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Anterior Chamber Depth Measurement in Pseudophakic Eyes: A Comparison of

Pentacam and Ultrasound

Article  in  Journal of refractive surgery (Thorofare, N.J.: 1995) · May 2010

DOI: 10.3928/1081597X-20090617-02 · Source: PubMed

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Anterior Chamber Depth Measurement
in Pseudophakic Eyes: A Comparison of
Pentacam and Ultrasound
Giacomo Savini, MD; Thomas Olsen, MD; Claudio Carbonara, MD; Sebastiano Pazzaglia, MD;
Piero Barboni, MD; Michele Carbonelli, MD; Kenneth J. Hoffer, MD, FACS

A
fter cataract surgery, the position of the intraocular
ABSTRACT
lens (IOL) relative to the cornea has a major influence
PURPOSE: To compare the anterior chamber depth
on refractive outcome and is therefore regarded as
(ACD) measurements of a Scheimpflug camera (Pen- a key factor in IOL power calculation.1-6 However, although
tacam, Oculus Optikgeräte GmbH) and immersion ultra- other parameters needed for this purpose (eg, corneal power
sound biometry (UltraScan Imaging System, Alcon Labo- and axial length) can be assessed preoperatively, the distance
ratories) in pseudophakic eyes. between the cornea and IOL, known as anterior chamber
depth (ACD) or effective lens position, cannot be measured
METHODS: This prospective, multicenter study included
three independent sample groups. The ACD, defined as
and is thus predicted by relying on the formulas currently
the distance between the corneal epithelium and intra- used to calculate the IOL power.7-10 Once surgery has been
ocular lens anterior surface, was assessed by ultrasound performed, the ACD can be measured and compared to the
biometry. Two Pentacam ACD measurements were eval- predicted value to assess the accuracy of various methods
uated—the value automatically provided by the inter- adopted to calculate the IOL power. This has been done using
nal software and a manual measurement obtained by
moving the software calipers on a single Scheimpflug
several technologies, including contact and immersion ultra-
image. sound biometry,11-15 optical pachymetry,15,16 scanning-slit
topography,15 and partial coherence interferometry.17,18
RESULTS: For the comparison group (12 eyes), no In 2004, another instrument for measuring the ACD became
significant difference between the mean ultrasound available—the Pentacam (Oculus Optikgeräte GmbH, Wetzlar,
biometry and mean Pentacam manual measurement Germany)—which uses a rotating Scheimpflug camera to
(4.51⫾0.34 mm and 4.50⫾0.34 mm, respectively,
P⬎.05) was noted, whereas the mean automatic value
image the anterior segment of the eye. The ACD measure-
was significantly higher (4.94⫾0.41 mm, P=.0002), ments provided by this device have been extensively studied
as the posterior edge of the anterior chamber is in phakic eyes, where they have shown reliable repeatabil-
erroneously identified as coinciding with the bound- ity and non-significant or very small differences compared
ary of the posterior capsule. A strong correlation was to other methods, such as ultrasound, partial coherence
found between Pentacam manual measurements and
ultrasound biometry (r=0.98, P⬍.0001); this cor-
interferometry and scanning-slit topography.19-24 On the other
relation was confirmed by the confirmation group (17 hand, only two studies have evaluated ACD measurements
eyes), whose mean values were 4.76⫾0.39 mm and performed with the Pentacam in pseudophakic eyes.22,25
4.72⫾0.37 mm, respectively (r=0.98, P⬍.0001). After Regrettably, those authors found that the automatic values
merging the data for the comparison and confirmation provided by the instrument were significantly different from
groups, the difference between Pentacam manual mea-
surements (4.65⫾0.38 mm) and ultrasound readings
(4.63⫾0.38 mm) was not statistically significant. For
the assessment group (15 eyes), relative repeatability From G.B. Bietti Eye Foundation-IRCCS, Rome, Italy (Savini); University
and reproducibility of Pentacam manual measurements Eye Clinic, Aarhus Hospital, Aahrus, Denmark (Olsen); Studio Oculistico
were 1.17% and 1.59%, respectively. Carbonara, Rome, Italy (Carbonara, Pazzaglia); Studio Oculistico d’Azeglio,
Bologna, Italy (Barboni, Carbonelli); and Jules Stein Eye Institute, University
of California, Los Angeles, Calif (Hoffer).
CONCLUSIONS: In pseudophakic eyes, the Pentacam
provides ACD values that do not statistically differ from The authors have no proprietary interest in the materials presented herein.
those of ultrasound immersion biometry, on the condi- Correspondence: Giacomo Savini, MD, G.B. Bietti Eye Foundation-IRCCS, Via
tion that manual measurements are used rather than Livenza 3, Rome, Italy. Tel: 39 06 85356727; Fax: 39 06 84242333; E-mail:
automatic ones. [J Refract Surg. 2010;26:341-347.] [email protected]
doi:10.3928/1081597X-20090617-02
Received: August 7, 2008; Accepted: May 5, 2009
Posted online: June 22, 2009

