160 R EV IEW A RTIC LE DOI 10.5935/0034-7280.

20160035

C linical applications of the Scheim pflug

principle in O phthalm ology
A plicações clínicas do princípio de
Scheim pflug na O ftalm ologia

Fernando Faria-C orreia1 , R enato A m brósio Jr.2

A BSTRA C T
T his article presents a review of the principles and clinicalapplications of the Scheim pflug principle in the anterior segm entim aging.B y
providing a three-dim ensionalim age of the anterior segm ent,this technology provides elevation and curvature data of the anterior and
posterior surfaces of the cornea,pachym etric m apping,the totalrefractive pow er ofthe cornea and the anterior segm entbiom etry.For the
refractive surgery sub-specialty, this approach im proves the ability to identify cases at risk of ectasia, as w ell as the planning and
evaluation of the results of surgical procedures.R ecently,this technology w as introduced in corneal biom echanicalin vivo evaluations
and in fem tosecond laser-assisted cataract surgery.
K eyw ords:Scheim pflug;Tom ography;B iom echanics;C ornea;C ataract;R efractive surgery

R ESU M O
E ste artigo apresenta um a revisão dos princípios e das aplicações clínicas do princípio de Scheim pflug na área da im agiologia do
segm ento anterior.A o disponibilizar um a im agem tridim ensional do segm ento anterior,esta tecnologia perm ite a caraterização da
elevação e curvatura das superfícies anterior e posterior da córnea,o m apeam ento paquim étrico,o cálculo do poder refrativo total
da córnea e a biom etria do segm ento anterior.N a subespecialidade de cirurgia refrativa,esta abordagem m elhora a capacidade de
identificação de casos com risco de desenvolver ectasia,bem com o de planeam ento e de avaliação dos resultados dos procedim entos
cirúrgicos. R ecentem ente, esta tecnologia foi introduzida na avaliação biom ecânica in vivo da córnea e na cirurgia de catarata
assistida por laser de fem tossegundo.
D escritores:Scheim pflug;Tom ografia;B iom ecânica;C órnea;C atarata;C irurgia refrativa

1
Escola das C iências da Saúde, U niversidade do M inho, B raga, Portugal; Study G roup on C orneal Tom ography and B iom echanics of R io de
Janeiro, R io de Janeiro, R J, B razil.
2
U niversidade Federal de São Paulo, São Paulo, SP, B razil; Study G roup on C orneal Tom ography and B iom echanics of R io de Janeiro, R io de
Janeiro, R J, B razil
The authors declare no conflicts of interests.
R eceived for publication 10/07/2015 - A ccepted for publication 07/10/2015

