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Review Article

Angle Kappa and its importance in refractive surgery

Majid Moshirfar, Ryan N. Hoggan1, Valliammai Muthappan
John A Moran Eye Center, Salt Lake City, 1University of Utah, School of Medicine, Salt Lake City, Utah, USA

Angle kappa is the difference between the pupillary

and visual axis. This measurement is of paramount
consideration in refractive surgery, as proper centration
is required for optimal results. Angle kappa may
contribute to MFIOL decentration and its resultant
photic phenomena. Adjusting placement of MFIOLs
for angle kappa is not supported by the literature but
is likely to help reduce glare and haloes. Centering
LASIK in angle kappa patients over the corneal light
reflex is safe, efficacious, and recommended. Centering
in-between the corneal reflex and the entrance pupil is

also safe and efficacious. The literature regarding PRK

in patients with an angle kappa is sparse but centering
on the corneal reflex is assumed to be similar to
centering LASIK on the corneal reflex. Thus, centration
of MFIOLs, LASIK, and PRK should be focused on the
corneal reflex for patients with a large angle kappa.
More research is needed to guide surgeons approach
to angle kappa.
Keywords: Angle Kappa, Visual Axis, Pupillary Axis,
LASIK, PRK, Multi focal Intra ocular lenses.

Introduction
With recent advancements in the precision of refractive surgery
angle kappa stands as an important consideration in improving
visual outcomes. Angle kappa is defined as the angle between
the visual axis (line connecting the fixation point with the fovea)
and the pupillary axis (line that perpendicularly passes through
the entrance pupil and the center of curvature of the cornea).[1]
It can be identified clinically by the nasal displacement of the
corneal light reflex from the pupil center,[2] and it represents a
misalignment of light passing through the refractive surface of
the cornea and the bundle of light formed by the pupil. Figure 1
depicts a coronal view of angle kappa as well as the surgeons view
when seen through the microscope.
A large angle kappa is clinically significant as it may lead to
alignment errors during photo ablation in laser refractive surgery,[3]
as well lens decentration in intraocular refractive surgery. The
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DOI:
10.4103/0974-620X.122268

Figure 1: (a) Depicting angle , geometric center of the cornea (GCC), entrance pupil
center (EPC), and coaxially sighted corneal light reflex (CSCLR) as identified by Pande
and Hillman,[4] (b) Surgeons view of a large angle kappa, (c) Surgeons view of a
normal but small positive angle kappa. () = EPC (+) = CSCLR

decentration of ablation zones can lead to under correction[4] and

irregular astigmatism.[3] Decentration of intraocular lenses may
cause photic phenomenon[5] and decreased lens effectiveness.[6]
This issue is most important in hyperopic patients, who tend to
have larger angle kappa values.[3,7]
A Pubmed literature review was conducted for several terms related
to angle kappa and refractive surgery. Relevant manuscripts were

Copyright: 2013 Moshirfar M, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which
permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Correspondence:
Dr. Majid Moshirfar, John A. Moran Eye Center, 65 N Mario Capecchi, Salt Lake City, UT 84132, USA. E-mail: majid.moshirfar@hsc.utah.edu

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Moshirfar, et al.: Angle kappa and refractive surgery

compiled into this review to summarize the current literature
on the role of angle kappa in refractive surgery, specifically as it
relates to PRK, LASIK, and placement of multifocal intraocular
lenses (MFIOLs).

cause photic phenomenon [5] and is one of the main indications

for MFIOL exchange.[12] A large angle kappa could contribute to
functional decentration if the MFIOL is centered on one axis,
(pupillary or visual axis) and is not aligned with the other.

Materials and Methods

In 2011 Prakash et al reported that larger preoperative angle

kappa values in MFIOL placement were correlated with patient
complaints of glare (R2= 0.26, P= 0.033). They also reported that
perceived severity of haloes were correlated to angle kappa and
postoperative uncorrected distance visual acuity (UCVA) (R2 =
0.26, P = 0.029).[5] While positive angle kappa may play a role in
contributing to glare and haloes, dissatisfaction with MFIOLs is
truly multifactorial. Blurry vision of various etiologies,[13] other
forms of photic phenomenon,[14] and unsatisfactory postoperative
distance UCVA[5] are more common patient complaints after
receiving MFIOLs.