Journal of Refractive Surgery • Vol. 26, No. 5, 2010 341

Anterior Chamber Depth in Pseudophakic Eyes/Savini et al

24⫾17 months (range: 6 to 61 months) earlier. All eyes

received an AcrySof MA60AC IOL (Alcon Laborato-
ries, Ft Worth, Tex) with a mean power of 21.90⫾5.00
diopters (D) (range: 7.00 to 27.00 D).
Each patient underwent measurement of both the
“external” ACD (defined as the distance between the
central corneal epithelium and the central anterior IOL
surface) by means of the Pentacam (software version
1.16) and immersion biometry (UltraScan Imaging Sys-
tem, Alcon Laboratories).
The Pentacam examination was performed under
mydriasis to allow optimal visualization of the IOL
optic. While the patients were seated comfortably,
alignment was achieved using the table height adjust-
Figure 1. Manual analysis of the anterior chamber depth with Pentacam. ment, forehead strap, and chin rest. They were in-
The blue line is manually traced between the anterior surface of the cen-
structed to keep both eyes open and look directly at
tral apex of the intraocular lens and the central corneal epithelial apex.
The distance is 4295 µm for the eye shown. the black fixation target centered in the scanning-slit
light for the duration of the scan, which produced 25
those obtained by means of ultrasound. Prompted by pictures for each examination. Scans were repeated if
these findings, we investigated whether the differ- the quality specification provided by the instrument
ence between the two technologies could be lessened was other than “OK.” Once the scan had been correctly
by manually measuring the ACD on the Scheimpflug performed, both automatic and manual measurements
images provided by the Pentacam. Achieving accurate were assessed and used for statistical purposes. The
ACD measurements in pseudophakic eyes would, in manual measurements, which showed good repeatabil-
fact, enable the Pentacam to be used in future investi- ity in a previous study investigating IOL thickness,26
gations comparing the predicted and actual axial posi- were performed by analyzing a single Scheimpflug pic-
tion of the IOL within the eye. ture with the caliper tool included in the internal soft-
ware (Fig 1). Because multiple images of the anterior
PATIENTS AND METHODS chamber were generated for each eye, we arbitrarily
Three samples of patients were independently selected one of the scans that provided visualization
investigated at three separate centers. The first group of the whole IOL optic. The choice of the scan did not
(hereafter referred to as comparison group) was used to influence the result as we measured ACD in the other
compare both automatic and manual measurements by scans showing the whole IOL optic and never observed
Pentacam to those achieved by immersion ultrasound differences higher than 0.01 mm. A line was traced be-
biometry. With the second group (hereafter referred tween the anterior surface of the IOL and the central
to as confirmation group), we aimed to confirm the cor- corneal epithelium apex.
relation between manual measurements by Pentacam Immersion biometry was performed as the second
and ultrasound. The third group (hereafter referred to as examination (with dilated pupil). After administration
assessment group) was studied to assess the intraobserver of topical anesthesia with 0.4% oxybuprocaine hydro-
repeatability and reproducibility of Pentacam ACD chloride eyedrops (Novesina; Novartis Farma, Origgio,
manual measurements. Italy), an Ossoinig immersion shell filled with 2%
Before being included in the study, all patients were hydroxypropylmethyl cellulose (Gel 4000; Bruschetti-
informed of its purpose and gave written consent. The ni, Genoa, Italy) was placed between the eyelids in rou-
study methods adhered to the tenets of the Declara- tine fashion, and the distance between the corneal epi-
tion of Helsinki for the use of human participants in thelium and anterior surface of the IOL was measured
biomedical research. by means of a 10-Mhz A-scan probe with fixation light.
The ultrasound speed for the anterior chamber was set
COMPARISON GROUP at 1532 m/sec. The operator took 10 measurements that
Twelve consecutive patients who underwent un- showed for each surface vertical peaks with the same
eventful phacoemulsification and IOL implantation height and an average axial length with a standard de-
in the capsular bag were enrolled in a private practice viation lower than 0.05 mm. By satisfying these con-
(Bologna, Italy). Mean age was 71⫾8.9 years (range: 59 ditions, it was possible to obtain ACD measurements
to 82 years). Surgery had been performed a mean of within 0.05 mm for each eye. Finally, because the