R ev B ras O ftalm ol. 2016; 75 (2): 160-5

C linical applications of the Scheim pflug principle in O phthalm ology
IN TRO D U C TIO N
A
dvances in diagnostic capabilities have been critical to
the evolution of refractive surgery,w hich em erged as a
new subspecialty in the early 1980s.1 Im proving im aging
m ethods of the cornea and the anterior segm ent is related to the
continuous need to increase the safety and effectiveness of
surgical procedures.2 L inked to a better selection of candidates
for refractive surgery,the developm entofdiagnostic technologies
dram atically favored surgical planning capabilities, including
personalization of laser ablation treatm ent and the evaluation
o f resu lts an d co m p licatio n s o f th ese p ro ced u res.3-8 T h is
know ledge also had an im pact on the selection of the type and
pow er of the intraocular lens to be im planted in the cataract
surgery.9,10 In addition, the treatm ent of com plex cases such as
keratoconus, corneal dystrophies and other causes of irregular
astigm atism also has developed due to advances in the im aging
of the cornea and anterior segm ent.11-15
Initially,the m ain obstacle w as the lim itations inherent in
the com puter technology. T he technological developm ent has
allow ed the acquisition and analysis of im ages,having been key
to the developm ent of cornealtopography.Stephen K lyce,P hD ,
is k n o w n fo r h avin g d evelo p ed d erivative co lo r m ap s o f
quantitative analysis of various points of the corneal curvature
m aps.16 T he analysis of the reflected im ages of the P lacido’s disk
has been the dom inant technique for the analysis of the anterior
corneal surface.2 A lternatively,the scan photogram m etry uses a
stereo trian gu latio n tech n iq u e w h erein a regu lar p attern
consisting of horizontal and vertical lines is projected onto the
eye surface to reconstruct the elevation of the anterior corneal
surface.17 M ichaelB elin,M D ,developed the basis for calculating
the elevation m aps in relation to a reference surface being defined
by a geom etric shape (spheric,aspheric or toric ellipsoid) w hich
best fits the actual corneal surface.17,18_E N R E F _17 B oth the
P lacido’s disk and the scan photogram m etry are able to calculate
the m aps of axial (sagittal) and tangential (instantaneous)
curvature of elevation and refraction of the anterior corneal
surface.O ther system s,such as the H artm ann-Shack sensor for
analysis of front-of-w ave, also incorporate a device for corneal
topography analysis.2 H ow ever,these devices are lim ited to the
analysis of the anterior corneal surface.19
R egarding the m easurem entofthe thickness ofthe cornea,
the opticalpachym eter w as presented by D avid M aurice,P hD in
1955.20 T he ultrason ic techn ique has dem onstrated greater
repeatability than the opticalpachym eter,butonly provided data
of a single point.19-21 M andell e Polse proposed a study of the
horizontalprofile ofthe cornealthickness using a m odified optical
pachym eter. In this context, the variation of thickness in the
horizontal m eridian proved to be a feature for the diagnosis of
keratoconus.22
T he developm ent of the anterior segm ent tom ography
allow ed the assessm ent of the profile of the corneal thickness
from the pachym etry m apping.23,24 Tom ography (from the G reek:
“tom os” m eans slice and “grafia” m eans describe) is a concept
that represents the three-dim ensional reconstruction of the
cornea,providing detailed inform ation on the thickness and the
an terio r an d p osterior su rfaces o f th e co rn ea.19 D ifferen t
technologies such as the horizontal slit scanning, the rotating
Scheim pflug cam era, high frequency ultrasounds, and optical
coherence tom ography are com m ercially available from various
instrum ents.19,25
A d van ces in co rn eal im agin g w ere b eyo n d th e
to m o grap h ic characterizatio n . T he co n cep t o f cu stom ized
biom echanics in refractive surgery w as introduced by C ynthia
R oberts,P hD ,in 2005.26 T he O cular R esponse A nalyzer (O R A
- R eichert Inc.,D epew ,U SA ) w as introduced as the first device
to assess in vivo the biom echanics of the cornea.27,28 O R A is a
n o n -co n tact to n o m eter (N C T ) w h ich u ses an electro -
quantitative system for controlling the deform ation of the
co rn ea b y th e co rn eal reflectio n o f in frared ligh t. O th er
tech n o lo gies, su ch as th e S ch eim p flu g im age an d o p tical
161
F igure 1:Schem e of the Scheim pflug principle.
coherence tom ography,have also been recently introduced to
provide dynam ic m easurem ents of the cornealdeform ation.29,30
Finally, im aging of the cornea and the anterior segm ent w as
also used in cataract surgery assisted by fem tosecond laser.31-33
T his review focuses on the application of the Scheim pflug
principle for laser refractive surgery, including its diagnostic
capability and biom echanical assessm ent of the cornea, as w ell
as its recent use in the planning of assisted cataract surgery by
fem tosecond laser.
Scheim pflug P rinciple
T he Scheim pflug principle is a geom etric rule com m only
used in photography.T his concept w as first described by Jules
C arpentier in 1901,having been cited and credited in the origi-
nalpatent by T heodor Scheim pflug in 1904.34 In this technique,
three im aginary planes - the film plane,the lens plane and the
focalplane - are arranged in a non-parallel w ay (Figure 1).T he
lens is tilted so that the resulting plane of the lens intercept the
planes of the film and focus in a line of intersection know n as
Scheim pflug line. In a typical photographic cam era, the film
plane and the lens plane are parallel to each other, and also
relative to the focal plane.T his principle allow s increasing the
d ep th o f fo cu s an d sh arp n ess o f im age p o in ts lo cated o n
different planes.34
Scheim pflug im ages of the corneal and anterior segm ent
T he Scheim pflug photography w as used in the im aging