A thorough PubMed search was conducted using various

combinations of the following terms: Angle Kappa, LASIK, PRK,
Intraocular lenses, Capsulorrhexis, Centration, Refractive Surgery,
Cataract Surgery, Pupillary Axis, Visual Axis, Coaxial Axis, Pupil
Tracking, and Hyperopia. The search was limited to articles of
the following types: Reviews, systematic reviews, randomized
controlled trial, practice guidelines, meta-analysis, journal article,
guideline, clinical trial, and case reports. The initial literature
review resulted in 66 articles. From the initial inquiry articles
were chosen based on their relevance to Angle kappa, MFIOLs,
LASIK, PRK and Hyperopia. In total 40 articles were selected,
reviewed for relevant content, and compiled into this review.

Angle kappa in the general population

As the fovea lies slightly temporal to the point at which the
pupillary axis intersects with the posterior pole of the globe, the
normal angle kappa is slightly positive.[3] The high prevalence of
small positive angle kappa values in the non-hyperopic population
was reported in 2005 by Srivannaboon and Chotikavanich. In
408/420 (97%) eyes undergoing refractive surgery for correction
of myopia, a positive angle kappa of 0.5 mm or less was
observed.[8]
Several studies have been conducted to determine the populations
mean value of a positive angle kappa. The results of these studies
are summarized in Table 1. Based on current literature the mean
value of angle kappa in a normal population of emmetropes lies
between 2.78 0.12 in right eyes and 3.32 0.13 in left eyes when
measured by the Syntophore corneal topography system (Clement
Clarke International Ltd, London, UK).[3,9] The value lies between
5.55 0.13 and 5.62 0.10 in right and left eyes respectively
when measured by the Orbscan II corneal topographer (Bausch
and Lomb, USA).[3] The range may slightly differ (4.97 1.24) if
measured with the Orbscan IIz (Bausch and Lomb, USA).[10]

A large angle kappa may contribute to functional decentration of

MFIOLs, but the effect of this decentration is not clear. In 2010,
Rosales et al used simulated aberration models generated from
the anatomical, Purkinje, and Sheimpflug data of 21 eyes to show
that the tilt and decentration of IOLs have only a minor effect
on higher order aberrations.[15] However, it has been reported
that decentration of MFIOLs greater than 0.7 mm substantially
impairs distance visual acuity. [6]
If the lens is significantly decentered because of failure to
accommodate for angle kappa, then central light rays may miss
the central optical zone and pass through one of the multifocal
rings, leading to glare. In 2012, Berdahl suggested that MFIOLs
are unacceptable for use if the angle kappa is greater than half of
the diameter of the central optical zone for the respective lens. For
the ReSTOR lens (Alcon TX, USA) this would be an angle kappa
greater than 0.4mm and for the Tecnis lens (Abbott Illinois, USA)
this would be a value greater than 0.5 mm.[16]

Angle kappa and multifocal intra ocular lenses

One proposed method for compensating for large angle kappa in

MFIOLs is to purposely decenter the lens toward the visual axis.
Due to contraction of the capsule, memory of the haptics, and IOL
rotation, it is uncertain if the lens would stay in the decentered
position.[5] Gluing a single haptic of the IOL to align its position
with the visual axis has also been suggested.[5] Solomon and
Donnefield have reported performing post-operative pupilloplasty
with argon laser to center the pupil, and move the pupillary
axis closer to the visual axis in MFIOL cases with a large angle
kappa.[17] Melki and Harissi-Dagher described a method for
centering the capsulorrhexis on the coaxially sighted intraocular
lens reflex instead of the corneal reflex as a way to accommodate
for angle kappa.[18] These methods may be effective but have
not been validated in large studies. More research is needed to
determine their clinical relevance.

Multi-focal intraocular lenses (MFIOLs) are designed with

concentric apodization to provide functional vision at distance
as well as near. With this design distance and intermediate visual
acuity are adversely affected if the lens is decentered.[6] The
etiology of this is not fully understood. Decentration can also

Based on the current literature, a large angle kappa may contribute

to decentration of MFIOLs potentially resulting in glare and
decreased visual acuity. However, the clinical significance of
lens decentration as a direct result of angle kappa is not fully

The significance of eye dominance as well as the machine used to

measure angle kappa is not fully understood however, these are
two variables that should likely be considered when contemplating
issues related to angle kappa. Additionally gender does not appear
to be correlated with angle kappa.[1] While angle kappa tends to
decrease with age,[1] the change in direction or magnitude is not
significant.[11]

