The detection of ectasia risk among refractive surgery candidates should go beyond corneal topography and CCT. The identification of mild forms of keratoconus and related disorders is not the ultimate goal. Rather, surgeons are attempting to evaluate whether a cornea can biomechanically withstand the refractive procedure. Along with CTm, ophthalmologists should consider performing a corneal biomechanical assessment to increase patients’ safety and enhance surgical efficacy. In addition, it is worth taking these novel parameters into account when treating ectatic eyes with alternative procedures to corneal transplantation such as corneal collagen cross-linking, surface ablation, and the implantation of intracorneal ring segments.

Scheimpflugtopography

One of the most common challenges for any refractive surgeon is to properly identify and address patients at increased risk of ectatic progression. Traditionally, surgeons have used Placido disk-based corneal topography and ultrasound central corneal thickness (CCT) measurements when screening refractive surgery candidates for their risk of ectasia.1,2

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Elevation maps are calculated as the difference between the examined corneal surface (anterior or posterior) and a reference body.15 The best-fit reference with more coincident points is calculated. The geometric body of best fit and the considered area of the corneal surface will influence the elevation map. Both the best-fit sphere (BFS) and the best-fit toric ellipsoid are adequate references for ectasia screening, but different patterns and elevation values will be obtained. For practical purposes, I routinely use the BFS to the fixed area of 8 mm.12 In normal eyes, an average elevation value at the thinnest point using a floated BFS for 8 mm is 3.6 ±4.7 μm.16,17 The best cutoff for keratoconus is 14 μm. The Belin intuitive scale with 61 colors and a 2.5-μm step (Figure 2) has been found to be the most reliable for elevation maps. The yellow value of +15 at the thinnest point warrants suspicion, because it would occur in less than 1% of normal corneas.18

ScheimpflugMeaning

In a normal population (n = 226; R. Ambrósio, MD, unpublished data, 2009), the mean central keratometry reading was 43.10 ±1.43 D (standard deviation [SD]). For the highest keratometry reading, it was 44.60 ±3.40 D (SD). I developed the absolute scale Ambrósio 2, with 61 colors, for curvature maps so that these normal values would be in the range of green to green-blue and the suspicious values would be in the yellow-to-orange range. This scale is also used for pachymetric maps. Artificial intelligence algorithms that employ curvature data can be utilized as the Oculus topometric keratoconus classification as well (Figure 1).

Deviation of normality values were implemented for the front and back enhanced elevations. Thinnest value, pachymetric distribution, and vertical displacement of the thinnest value in relation to the apex are calculated. In this approach, a value of zero represents the average of the normal population, and a value of one is one SD toward the disease (ectasia) value. A final deviation value is calculated from a regression analysis that weighs each parameter differently. Based on studies involving eyes with normal front curvatures from cases of asymmetric keratoconus, eyes that had ectasia after LASIK with no identifiable risk factors, and eyes that experienced a natural progression of ectasia, my colleagues and I found that a deviation value higher than 1.42 is suspicious for ectasia risk.12

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Blood Harmony affirms Larkin Poe as an essential force in shaping the identity of Southern rock ‘n’ roll, breathing new energy into the genre with both forward-thinking perspective and a decidedly feminine strength. In a departure from the self-contained approach of past albums like 2020’s Self Made Man – praised by American Songwriter as “pumped up for arena-sized consumption without compromising any of its stripped-down command and intensity” – Larkin Poe co-produced the new album alongside Texas-bred musician Tyler Bryant (also Rebecca’s husband). With Megan handling harmony vocals, lap steel, and resonator guitar and Rebecca on guitar and keys, Larkin Poe also enlisted members of their longtime live band, including drummer Kevin McGowan and bassist Tarka Layman. Mainly recorded at Rebecca and Tyler’s home studio, the result is an electrifying new work that fully harnesses the fiery vitality they’ve shown in touring across the globe, imbuing their songs with equal parts soulful sensitivity and thrilling ferocity. From the feverish guitar work of “Bad Spell” to the soul-stirring “Southern Comfort” and smoldering title track, Blood Harmony reveals a band in complete touch with their formidable intuition, their storytelling fortified with a blues-heavy sound that hits right in the heart.