342 Copyright © SLACK Incorporated

 Anterior Chamber Depth in Pseudophakic Eyes/Savini et al

Ultrascan outputs an ACD only for the scan chosen to examiner 1 as recommended by Bland and Altman and
appear in the printout, the operator arbitrarily chose 1 proposed by the British Standards Institution; the coef-
of the 10 ACD measurements. ficient of repeatability was defined as 2 standard devia-
tions of the differences between pairs of measurements
CONFIRMATION GROUP in the same patients obtained during the same visit by
Seventeen consecutive patients who had undergone the same observer. The interobserver reproducibility
uneventful phacoemulsification and IOL implantation was assessed by analyzing the difference between the
in the capsular bag were enrolled in a hospital-based first measurements obtained by the two examiners; the
center (Aarhus, Denmark). Mean age was 58.8⫾16.1 coefficient of reproducibility was defined as 2 standard
years (range: 38 to 87 years). Surgery had been per- deviations of the differences between pairs of measure-
formed a mean of 22⫾18 days earlier (range: 7 to 57 ments in the same patients obtained during repetition
days). All eyes received an AcrySof SA60AT IOL of the test under different conditions, such as a differ-
(Alcon Laboratories) with a mean power of 24.30⫾3.00 D ent examiner.27-29
(range: 8.50 to 31.00 D). Pentacam and ultrasound bi- Relative repeatability and relative reproducibil-
ometry measurements were performed following the ity were calculated as a percentage of the ratio of the
same method described for the comparison group. repeatability and reproducibility coefficients, respec-
tively, to the mean value of the measurements.20
ASSESSMENT GROUP
Fifteen consecutive patients who had undergone RESULTS
uneventful phacoemulsification and IOL implanta- For the comparison group, mean ACD as mea-
tion in the capsular bag were enrolled in a hospital- sured by immersion ultrasound biometry was
based center (Rome, Italy). Mean age was 74.4⫾19.1 4.51⫾0.34 mm (range: 3.99 to 5.11 mm). The mean
years (range: 60 to 85 years). Surgery had been per- automatic reading of the Pentacam was significantly
formed a mean of 12⫾5 months (range: 5 to 21 months) higher than ultrasound biometry (4.94⫾0.41 mm,
earlier. All eyes received an AcrySof MA60AC IOL P=.0002), whereas manual measurements were simi-
(Alcon Laboratories) with a mean power of 21.20⫾1.60 D lar (4.50⫾0.34 mm, P⬎.05). The difference compared
(range: 18.50 to 24.50 D). Pentacam measurements to ultrasound biometry ranged between ⫺0.11 and 0.73
were performed following the same methods described mm in the automatic mode and between ⫺0.06 and
for the comparison group by two independent exam- ⫹0.09 mm in the manual mode. Accordingly, Bland-
iners in a single session. Ultrasound biometry was Altman plots revealed wider 95% limits of agreement
not performed for the assessment group. To assess between ultrasound readings and Pentacam automatic
intraobserver repeatability, examiner 1 acquired two sets values (⫺0.12 to ⫹0.98 mm, Fig 2A) than between ul-
of scans. To assess interobserver reproducibility, a sec- trasound readings and Pentacam manual values (⫺0.11
ond operator acquired one more set of scans. to ⫹0.1 mm, Fig 2B). Statistical analysis revealed a
stronger correlation between the ultrasound readings
STATISTICS and the manual Pentacam values (r=0.98, P⬍.0001)
Because in all groups some patients had surgery in than between the ultrasound readings and the auto-
both eyes, only one eye for each patient was used for matic Pentacam values (r=0.69, P=.01).
statistical analysis (in the event of bilateral surgery, The confirmation group values confirmed good corre-
it was randomly chosen using a computer-generated, lation between manual Pentacam (4.76⫾0.39 mm) and
predetermined randomization schedule). In the com- immersion biometry (4.72⫾0.37 mm) measurements
parison and confirmation groups, pairs of measure- (r=0.98, P⬍.0001), as well as good agreement (95% lim-
ments were compared by means of paired t test and its of agreement: ⫺0.14 to 0.07 mm). After merging the
linear regression was used to quantify how well the data for the comparison and confirmation groups, the
measurements varied together. Statistical analyses difference between Pentacam manual measurements
were performed using GraphPad InStat Version 3a for (4.65⫾0.38 mm) and ultrasound readings (4.63⫾0.38 mm)
Macintosh (GraphPad Software, San Diego, Calif). The was not statistically significant (P⬎.05).
relationship between pairs of measurements was also Regarding repeatability and reproducibility, both
analyzed by means of Bland-Altman analysis.27 intra- and interobserver measurements did not show
Regarding the assessment group, pairs of measure- statistical differences (P⬎.05). Coefficient of repeat-
ments were compared by paired t test. Intraobserver ability and reproducibility were ⫾0.05 and 0.06 mm,
repeatability was assessed by analyzing the difference respectively. Relative repeatability and reproducibility
between the first and second measurements obtained by were 1.17% and 1.59%, respectively.