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Moshirfar, et al.: Angle kappa and refractive surgery

Table 1: Summary of studies reporting normative angle kappa values

Author

Type of
study

# of eyes/
patients
studied
108 strabismic
subjects and
102 healthy
controls

Method of
measurement

Angle kappa
values

Signicant
ndings

Basmak et al.
(2007)[9]

Prospective
group
comparison

Synoptophore
Topographer
(Clement
Clarke,
London, UK)

Esotropic group: OD 2.35 0.41 OS

2.55 0.42
Exotropic group: OD 3.83 0.36 OS
4.38 0.28

Prospective
group
comparison

150 men and

150 women

Synoptophore
Topographer
Orbscan
II (Bausch
and
Lomb, USA)

Hashemi et al.
(2010)[1]

Cross
sectional
survey

800 eyes from

442
participants

Orbscan
Topographer
(Bausch and
Lomb,
USA)

Zarei-Ghanavati
et al.
(2013)[10]

Prospective
controlled
study

96 eyes from
48 myopic
patients

Orbscan II
z (Bausch
and
Lomb, USA)

Synoptophore
Myopic Group: OD 1.74 0.13 OS 1.91
0.14
Hyperopic group: OD 3.44 0.14 OS
3.84 0.17
Orbscan II
Mypoic Group: OD 4.51 0.11 OS
4.73 0.11
Hyperopic Group: OD 5.65 0.10 OS
5.73 0.10
Myopic Group: 5.13 1.50
Emmertropic Group: 5.72 1.10
Hyperopic Group: 5.52 1.19
Mild Hyperopic Group: 5.53 1.24
Moderate Hyperopic Group: 5.45
1.26
Severe Hyperopic Group: 5.59 2.61
Preoperative mean angle kappa values:
4.97 1.24
Postoperative mean angle kappa values:
4.99 1.10

Exotropes have signicantly

higher values of angle kappa
than esoptropes or controls.
Angle kappa tends to be
larger in left eye than in right eye.
Positive correlation between
angle kappa and positive
refractive errors.
Orbscan II values are an
average of 1.55 mm larger than
Synoptophore values

Basmak et al.
(2007)[3]

understood. There is no evidence to show that altering centration

of MFIOLs is detrimental or dangerous for the patient. Thus
we recommend centering these lenses on the corneal reflex in
eyes with angle kappa values greater than the normative values
discussed earlier as per eye and per topography system used.

Angle kappa in laser guided refractive surgery: the debate

over where to center ablation profiles
There are four main methods for centration of laser refractive
surgery that have been suggested in the literature:
1. Center of the pupil: In 1987, Uozato and Guyton suggested
using the center of the pupil[19] as it has been shown that
photoreceptors actively orient themselves toward the
pupillary center.[20] Mandell seconded this suggestions with
the rationale that the pupil defines the bundle of light that
passes through the eye and forms the retinal image.[21]
2. Coaxially Sighted Corneal Light Reflex: In 1993, Pande and
Hillman concluded that the coaxially sighted corneal light
reflex (CSCLR) should be used for centration as it was the
closest measurable point to the visual axis.[4] Additionally,
they noted that the center of the pupil changes position with
changes in the size of the pupil,[22] and thus should not be
used for centration.[4]
3. Corneal Vertex Normal: In 2006, De Ortueta et al centered
ablation zones on the corneal vertex normal,[23] which is the
point of maximum elevation in corneal topography.[2] This
was combined with videokeratoscopy/pupil tracking which
allowed the ablation zone to shift a fixed amount in relation
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Angle kappa is larger in

hyperopes than myopes.
Angle kappa slightly decreases
with age but is not correlated to
gender

There is no signicant change

in angle kappa before and after
PRK

to the center of the pupil as it changed with differing light

conditions.[23] The results of this study are summarized in
Table 2.
4. Between the pupillary and visual axis: In 2009 Kermani et
al centered on a distance halfway between the center of the
pupil (line of sight) and the corneal light reflex (visual axis)
in patients with a large angle kappa.[24]
These four methods of centration have not simultaneously been
compared in head to head trials. The following will discuss what
has been accomplished in the literature specifically as it relates
centering in patients with a large angle kappa.