of the anterior segm entby devices E A S 1000 by N idek (G am agori,
Japan) and SL -45 by Topcon (Tokyo, Japan).35,36 T hese system s
have the ability to m easure the dispersion oflightalong the optical
axis,allow ing the detection of changes in the transparency of the
lens over tim e.35 A ssociated to the opticaldensitom etry,recording
these im ages also offer biom etric m easurem ents of the anterior
segm ent such as the anterior cham ber depth and peripheralangle
m easurem ents.37 H ow ever,these system s did not hold the three-
dim ensional reconstruction of the anterior segm ent.
In 1995,the opticalcross-sectioning for exam ination of the
cornea w as first introduced com m ercially w ith the O rbscan
[(originally O rbtek, Inc.) B ausch & L om b Surgical, Salt L ake
C ity, U SA ].38-42 _E N R E F _39_E N R E F _39 T his instrum ent is
design ed to provid e to m o graph ic d ata (three-d im en sion al
reconstruction),butthe nom enclature regarding the C T concept
w as not set yet,so that it w as still referred as topography.19,38,42
T his system introduced the slit-scanning im aging technique or
the cobblestone m ethodology,involving the projection of40 slits
(12.50 m m height and 0.30 m m w ide) w ith a Scheim pflug angle
of 45 degrees.H ow ever,O rbscan slit im ages do not exhibit the
sam e depth of field as com pared to those obtained by the
Scheim pflug system s (F igure 2).In its first version,the O rbscan
R ev B ras O ftalm ol. 2016; 75 (2): 160-5
162 C orreia F F ,A m brósio Jr.R
F igure 2:Scheim pflug im age of the cornea and anterior segm ent
F igure 3:H igh-resolution frontiris cam era.
provided inform ation from the anterior curvature extrapolated
from elevation data.In 1999,a P lacido disk w as integrated into
the O rbscan II to obtain data directly from the anterior curvature.
T he digital tom ography w ith rotating Scheim pflug cam era
has been recognized as an evolution ofthe horizontalcross section
(cobblestone m ethodology) in the tom ographic assessm ent of
the cornea and anterior segm ent.A lthough the capture of hori-
zontal im ages does not have points in com m on,the system has a
rotating center com m on to all the im ages, w hich m akes the
registration m ore precise.43,44 T he P entacam (O culus, W etzlar,
G erm any) w as the first system available to perform digital
tom ography of the cornea and anterior segm ent using rotational
F igure 4: D etailed analysis of a norm al Figure 5:D etailed analysis ofboth eyes in the sam e patientw ith very asym m etricalkeratoconus.
cornea, including the m ap of front curve A .K eratoconus in the anterior curvature m ap,B A D -D > 2.5,A R T-M ax < 360 and “C orvis
(sagittal) using the absolute scale ofSm olek- Factor 1” > 0.35;B .Form e fruste keratoconus w ith a relatively norm alanterior curvature m ap,
K lyce,B A D and biom echanical evaluation butw ith B A D -D >1.45,A R T-M ax <412 and ‘C orvis Factor 1" >0.25.A R T,A m brosio R elational
w ith C orV IS ST. B A D -D < 1.45,A R T-M ax T hickness;B A D ,B elin-A m brosio E nhanced E ctasia D isplay
> 412 e “C orvis Factor 1” < 0.2 are the m ost
relevantfindings.A R T,A m brosio R elational
T hickness;B A D ,B elin-A m brosio E nhanced
E ctasia D isplay
R ev B ras O ftalm ol. 2016; 75 (2): 160-5
Scheim pflug photography.T his device w as introduced in 1999,
and introduced com m ercially in 2002. P entacam , along w ith the
rotating Scheim pflug cam era,is partof a second front cham ber to
control the attachm ent and com pensate the ocular alignm ent.
In the acquisition m ode,optim alalignm entis obtained w ith
the first P urkinje reflection of the cornea using both the front
cham ber and the Scheim pflug one before autom atically initiating
the exam . A second high-resolution front cam era records the
size and orientation of the pupillary opening,serving as a guide
for three-dim ensionalreconstruction.T his cam era also provides
black-and-w hite m easurem ents of the pupil size (Figure 3).T he
analysis of the three-dim ensional Scheim pflug im age provides
data from the anterior and posterior surface of the cornea,ante-
rior surface of the iris and the crystalline.A s the system em ploys
blue visible light (w avelength of 475 nm , free from ultraviolet
radiation in P entacam ), that is sensitive to corneal opacities,
resulting in hyperreflective im ages ofinaccurate contour.D ue to
to tal in tern al reflectio n in th e p erip h eral co rn ea, d irect
visualization of the anterior cham ber angle is not possible.
H ow ever, the extrapolation softw are is able to provide an
estim ate of the iris-cornealangle w ith relatively high accuracy.45
C urrently, there are other b usin ess u nits th at in co rp orate
rotational Scheim pflug im aging technology, and in particular
G alilei (Z iem er, Sw itzerland),T M S-5 (Tom ey,N agoya, Japan);
Sirius (C SO ; F lorence, Italy) and P reciso (Ivis Technologies,
Taranto,Italy).Table 1 presents the diagnostic capabilities of all
devices w ith Scheim pflug im aging technology.
C orneal tom ography using the Scheim pflug principle for
screening ectasia
O n e o f th e m o st im p o rtan t ap p licatio n s o f co rn eal
com puted tom ography relates to the diagnosis of keratoconus
and other ectasia diseases of the cornea.3,46-49 P achym etry and
elevation indices proved to be effective to detect keratoconus.50-
52
T he graphics of the spatialprofile and the percentage increase
in cornealthickness describe the ring pachym etry increase since
the thinnest point.23,24,51 T hese charts are available on P entacam
an d h ave b een u sed su ccessfu lly in th e d iagn o sis o f
keratoconus.24,50,53 P achym etry progression indices (P P I) are
calculated for all sem i-m eridians of the cornea, such that the
average of all m eridians (P P I A ve) and the m eridian w ith
m axim um pachym etry progression (P P I m ax) are reported.T he
“A m brósio R elationalT hickness” (A R T ) param eter is the ratio
C linical applications of the Scheim pflug principle in O phthalm ology 163