Journal of Refractive Surgery • Vol. 26, No. 5, 2010 343

Anterior Chamber Depth in Pseudophakic Eyes/Savini et al

tive errors are still possible.

In a recent study of 643 eyes,
Narváez et al30 reported that
errors higher than 2.00 D can
still occur with the most wide-
ly used formulas (ie, Hoffer Q,
Holladay 1 and 2, SRK/T). The
maximum error was lower in
a study of 317 eyes by Hoffer,31
but still exceeded 1.00 D. Accord-
ing to Olsen,32 a refractive error
higher than 1.00 D may occur in
approximately 10% of eyes, even
assuming optimized conditions.
Refractive surprises are more
likely in the case of very short
eyes, where they can sometimes
be as high as 2.00 D or more even
A with the best formulas, and most
of all in patients who had previ-
ously undergone corneal refrac-
tive surgery.33,34
Several factors may lead to
inaccuracy in IOL power cal-
culation, with ACD prediction
being the most important. The
relative contribution of ACD
prediction to refractive errors
has been estimated to range
between 20% and 40%.2,6 For
this reason, theoretical formulas
(such as the Hoffer Q, Holladay,
and SRK/T) are now preferred
over regression formulas (such
as the SRK I and II),35 as the
former allow better prediction
of ACD. In recent years, several
authors have attempted to fur-
B ther improve ACD prediction
Figure 2. Bland-Altman plots showing 95% limits of agreement between the A) Pentacam automatic and these studies have led to
measurements and ultrasound (US) measurement and between the B) Pentacam manual measurement the development of the Holla-
and ultrasound measurement in the comparison group. Continuous lines represent the upper and lower day 2 (unpublished), Olsen,11
limits of agreement (from ⫺0.12 to ⫹0.98 mm and from ⫺0.11 to ⫹0.1 mm, respectively). The dashed and Haigis7 formulas as well as
line represents mean measurement of the two methods. ACD = anterior chamber depth
the lens haptic plane concept
by Norrby.36
DISCUSSION Measuring postoperative ACD is not part of the rou-
Modern cataract surgery aims to provide the best tine follow-up of patients after cataract surgery, but
refractive outcome. Several steps are required to can be of utmost importance in the development of
achieve the desired precision in IOL power calculation: new algorithms of ACD prediction.37 Such measure-
accurate measurements of the axial length and corneal ments are conventionally performed by ultrasound
power,2 entry of the data into the most accurate IOL biometry,11,15,22 as noted in a previous study by Olsen
power formulas, and constant optimization to produce et al11 who found a mean external ACD (4.48⫾0.30 mm)
a mean zero prediction error.7-10 Nevertheless, refrac- extremely close to the mean distance we found between

