-a-m.de
www.augenklinik-marienplatz.de
Tel: +49-89 230 8890 Renato Ambrósio Jr, MD, PhD
Fax: +49-89 230 88910 Director of Cornea and Refractive Surgery
Instituto de Olhos Renato Ambrósio & Refracta -
RIO
Michael W. Belin MD Rua Conde de Bonfim 211/712
Professor of Ophthalmology 20520-050 Tijuca, Rio de Janeiro,
7 Old English Road Brazil; zip code 20520-050
Slingerlands, New York 12159 http://www.iolhosrenatoambrosio.com.br/
USA renatoambrosiojr@terra.com.br
MWBelin@aol.com

Oculus Optikgeräte GmbH

Jack T. Holladay, MD, MSEE, FACS Münchholzhäuser Str. 29
Holladay LASIK Institute 35582 Wetzlar
Bellaire Triangle Building Tel: +49-(0)641-2005-0
6802 Mapleridge, Suite 200 Fax: +49-(0)641-2005-295
Bellaire, TX 77401-3947 www.oculus.de
USA
docholladay@docholladay.com

Gilg A.N., MD
Lyon-Europe Vision Center
14 Rue Rabelais
F - 69003 Lyon
FRANCE
docteurangilg@club-internet.fr