Tab le 1
C o m p arative tab le o f in stru m en ts w ith S ch eim p flu g im ag e
Pentacam G alilei T M S-5 P recisio Sirius O rbscan
C om pany O culus,G erm any Z iem er,Sw itzerland Tom ey, Japan Ivis,Italy C SO ,Italy B ausch& L om b,U SA
P hotography R otational R otational R otational R otational R otational H orizontal
cross section
P lacido’s disk No Y es Y es Y es Y es Y es
E levation m aps Y es Y es Y es Y es Y es Y es
R efractive pow er
m ap of the cornea Y es Y es Y es Y es Y es Y es
P achym etric m ap Y es Y es Y es Y es Y es Y es
G raphic of the space
profile of the thickness No No No No No No
C ataract analysis Y es Y es Y es No Y es Y es
A nalysis of the
anterior cham ber Sim Sim Sim Sim Sim Sim

Tab le 2
R esu lts o f th e cu rves “receiver o p eratin g ch aracteristic” (R O C ) o f th e p aram eters
o f P en tacam (331 n o rm al p atien ts vs. 242 p atien ts w ith b ilateral clin ical kerato co n u s)
C utoff AU C Standard errora 95% C I Sensibility 95% C I of Specificity 95% IC da
value of A U C b sensibility specificity

BA D D > 2.11 1 0.0000743 0.993- 1.000 99.59 97.7-100.0 100 98.9-100.0

Posterior elevation
in the thinnest
point(B F S) > 12 0.991 0.00396 0.979-0.997 96.28 93.1-98.3 98.79 96.9-99.7
Posterior elevation
in the thinnest
point(B F T E ) >8 0.994 0.00218 0.984-0.999 95.04 91.5-97.4 99.09 97.4-99.8
A R T A vg 474 0.999 0.000663 0.991-1.000 99.59 97.8-100.0 98.19 96.1-99.3
A R T M ax 386 0.999 0.000674 0.991-1.000 99.17 97.0-99.9 97.28 94.9-98.7
K M ax > 47.8 0.978 0.00633 0.963-1.000 90.50 86.1-93.9 97.89 95.7-99.1
a M ethod for standard error calculation (D eL ong,1988),listed in the softw are M edC alc.
b 95% C I, confidence interval; A U C , area under the curve “receiver operating characteristic”.
A R T A ve,A m brósio’s R elationalT hickness m edium ;A R T M ax,A m brósio’s R elationalT hickness m axim um ;B A D -D ,D -finalvalue of B elin-A m brósio E nhanced E ctasia
D isplay;B F S,B estF itSphere;B F T E ,B estF itToric E llipsoid;K M ax, m axim um keratom etry value;SE ,Standard error calculated by the binom ialm ethod.