Angle kappa and hyperopic laser assisted in situ

keratomileusis (LASIK)
Several studies are found in the literature that demonstrate the
benefits of moving centration for hyperopic LASIK to the CSCLR
to adjust for a large angle kappa. This review focused on hyperopic
LASIK as hyperopes are more likely to have a large angle kappa.
These studies are summarized in Table 2.
Nepomuceno et al was the first to validate this method in 2004
with patients who underwent hyperopic LASIK correction using
the LADARVision 4000 excimer laser (Alcon, TX, USA). They
reported an increased safety profile which they attributed to this
centration technique because the same surgeon did not have
equivalently good results when using other centration sites. The
authors stressed the importance of centering over the CSCLR for
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Moshirfar, et al.: Angle kappa and refractive surgery

Table 2: Summary of articles relating angle kappa to LASIK

Author

Study
type

Centration
point used

# of
eyes/
patients
studied
2 eyes
with
positive
angle
kappa

Boxer Walchler
et al.
(2003)[29]

Case report

Entrance pupil
in the right
eye;
CSCLR in the
left eye

Nepomuceno
et al.
(2004)[25]

Retrospective
chart review

CSCLR

61 eyes
of 48
hyperopic
patients

Chan and
Boxer Wachler
(2006)[27]

Retrospective
chart review

CSCLR

21 eyes
from 12
hyperopic
patients

De Ortueta
et al.
(2006)[23]

Retrospective
chart review

Corneal
vertex with
pupil tracker
to maintain
ablation
position

Kermani et al.
(2009)[24]

Retrospective
comparative
chart review

CSCLR
compared to
entrance pupil

52 eyes
of 27
hyperopic
patients
with a
positive
angle
kappa
64 eyes
centered
on the
CSCLR
and 181
eyes
centered
on the
entrance
pupil.

Soler et al.
(2011)[30]

Randomized
prospective
double
masked
comparison

CSCLR
compared to
entrance pupil

30 eyes
centered
on the
CSCLR
30 eyes
centered
on the
entrance
pupil

Results

Signicant
ndings

UDVA 20/80 in the right eye,

20/20 in the left eye.
BSCVA 20/30 in the right eye,
20/16 in the left eye.
BSCCS of 60% in the right eye,
90% in the left eye.
Optical zone decentration in
the right eye of 0.7 mm.
Optical zone decentration in
the left eye of 0.2 mm
UCVA of 20/20 or better in
44.4% of eyes and 20/25 or
better in 88.9% of eyes.
65.6% of eyes within 0.50
diopters of target correction.
Zero eyes lost more than two
lines of BSCVA
Mean UCVA improved from
20/70 to 20/32.
Mean BSCVA went from 20/20
to 20/20-2.
Zero eyes lost two or more
lines of BSCVA.
Mean amount of theoretical
decentration from entrance
pupil 0.45mm or 5.6
100% of eyes had
UCVA20/40.
94% of eyes within 0.50
dipoters of goal refraction.
Zero eyes lost more than one
line of BSCVA.

Single example of
superiority of centering
on the CSCLR
compared with the
entrance pupil in an
angle kappa patient

Visual axis group: (CSCLR)

73% of eyes had a UCVA of
0.8 (20/25) or better.
81% of the eyes within 0.5
diopters of target refraction.
6% of eyes gained two or more
lines of BSCVA.
Line of sight group: (entrance
pupil)
73% of eyes had a UCVA of
0.8 (20/25) or better.
64% of eyes were within 0.5
diopters of target refraction.
3% of eyes gained two or more
lines of BSCVA.
Pupil centered group:
33.3% of eyes set for near and
53.3% of eyes set for distance
achieved UCVA of 20/20.
73.3% of eyes were within 0.5
diopters of intended refraction.
93.3% of eyes had no loss of
BSCVA.
Vertex centered Group
40.0% of eyes set for near and
60.0% of eyes set for distance
achieved UCVA of 20/20.

First to validate
centering ablation zone
over the CSCLR.
Centering on the
CSCLR does not
adversley affect
BSCVA or BSCCS
Theoretical
decentration from
centering over the
entrance pupil is
signicantly larger
than decentration
from centering on the
CSCLR
Validated the safety
and efcacy of LASIK
centered
on the corneal vertex
with pupil tracking in
patients with
a positive angle kappa.
First large head to
head study comparing
centration on
the CSCLR to the
entrance pupil.
Showed only minimal
differences in the
safety and efcacy
between the two
centration points.