There is a high level of agreement between curvature maps obtained from Placido disk-based topography and rotating Scheimpflug tomography (R. Ambrósio, MD, unpublished data, 2009 and 2010; M.W. Belin, MD, unpublished data, 2008). Nonetheless, differences are expected because of the fundamental differences between the reflection and projection techniques. The curvature patterns described in normal corneas using Placido disk-based topography13 are therefore applicable when evaluating Scheimpflug-based corneal tomography, along with the classic criteria for detecting ectasia. The Rabinowitz- McDonnell indices are highly popular. In these, steepness is suspicious when higher than 47.20 D, and superior-inferior asymmetry is suspicious when higher than 1.40 D.14

Larkin Poe are currently celebrating Blood Harmony on a marathon world tour, including North American dates as part of Willie Nelson & Family’s Outlaw Music Festival Tour beginning July 29 at Cuyahoga Falls, OH’s Blossom Music Center and continuing into September. For complete details and ticket information, please visit www.larkinpoe.com/tour.

Scheimpfluglens

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The importance of the pachymetric map was once unrecognized. It allows clinicians to determine the truly thinnest point value and its location in relation to the center of the cornea. In addition, it permits characterization of the distribution of thickness throughout the entire cornea.

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The interpretation of color-coded topographic and tomographic maps for clinical decisions is a relatively complex and confusing task. Users must have a basic knowledge of the type of maps that are evaluated in order to carefully and consciously choose the colorcoded scale for each map.

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The PPI is combined with the thinnest point for the calculation of relational thickness. The Ambrósio relational thickness (ART) for the average meridian and the ART maximal meridian are useful for detecting ectasia and ectasia risk. The cutoff values are 480 μm for ART average and 390 μm for ART maximal.

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Twenty-five to 50 Scheimpflug images are acquired during one scan for a 3-D tomographic reconstruction with the Pentacam. A second frontal pupillary camera aligns the images and compensates for ocular movement. The device calculates a quality specification score, which takes into account the area covered, alignment, and ocular motion. This score helps users assess the validity of the data in each examination.

Scheimpflugcamera

The Belin-Ambrósio Enhance Ectasia Display (BAD; Figures 2 and 3) combines the described pachymetric distribution data and the enhanced elevation introduced by Michael W. Belin, MD. In this approach, a new (enhanced) BFS is calculated for the 8-mm zone, excluding an area centered on the thinnest portion of the cornea. If the excluded area protrudes, the resultant BFS will be flatter, and the difference between the standard and enhanced BFS will be high. This approach is used for the anterior and posterior elevations. Normal population studies served as the basis for the green-yellow-red color thresholds on the display.

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Scheimpflugcamera Ophthalmology

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My colleagues and I have described the concepts of a corneal thickness spatial profile and a percentage thickness increase (PTI) that are displayed in graphs containing the mean and two SD values obtained in a normal population (black dotted lines).19-21 In addition, pachymetric progression indices (PPIs) are calculated for all hemimeridia over the entire 360º of the cornea, starting from the thinnest point. The PPI will be higher if the cornea abruptly gets thicker from the thinnest point out to the periphery (PTI and corneal thickness spatial profile graphs falling down; Figures 2 and 3). In a normal population, the averages and SD of PPI of the minimal and maximal meridians and the average of all meridians are 0.58 ±0.3, 0.85 ±0.18, and 0.13 ±0.33, respectively.

Scheimpflugtomography

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Scheimpflugprinciple Pentacam

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“When steering by your own stars, you never quite know where you’re going to wind up,” says Larkin Poe. “Our true north is unique to us, and in following our true north without compromise, we have been out freewheeling this world on the ride of our lives. And it still feels like just the beginning. Blood Harmony is a creative step we are proud to have taken together as sisters. We grew these songs in a sweet part of our hearts and we hope they bring beauty.”