Tab le 3
R esu lts o f th e cu rves “receiver o p eratin g ch aracteristic” (R O C ) o f th e p aram eters
o f P en tacam (331 n o rm al p atien ts vs. 47 p atien ts w ith fo rm e fru ste kerato co n u s).

C utoff AU C Standard error 95% C I Sensibility 95% C I of Specificity 95% C I of

value ofA U C sensibility specificity

BA D D > 1.22 0.975 0.0121 0.954-0.989 93.62 82.5-98.7 94.56 91.5-96.7

Posterior elevation
in the thinnest
point(B FS) >5 0.825 0.0348 0.783-0.862 74.47 59.7-86.1 74.92 69.9-79.5
Posterior elevation
in the thinnest
point(B FT E ) >1 0.849 0.0324 0.809-0.883 80.85 66.7-90.9 72.51 67.4-77.2
A R T A vg 521 0.956 0.0203 0.930-0.974 91.49 79.6-97.6 93.05 89.8-95.5
A R T M ax 416 0.959 0.0153 0.934-0.977 85.11 71.7-93.8 93.05 89.8-95.5
K M ax > 45 0.635 0.0431 0.584-0.683 53.19 38.1-67.9 64.05 58.6-69.2
a M ethod for standard error calculation (D eL ong,1988),listed in the softw are M edC alc.
b 95% C I, confidence interval; A U C , area under the curve “receiver operating characteristic”.
A R T A ve,A m brósio’s R elationalT hickness m edium ;A R T M ax,A m brósio’s R elationalT hickness m axim um ;B A D -D ,D -finalvalue of B elin-A m brósio E nhanced E ctasia
D isplay;B F S,B estF itSphere;B F T E ,B estF itToric E llipsoid;K M ax,m axim um keratom etry value;SE ,Standard error calculated by the binom ialm ethod.

betw een the P P I and the thinnest point.
T he “B elin-A m brósio E nhanced E ctasia D isplay” (B A D ;
F igures 4 and 5) allow s an overview of tom ographic structure of
the cornea by com bining data from the anterior and posterior
elevation , p achym etry and cu rvature. T he B A D co n sid ers
deviations from norm ality for different param eters, so that a
zero value represents the m ean of the norm al population and
one is the value of a standard deviation value tow ard the value
of the disease (ectasia).3 T he final‘D ’ is calculated based on the
regression analysis,w eighing differently the various param eters.
A lternatively,Saad and G atinel developed an efficient m ethod
of com bining pachym etry and elevation data of O rbscan in
discrim inant functions to detect keratoconus and form e fruste
keratoconus (F F K C ).54
Tables 2 and 3 provide the cutting values and the details of
curves “receiver operating characteristic” (R O C ) of the m ost