No statistically
signicant differences
in visual acuity
outcomes between
centration on the two
points.
Centering on the CSCLR
produces a decrease in
higher order aberrations
which is not seen when
centering on entrance
pupil.
Contd...

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Moshirfar, et al.: Angle kappa and refractive surgery

Table 2: Contd
Author

Study
type

Centration
point used

# of
eyes/
patients
studied

Results

Signicant
ndings

66.7% of eyes were within 0.5

diopters of intended refraction.
83.3% of eyes had no loss of
BSCVA.
Kanellopoulos
(2012)[26]

Prospective
group
comparison

CSCLR

202
eyes of
hyperopic
patients

Mean UDVA improved from

5.5/10 to 8.2/10.
Mean BSCVA increased from
9.1/10 to 9.5/10.
94.4% of eyes within1.00
diopters of refractive goal.
46.6% of eyes gained at least
one line of Snellen acuity.

Centering on the
CSCLR leads to
improvements in
UCVA,
BSCVA, and safety
prole.

CSCLR: Coaxially sighted corneal light reex, UDVA: Uncorrected distance visual acuity, BSCVA: Best spectacle corrected visual acuity, BSCCS: Best spectacle
corrected contrast sensitivity, UCVA: Uncorrected visual acuity, D: Diopters, EP: Entrance pupil

hyperopes due to a large angle kappa, and also because hyperopes

have smaller functional optical zones and less tolerance of
decentration.[25] Several years later, Kanellopoulos also reported a
good safety profile when centering on the CSCLR to accommodate
for angle kappa. In addition, he reported a significant postoperative
improvement in uncorrected visual acuity and an increase in best
spectacle corrected visual acuity (BSCVA).[26]
Chan and Boxer Wachler measured the amount of post-operative
decentration of ablation zones centered on the CSCLR in patients
with a large angle kappa. This value was added to the preoperative angle kappa to represent the amount of decentration
that would have occurred if the ablation had been centered on
the entrance pupil. The theoretical decentration from entrance
pupil centration was significantly larger than the decentration
that actually occurred when centering on the corneal reflex.[27]
Kermani reported a case of a patient with a large angle kappa who
underwent LASIK with ablation centered on the entrance pupil.
Postoperatively he had lost two lines of BSCVA, his hyperopia
was under corrected, and astigmatic error was introduced. The
patient later had a repeat procedure centered on the CSCLR. The
refractive error was corrected and the BSCVA was restored.[28]
The above reviewed studies helped establish the safety and efficacy
of centering ablation profiles on or near the visual axis in patients
with a large angle kappa. In 2003, a case report of a patient with
bilateral large angle kappa provided the first direct comparison of
centering on the entrance pupil versus centering on the CSCLR.
He had LASIK centered on the entrance pupil in the right eye,
and over the CSCLR in the left eye. The left eye demonstrated
significantly better visual acuity, smaller refractive error, and a
smaller amount of post-operative decentration.[29]
While this case report was intriguing, it was not until 2009
that a larger study comparing the two methods was published.
Kermani et al conducted a retrospective review of LASIK centered
Oman Journal of Ophthalmology, Vol. 6, No. 3, 2013

on the pupil versus centration focused on the CSCLR in eyes

with a positive angle kappa. Based on their previous experience
the researchers centered the CSCLR group on a point midway
between the line of sight and the corneal reflex. They reported
only minimal differences in safety and efficacy between the two
centration points. However, they did report a decrease in total
higher order aberrations in the CSCLR group; this effect was not
seen in the pupil centered group.[24]
In 2011, Soler et al published the only randomized double masked
comparison of pupil centered vs. corneal reflex centered hyperopic
LASIK. This study concluded that there were no statistical
differences in terms of safety, efficacy, or accuracy between the two
different centration points[30] However, this study was limited by a
small sample size and by a patient population of mild to moderate
hyperopes. The smaller angle kappa values associated with lower
degrees of hyperopia may have masked prominent differences
between the two centration options.
From the current literature, several conclusions can be drawn.
Angle kappa generally is larger in hyperopic patients. [3] A larger
angle kappa increases the risk for decentration of the optical
zone from the visual axis if ablation is centered over the entrance
pupil. Such decentration can cause many optical problems, induce
astigmatism,[26] and leave the patients visual deficits uncorrected.
Thus, centering over the corneal reflex may decrease higher order
aberrations which the patient is likely to appreciate.[30]
We recommend using the corneal reflex when performing LASIK
on hyperopes, especially when they have a large angle kappa.
Centering over a point half of the distance between the CSCLR
and the pupil center may also be an effective method in angle
kappa patients.[24] Using the entrance pupil when performing
LASIK on myopes or mild hyperopes with a small angle kappa is
safe and efficacious as the entrance pupil and CSCLR will nearly
align. A large double masked head to head trial comparing the
various centration techniques is needed to further guide this
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Moshirfar, et al.: Angle kappa and refractive surgery

