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• W2922566957 abstract "We read with interest the article by Hwang et al,1Hwang E.S. Perez-Straziota C.E. Kim S.W. et al.Distinguishing highly asymmetric keratoconus eyes using combined Scheimpflug and spectral-domain OCT analysis.Ophthalmology. 2018; 125: 1862-1871Abstract Full Text Full Text PDF PubMed Scopus (62) Google Scholar which reported that the addition of posterior corneal indices into a combined Scheimpflug/OCT metrics was not useful in differentiating the unaffected asymmetrical keratoconus (AKC) eye from the control population. Subjective pattern recognition by 1 author was performed to identify the unaffected AKC eye in the present study, which was defined as eyes with “no clinical evidence of disease, no physical findings on slit-lamp examination, no definitive abnormalities on corneal imaging, and corrected distance acuity of 20/20 or better.” These inclusion criteria are qualitative and do not allow other authors to reproduce the study cohort for comparison. Considering the limitations of subjective interpretation of corneal topography maps, we believe objective criteria should be rigorously applied before a corneal topography map can be considered normal. Surface curvature indices used to objectively define the inclusion criteria of the topographically normal AKC eyes should be considered, such as a keratoconus percentage index score of <60 and a paracentral inferior–superior asymmetry value at 6 mm (3-mm radii) of <1.45 as described by Rabinowitz and Rasheed.2Rabinowitz Y.S. Rasheed K. KISA% index: a quantitative videokeratography algorithm embodying minimal topographic criteria for diagnosing keratoconus.J Cataract Refract Surg. 1999; 25: 1327-1335Abstract Full Text Full Text PDF PubMed Scopus (300) Google Scholar Ambrósio et al3Ambrósio Jr., R. Lopes B.T. Faria-Correia F. et al.Integration of Scheimpflug-based corneal tomography and biomechanical assessments for enhancing ectasia detection.J Refract Surg. 2017; 33: 434-443Crossref PubMed Scopus (188) Google Scholar applied these objective criteria and relabeled 23 eyes initially thought to be topographically normal as keratoconus eyes in their study evaluating the role of the tomographic and biomechanical index in detecting the very asymmetric ectasia eyes with normal topography. Despite applying these quantitative cutoffs, some of the 94 very asymmetric ectasia with normal topography eyes were still regarded to have a suspicious curvature map.3Ambrósio Jr., R. Lopes B.T. Faria-Correia F. et al.Integration of Scheimpflug-based corneal tomography and biomechanical assessments for enhancing ectasia detection.J Refract Surg. 2017; 33: 434-443Crossref PubMed Scopus (188) Google Scholar A recent study by Shajari et al4Shajari M. Jaffary I. Herrmann K. et al.Early tomographic changes in the eyes of patients with keratoconus.J Refract Surg. 2018; 34: 254-259Crossref PubMed Scopus (23) Google Scholar performed sequential measurements in 27 fellow eyes of unilateral keratoconus, which have not yet shown any ectatic changes. The D-index changed from 0.91±0.39 to 1.48±0.45 between the 2 measurements separated by a mean duration of 360±246 days. These eyes were tomographically normal according to the elevation maps, corneal thickness, maximum keratometry, and D-index. They found that nearly all 27 of the eyes had a progression in the posterior cornea elevation whereas the keratometry and pachymetry did not necessarily change between the 2 measurement points.4Shajari M. Jaffary I. Herrmann K. et al.Early tomographic changes in the eyes of patients with keratoconus.J Refract Surg. 2018; 34: 254-259Crossref PubMed Scopus (23) Google Scholar It is possible that keratoconus eyes could have been erroneously labeled as the unaffected AKC eyes (D-index = 1.56±0.79) in the present study,1Hwang E.S. Perez-Straziota C.E. Kim S.W. et al.Distinguishing highly asymmetric keratoconus eyes using combined Scheimpflug and spectral-domain OCT analysis.Ophthalmology. 2018; 125: 1862-1871Abstract Full Text Full Text PDF PubMed Scopus (62) Google Scholar resulting in a more “advanced form” of subclinical keratoconus in the current study cohort. This could have reduced the impact of the posterior corneal elevation, which is particularly relevant for the diagnostic sensitivity in the early stage of the disease. It was also unclear from the methodology and results what were the posterior corneal indices and elevation parameters tested in the authors’ combined variable modeling. Posterior corneal elevation near the pupil is valuable in detecting subclinical keratoconus. We believe it is necessary to evaluate the role of the posterior corneal elevation in the central or paracentral cornea, rather than the elevation of the entire posterior corneal surface represented by the deviation of the back surface elevation difference from the Belin/Ambrósio Enhanced Ectasia Software. The recently introduced posterior radius curvature parameter on the Pentacam HR (Oculus GmbH, Wetzlar, Germany), which reflects the corneal curvature at the zone 3 mm away from the thinnest point on the posterior corneal surface, should also be considered. The conclusions drawn by the authors apply to the machine-derived metrics from Scheimpflug imaging and spectral-domain OCT only. Whereas some studies reported minimal or no changes in posterior corneal elevation after LASIK using Scheimpflug imaging, we previously demonstrated that, using swept-source OCT, a mild but significant forward protrusion of the posterior cornea were demonstrated after LASIK in our longitudinal study.5Chan T.C. Liu D. Yu M. et al.Longitudinal evaluation of posterior corneal elevation after laser refractive surgery using swept-source optical coherence tomography.Ophthalmology. 2015; 122: 687-692Abstract Full Text Full Text PDF PubMed Scopus (33) Google Scholar Swept-source OCT can image the posterior cornea better than Scheimpflug imaging because of its shorter scanning time (0.3 vs 2.0 seconds) and longer wavelength (1310 vs. 475 nm). Longitudinal studies using swept-source OCT are needed before we can refute the role of the posterior corneal elevation as a potential index in identifying eyes at risk of developing ectasia. Distinguishing Highly Asymmetric Keratoconus Eyes Using Combined Scheimpflug and Spectral-Domain OCT AnalysisOphthalmologyVol. 125Issue 12PreviewTo determine optimal objective, machine-derived variables and variable combinations from Scheimpflug and spectral-domain (SD) OCT imaging to distinguish the clinically unaffected eye in patients with asymmetric keratoconus (AKC) from a normal control population. Full-Text PDF ReplyOphthalmologyVol. 126Issue 4PreviewWe thank Drs Wan and Chan for their interest in our article and for the opportunity to clarify some points they bring up regarding patient selection and posterior corneal surface metrics. In our study,1 we did not use any predetermined indices to identify the study population; this was by design, because the ideal quantifiable parameters to identify subclinical disease in patients with highly asymmetric keratoconus have not yet been determined. Identifying the optimal metrics to distinguish between the clinically unaffected eye from patients with asymmetric keratoconus and normal control eyes was the clearly stated objective of this study. Full-Text PDF" @default.
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• W2922566957 title "Re: Hwang et al.: Distinguishing highly asymmetric keratoconus eyes using combined Scheimpflug and spectral-domain OCT analysis (Ophthalmology. 2018;125:1862-1871)" @default.
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