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164 C orreia F F ,A m brósio Jr.R
effective P entacam param eters for identifying cornea w ith ectasia.
Table 2 refers to a study involving an eye random ly selected
from 331 norm alpatients and 242 patients w ith bilateralclinical
keratoconus.3
Interestingly,the factthatthe screening ofthe risk ofectasia
should go beyond keratoconus detection is crucial to consider
the studies that include m ild or subclinical form s of ectasia.3,55
O ne of the m ost im portant subgroups consists of eyes w ith
relatively norm al topography of keratoconus patients detected
in the contralateral eye, being referred as F F K C .3,54,56 Table 3
refers to a study w hich included 47 corneas w ith F F K C ,and the
sam e controlgroup of study57 ofTable 2.Itis criticalto adjust the
cutoff values to identify such m ild cases or those of susceptibility
to ectasia. For exam ple, B A D -D has a cutoff value of 2.11 to
detectkeratoconus (99.59% sensitivity and 100% specificity;Table
2), but the best cutoff value to detect F F K C is 1.22 (93.62%
sensitivity and 94.56% specificity).T he optim ization of the area
under the R O C curve can be possible w ith the cutoff value,but
w ith a m inim aland tolerable loss ofspecificity value.For exam ple,
som e param eters that are very efficient in the detection of
keratoconus, such as the m axim um keratom etry, m ay not be
useful in identifying cases w ith F F K C .
D ynam ic Scheim pflug im aging to asses cornealdeform ation
C orV IS ST (O culus,W etzlar,G erm any) is an N C T w ith a
h igh -sp eed S ch eim p flu g cam era th at w as lau n ch ed in
2010.3,29_E N R E F _28 T he coupled Scheim pflug cam era covers
the horizontal 8.5 m m of the cornea and captures m ore than
4300 im ages per second to m onitor the response of the cornea
to a collim ated and calibrated puffof air.T he air pulse has a fixed
profile w ith sym m etrical con figuration and w ith m axim um
internal pressure of the pum p of 25 kP a.29 D uring the recording
tim e of30 m s,140 digitalim ages are acquired w ith 576 m easuring
points in each.A dvanced algorithm s for detecting the cornea
contours are applied to each im age. T he m easurem ent starts
w ith the cornea in its naturalconvex shape.T he puff of air forces
the cornea inside (ingoing phase), going through a tim e of
aplannation (ingoing aplannation) in a concavity phase until it
reaches its peak.T here is a period of oscillation before starting
th e o u tp u t o r retu rn p h ase (o u tgo in g p h ase). T h e co rn ea
u n d ergo es a seco n d m o m en t o f ap p lan atio n (o u tgo in g
applanation) untilreturning to its naturalshape.A possible cam
m otion can occur in this phase of the m easurem ent.T he tim e
and pressure in the first and second applanation m om ents and
w hen the cornea reaches the m axim um point of concavity are
reco rded . T h e intrao cu lar p ressu re (IO P ) is b ased o n th e
deform ation data.T he am plitude of deform ation is detected as
the largest displacem ent of the corneal apex on the im age
corresponding to the m om ent of greatest concavity.T he radius
ofcurvature in the phase of largestconcavity,the lengths and the
speeds of the cornea during the applanation phases are also
recorded.T he low est value of cornealthickness is also available,
and is derived from the first horizontal Scheim pflug im age.29
P relim inary results have show n that IO P has strong and
significant influence on the corneal deform ation param eters.
In a study involving a m odel of the eye’s anterior cham ber
com posed of hydrophilic contact lenses m ounted in a sealed
w ater cham ber w ith adjustable pressure, three lenses w ith
know n constitution w ere evaluated under different pressure
levels.58 E ach different lens show ed different deform ation am -
plitude in the pressure levels evaluated, w hich w ere greater
(less rigid beh avior) w ith low er pressure levels (P < 0.001;
B onferroni posthoc test).Interestingly,w hen evaluated under
th e sam e in tern al p ressu re, th e d efo rm atio n am p litu d e
dem onstrated to be inversely related to the percentage of
polym er in the lens com position. H ow ever, the thinner lens
and w ith less polym er had an inferior deform ation am plitude
(m ore rigid behavior) at higher pressures than the thicker lenses
and w ith m o re percen tage o f p olym er in lo w er p ressures.
F urtherm ore, the im pact of the IO P reduction in the corneal
d efo rm atio n h as b een w ell d o cu m en ted in m an y clin ical
R ev B ras O ftalm ol. 2016; 75 (2): 160-5
situations,particularly a case of pressure-induced keratopathy.59