debate. This study would be most helpful if it had a large array of
hyperopes with multiple ranges of angle kappa values that could
be individually analysed.

Angle kappa and photorefractive keratectomy (PRK)

There have been very few studies conducted concerning angle
kappa and PRK. Many of these studies only indirectly address
angle kappa by touching on principles of decentration in myopes
or principles applied to hyperopic surgery where angle kappa is
more prevalent. The results of these studies are summarized in
Table 3.
In 1993, Cavanaugh et al noted that angle lambda, the angle
between the pupillary axis and the line of sight, could contribute
to decentration error when performing PRK.[31] Angle kappa and
angle lambda are nearly identical at distance fixation.[32] This study
emphasized centering ablation zones for PRK over the entrance
pupil as crucial to the success of the procedure.[31] However, it
should be noted that this study was conducted on myopes, who
are not as likely as hyperopes to have a large angle kappa.[3]
In 1993, Cavanaugh et al published a separate study on PRK
centered over the entrance pupil, which measured the average
amount of decentration from the corneal vertex that occurs
and resultant effects on visual acuity. They reported a positive
correlation between preserved UCVA and BCVA in patients

whose decentration was less than 1.0 mm.[33] This would suggest
that if PRK is centered on the entrance pupil in a patient with a
large angle kappa, decentration may be insignificant if it is less
than 1.0 mm. However, the relevance of this measurement is hard
to extrapolate as the authors centered their procedures over the
entrance pupil but then measured decentration from the corneal
vertex.
In 1998, Kim et al measured and compared the post-operative
decentration of ablation zones in PRK using three different
methods: 1) ablation zones centered on the corneal light reflex
as viewed by both eyes of the surgeon, 2) ablation zones centered
on the corneal reflex viewed with only the surgeons left eye, and
3) ablation zones centered on the entrance pupil viewed with
only the surgeons left eye. The smallest amount of decentration
was seen in the group which was centered on the entrance pupil
viewed by the surgeons left eye. The largest decentration was
seen when centered on the corneal reflex viewed by the surgeons
left eye only. They attributed this result partly to a large angle
kappa and misalignment, but mainly thought it to be a product
misalignment of the fixation tube when viewing the patients right
eye with the surgeons left eye.[34]
In 2012, Reinstein et al reported a case of PRK centered on the
corneal vertex in a patient with a large vertical angle kappa. The
patient had significant night vision disturbances after having

Table 3: Summary of articles relating angle kappa to PRK

Author

Type of
study

# of eyes/
patients
studied
110
myopic
patients

Method for
centration

Results

Signicant
ndings

Cavanaugh
et al.
(1993)[33]

Unmasked
combined
retrospective
prospective
evaluation
of phase III
clinical trial

Entrance pupil

Decentration less than

1.0 mm from conreal
vertex in PRK likely has
little effect on visual
acuity.

Prospective
head to
head trial

97 myopic
patients

Case report

1 with
haloes and
starbursts
after radial
keratotomy

49 patients
centered on the
CSCLR viewed
binocularly by the
surgeon.
27 patients
centered on the
CSCLR viewed by
surgeons left eye
only.
21 patients
centered on the
entrance pupil
viewed by the
surgeons left eye
only.
Corneal vertex
approximated
by the
rst Purkinje
reex.

Mean UCVA was 20/20 for

decentrations up to 1.00 mm.
BCVA preserved to less than 2 lines
of lost acuity if decentration was
less than 1.00 mm.
Average ablation zone decentation
from corneal vertex of 0.52 mm.
Mean decentration of
0.690.45 mm in the binocularly
viewed corneal light reex group.
Mean decentration of
1.050.48 mm in the left eye
viewing of the corneal light reex
group.
Mean decentration of
0.630.28 mm in the entrance pupil
centration group.