The advent of corneal tomography (CTm) represents an evolution in corneal analysis.11 CTm computes a three-dimensional (3-D) image of the cornea, beyond corneal surface topography and CCT. CTm permits the characterization of the front and back surfaces of the cornea, thereby generating a pachymetric map. As with any auxiliary examination, users must have a proper understanding of the fundamental clinical questions related to the need for the complementary data to appreciate the test’s relevance. Regarding the role of CTm for screening refractive surgery candidates, it is critical to understand that a susceptibility to ectasia (often referred to as forme fruste keratoconus) usually occurs in eyes with relatively normal front-surface topography. In these cases, an abnormal back elevation and pachymetric distribution provide evidence that the tomographic characterization enhances the sensitivity of this approach for detecting a predisposition to ectasia.12

In addition to topography and CCT, researchers considered the patient’s level of correction, residual stromal bed, and age when developing the Ectasia Risk Scoring System,3 which was later validated.4 This system originally had 4% to 8% false negatives.3-5 In a separate retrospective study involving 36 cases of ectasia after LASIK, nine eyes (25%) were classified as low risk.6 These observations are in agreement with other cases of ectasia after LASIK in the absence of apparent risk factors based on classic screening methods.7-9 The incidence of false positives is also relatively high among cases that are stable after LASIK.10 The need for more sensitive and specific tests to evaluate refractive surgery candidates’ risk of ectasia is therefore without question.

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Scheimpflugpronunciation

“‘Blood Harmony’ came together after Megan and our mom and I all read Ruth Ozeki’s A Tale for the Time Being, which is about the ways we perceive the passage of time,” says Rebecca Lovell. “There was just something about the sweetness of all three of us reading the same book, and then being able to talk about how it related to our love for each other and our love for music. Of all the songs I’ve ever written, I’m particularly proud of this one; I cannot wait to sing it loudly with all of our chosen family out on the road.”

Renato Ambrósio Jr, MD, PhD, is the clinical director of cornea and refractive surgery at Instituto de Olhos Renato Ambrósio in Rio de Janeiro, Brazil. He is a consultant to Oculus GmbH. Dr. Ambrósio may be reached at +55 21 2274 5694; renatoambrosiojr@wavefront.com.br.

Oculus Optikgeräte GmbH (Wetzlar, Germany) introduced the Pentacam Comprehensive Eye Scanner in 2002 as the first corneal and anterior segment tomography system using digital rotating Scheimpflug photography. Initially described by Jules Carpentier in 1901, the Scheimpflug principle is a geometric rule commonly used in photography to enhance the depth of focus without significantly distorting the image. Carpentier’s innovative work was cited and credited in the original patent by Theodor Scheimpflug in 1904. In this technique, the three imaginary planes (the film plane, the lens plane, and the plane of sharp focus) are disposed in a nonparallel manner.

Larkin Poe – the GRAMMY® Award-nominated duo of Georgia-bred, Nashville-based multi-instrumentalist sisters Rebecca and Megan Lovell – have shared “Blood Harmony,” available now at all DSPs and streaming services. The smoldering title track from their upcoming sixth studio album is joined by an official music video that premiered today via Guitar World. Blood Harmony arrives via Larkin Poe’s own Tricki-Woo Records on Friday, November 11. Pre-orders are available now, including limited edition magenta colored vinyl, CD, cassette, and more.

Blood Harmony was first heralded this spring by the ferocious “Bad Spell,” available now at all DSPs and streaming services. An official music video is streaming now via YouTube. “Bad Spell” – which Rebecca Lovell describes as “a female response” to Screamin’ Jay Hawkins’ classic “I Put a Spell on You” – was met by critical applause around the world, with Americana-UK hailing its “leather jacket swagger,” adding, “This fierce blues rock barnburner from Larkin Poe conjures arena strutting 70’s rockers and the first wave of British blues in the 60’s.” “Rebecca delivers some monumental riffage on the tune,” wrote Guitar World, “with her sister Megan adding some singeing lap steel statements to the picture.”

Progressive jam giants Umphrey's McGee‘s return to Las Vegas for the seventh installment of the massively popular UMBowl production was marked once again by a stand-out tour closing dual evening extravaganza where all stops were pulled out and the power given directly to the fans, for better or for worse.