S tu dies co m p aring n o rm al an d keratocon us co rn eas sho w
statistically significant differences for m ost of the deform ation
param eters provided by C orV IS, but w ith a relatively high
o verlay betw een th e gro u ps, w h ich lim its th eir diagno stic
ap p lication s. T h e co m b in ation o f p aram eters u sin g lin ear
d iscrim in an t an alysis an d o th er tech n iq u es o f artificial
intelligence has been the subject of intense studies by the
B razilian Study G roup of A rtificial Intelligence and C orneal
A nalysis (B rA In). For exam ple, the “C orvis F actor 1” w as
effective to im prove the ability to distinguish norm al corneal
from those w ith ectasia, including cases of F F K C (P < 0.001,
K ruskal-W allis test w ith D unn’s post-hoc test).A long w ith the
d iagn o sis o f ectasia, th e b io m ech an ical stu d y w ith th e
Scheim pflug technology w as effective to assess changes after
th e cro sslin king (R oberts, un pu blish ed data, 2011). In the
studies conducted at O hio State U niversity, in the 1st m onth
after th e p ro ced u re a sm aller d efo rm atio n am p litu d e (P
< 0.0014) w as recorded.T his result is justified by the increased
rigidity of the cornea after the procedure.
T h e in tegratio n b etw een th e b io m ech an ical an d
tom ographic data dem onstrated a significant im provem ent in
identifying m uch m ilder form s of ectasia (Figure 5).T his has also
to be considered w hen assessing the risk ofprogression ofectasia
and the prognosis of keratoconus.In a study involving 119 eyes
w ith no rm al corneas and 19 eyes w ith F F K C , a co m bin ed
p aram eter d erived fro m to m o grap h y an d b io m ech an ical
assessm ents w as designed and presented an area under the R O C
curve of 0.999. T his com bined param eter had a sensitivity of
100% and a specificity of 99.2% .3
S ch eim p flu g im ae in cataract su rgery assisted b y
fem tosecond
C ataract surgery assisted by fem tosecond laser depends
fundam entally on the im aging of the anterior segm ent to guide
th e co rn eal in cisio n s, th e cu rvilin ear an d co n tin u o u s
capsulorhexis and the fragm entation of cataracts.33 L E N SA R
L aser System (L E N SA R Inc.,W inter P ark,U SA ) incorporates
a three-dim ensional confocal illum ination (3D -C SI) consisting
of an advanced transm itter of scaning lighting w hich increases
the accuracy of the three-dim ensional reconstruction using the
Scheim pflug im aging technique.60 T he system has a lateral(x,y)
and longitudinal(z) resolution ofless than 10 m icrons.T he ability
to determ ine the position of the anterior and posterior surfaces
of the crystalline is increased due to the high-contrast of the
optic system on the anatom ical edges,w hich m akes the 3D -C SI
relatively less sensitive to the dispersion present in higher density
cataracts.A dditionally,the 3D -C SI provides detailed structural
details of cataract,w ith the potential of autom atic classification
of their density.D ue to the layout of the optical rays,L E N SA R
can collect biom etric data (including rays of anterior and poste-
rior cornealcurvature,cornealthickness,anterior cham ber depth,
anterior and posterior curvature rays of the crystalline and the
thickness of the crystalline), also allow ing the detection of the
crystalline tiltto the opticalaxis.60 O ther system s available on the
m arket,and in particular L enSx (A lcon L aboratories,FortW orth,
Texas,U SA ),C atalys (O ptiM edica C orp.,C alifornia,U SA ) and
V ictus Technolas (B ausch & L om b/Technolas P erfect V ision
G m bH ,G erm any) use optical coherence tom ography (O C T ) to
assess the location of the intraocular structures.33
C O N C LU SIO N
T he Scheim pflug im aging technique w ill coexist w ith other
technologies such as O C T and high-frequency ultrasound, but it
w ill have an evolutive role in the area of laser refractive surgery.
C ontinuous advances are expected to strengthen the diagnostic
capabilitiesand surgicalplanning.Fastercom putersystem s and high-
resolution cam eras also have a significant role in this evolution.
Furtherm ore,artificialintelligence is ofkey im portance in order to
increase the safety and efficacy ofcustom ized refractive treatm ents.
C linical applications of the Scheim pflug principle in O phthalm ology
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C orresponding author:
Renato A m brósio Jr,M D ,PhD -Instituto de O lhos Renato A m brósio
R ua C onde de B onfim 211 / 712 - 20520 - 050
Phone: 55 21 2234-4233
E-m ail:dr.renatoam brosio@ gm ail.com
R ev B ras O ftalm ol. 2016; 75 (2): 160-5