344 Copyright © SLACK Incorporated

 Anterior Chamber Depth in Pseudophakic Eyes/Savini et al

Figure 3. By clicking on the “edge detection” option of the Pentacam

software, the Pentacam automatically identifies the posterior capsule
(yellow line) as the posterior boundary of the anterior chamber and thus
overestimates the anterior chamber depth. Asterisks show the anterior
surface of the intraocular lens.

the corneal epithelium and the anterior surface of

the IOL (4.51⫾0.34 mm) with the same IOL (AcrySof
MA60AC). Optical methods, however, are preferable
over ultrasound biometry as they do not require con-
tact with the ocular surface and thus cause less discom-
fort to the patient and fewer potential complications.
Optical methods have been extensively investigated
in phakic eyes with contradictory results. Anterior
segment optical coherence tomography,38 partial co-
herence interferometry,18 and Haag-Streit (Koeniz,
Switzerland) slit-lamp optical pachymetry (Hoffer,
personal communication) gave higher measurements
than ultrasound biometry (Hoffer, who compared im-
mersion biometry, could not correct this by changing
the ultrasound velocity), whereas both the Pentacam
and IOLMaster (Carl Zeiss Meditec AG, Jena, Germany)
showed little or no difference in comparison to ultra-
sound.22,39 Many of these investigations, however, are
biased by the adoption of contact biometry, which pro-
duces shorter measurements compared to immersion
biometry due to inadvertent cornea applanation.40 On
the other hand, no published studies report that optical Figure 4. Upper panel) Immersion biometry shows a distance of 4.21 mm
methods and ultrasound can be used interchangeably between the corneal epithelium and anterior surface of the intraocular
in pseudophakic eyes; these results have been reported lens. Middle panel, right) Pentacam anterior chamber depth map and
middle panel left) reveals a central value for same patient of 4.91 mm
with a variety of technologies, including Scheimpflug (up to the corneal epithelium), which is considerably higher than the
imaging (EAS-1000 [NIDEK Co Ltd, Gamagori, Japan] ultrasound measurement of the anterior chamber depth. Bottom panel)
and Pentacam),15,22 scanning-slit topography, and par- Manual measurement of the distance between the corneal epithelium
tial coherence interferometry.41 and anterior surface of the lens shows a value (4235 µm) that closely
Our results show that Pentacam and ultrasound corresponds to the ultrasound measurement.
measurements of pseudophakic ACD do not signifi-
cantly differ and thus can be considered interchange- Pentacam are not reliable, as they tend to give higher
able, on the condition that immersion biometry is values than ultrasound. For the comparison group, the
used and manual measurements are performed on the difference ranged between 0.49 and 0.73 mm in 9 of 12
Scheimpflug images provided by the Pentacam. In the eyes, whereas it was ~0.1 mm in the remaining 3 eyes.
presence of an IOL, the automatic measurements of the The most likely explanation for the higher values esti-