Kim et al.
(1998)[34]

Reinstein
et al.
(2012)[35]

Whole eye higher order root mean

square reduced by 43%.
Corneal higher order root mean
square reduced by 61%.
Patient reported large subjective
improvement in visual symptoms.

Centration of PRK on
CSCLR maybe more
appropriate if corneal
surface is irregular.

Greatest decentration
in PRK is due to angle
kappa and misalignment
of the viewing tube and
the patients eye.

UCVA: Uncorrected visual acuity, BCVA: Best corrected visual acuity, CSCLR: Coaxially sighted corneal light reex

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Moshirfar, et al.: Angle kappa and refractive surgery

radial keratotomy. The authors speculated that wave front guided
profiles centered on his pupil would have been inappropriate for
the irregular surface of his cornea and potentially could have made
his symptoms worse. The corneal topography ablation profile
centered on his corneal reflex addressed these irregularities and
was better suited to fix his problem. PRK was performed using
the profile centered on the corneal light reflex. The patient had
improved visual results and a subjective reduction in his night
vision disturbances.[35]

of induced ocular aberrations and asphericity, but there was no

difference in photopic visual acuity.[40] In 2009 Okamoto et al
compared myopic LASIK centered on the CSCLR with centration
on the entrance pupil in 556 eyes with unknown angle kappa
values. LASIK centered on the CSCLR was significantly safer,
more effective, and had lower induction of coma and total higher
order aberrations than LASIK treatments centered on the pupil.[39]

While investigating decentration patterns in myopic patients that

underwent PRK, Lin et al reported moving the ablation zone to a
point half of the distance between the pupil center and the corneal
reflex when the discrepancy between them (angle kappa) was
more than 0.2 mm. This represented an undisclosed percentage of
the study population and they did not perform sub group analysis.
However, they did report that moving the ablation zone such a
small distance was tolerable for the patients.[36]

Angle kappa is of great importance in refractive surgery, particularly

when treating hyperopes, who tend have large angle kappa values.
In some instances, this may also be important for myopes. Angle
kappa may play a role in MFIOL decentration, possibly leading
to increased glare and haloes. This decentration may be clinically
insignificant; however, centering the MFIOLs on the corneal
reflex will likely decrease this risk. In hyperopic LASIK or PRK,
centration should be focused on either the corneal reflex or the
distance half way between pupillary center and the corneal reflex,
especially in patients with a large angle kappa. Further studies
are needed to fully establish the difference between the various
centration methods used in refractive surgery and their effects on
eyes with a large angle kappa.

Although centering PRK over the entrance pupil has not been
specifically tested in patients with a large angle kappa, it has
been tested in hyperopes which tend to have larger angle kappa
values.[3] Dausch et al reported standard PRK with a 7.0 mm
ablation zone centered over the entrance pupil to be efficient and
relatively safe for correction of hyperopia up to 7.5 diopters.[37]
They also reported that PRK with a 9.0 mm ablation zone centered
over the entrance pupil is safe and efficient in treating hyperopia
up to 8.25 diopters.[38]
The data regarding angle kappa and PRK is very limited, and
no specific conclusions can be drawn. This is likely to be due
to the limited number of publications on the topic of angle
kappa combined with the nationwide trend to perform LASIK
more frequently than PRK. Although the limited data suggest
that centering on the entrance pupil is safe and effective, this
data comes largely from studies which only indirectly addressed
the issue of angle kappa. Centering on the entrance pupil may
be safe if the ablation zone is made large enough to cover the
misalignment induced by angle kappa. The optical and refractive
principles of PRK very closely mimic those used in LASIK. Given
this similarity and the body of evidence which supports LASIK
centration over the corneal reflex, we recommend centering PRK
over the corneal reflex in patients with a large angle kappa.

Conclusions

Acknowledgement
Special thanks to Cody Hockin, Graphic Designer, BFA Visual
Communication, for his assistance in generation of Figure 1. This
research received no specific grant from any funding agency in the
public, commercial, or not-for-profit sectors.

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Cite this article as: Moshirfar M, Hoggan RN, Muthappan V. Angle Kappa
and its importance in refractive surgery. Oman J Ophthalmol 2013;6:151-8.
Source of Support: Nil, Conflict of Interest: None declared.

Oman Journal of Ophthalmology, Vol. 6, No. 3, 2013