Journal of Refractive Surgery • Vol. 26, No. 5, 2010 345

Anterior Chamber Depth in Pseudophakic Eyes/Savini et al

mated by the automatic Pentacam measurements is an 7. Haigis W, Lege B, Miller N, Schneider B. Comparison of immer-
sion ultrasound biometry and partial coherence interferometry
erroneous detection of the anterior IOL surface by the for intraocular lens calculation according to Haigis. Graefes
internal software. This can be easily observed by click- Arch Clin Exp Ophthalmol. 2000;238:765-773.
ing on the “edge detection” option on the Scheimpflug 8. Hoffer KJ. The Hoffer Q formula: a comparison of theoretic and
image, as shown in Figures 3 and 4. The Pentacam regression formulas. J Cataract Refract Surg. 1993;19:700-712.
tends to identify the posterior capsule as the posterior 9. Retzlaff JA, Sanders DR, Kraff MC. Development of the SRK/T
limit of the ACD. Subsequent analysis revealed that intraocular lens implant power calculation formula. J Cataract
Refract Surg. 1990;16:333-340.
this error occurred in 9 eyes of the comparison group
10. Holladay JT, Prager TC, Chandler TY, Musgrove KH, Lewis JW,
where the automatic measurements of the Pentacam Ruiz RS. A three-part system for refining intraocular lens power
overestimated the ACD by a value higher than 0.46 calculations. J Cataract Refract Surg. 1988;14:17-24.
(which roughly corresponds to the thickness of the op- 11. Olsen T. Prediction of the effective postoperative (intra-
tic of the AcrySof MA60AC) and in all 17 eyes for the ocular lens) anterior chamber depth. J Cataract Refract Surg.
2006;32:419-424.
confirmation group. In contrast, performing manual
measurements with the caliper tool allows the opera- 12. Corder DM, McDermott ML, Shin DH, Parrow KA, Lau-Sickon
LK. Measured and predicted anterior chamber depth for trans-
tor to precisely identify the anterior surface of the IOL scleral suture-fixated posterior chamber intraocular lenses.
and take correct measurements. Moreover, manual Ophthalmic Surg. 1993;24:28-30.
measurements by the Pentacam feature good repeat- 13. Sorenson AL, Holladay JT, Kim T, Kendall CJ, Carlson AN.
ability and reproducibility as shown by the analysis Ultrasonographic measurement of induced myopia associ-
ated with capsular bag distention syndrome. Ophthalmology.
of the assessment group. 2000;107:902-908.
This study shows that in pseudophakic eyes, the man- 14. Arai M, Ohzuno I, Zako M. Anterior chamber depth after pos-
ual ACD measurements obtained from the Pentacam are terior chamber intraocular lens implantation. Acta Ophthalmol
not significantly different compared with those achieved (Copenh). 1994;72:694-697.
by ultrasound immersion biometry and can therefore be 15. Koranyi G, Lydahl E, Norrby S, Taube M. Anterior chamber
considered interchangeable. The Pentacam represents a depth measurement: a-scan versus optical methods. J Cataract
Refract Surg. 2002;28:243-247.
valid option for obtaining noncontact measurements of
16. Holladay JT, Maverick KJ. Relationship of the actual thick intra-
the ACD after cataract surgery and may be used to de- ocular lens optic to the thin lens equivalent. Am J Ophthalmol.
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refractive outcome in IOL implantation. 17. Kriechbaum K, Findl O, Preussner PR, Köppl C, Wahl J, Drexler
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AUTHOR CONTRIBUTIONS
Study concept and design (G.S., K.J.H.); data collection (G.S., C.C., 18. Kriechbaum K, Findl O, Kiss B, Sacu S, Petternel V, Drexler
W. Comparison of anterior chamber depth measurement meth-
S.P., M.C.); analysis and interpretation of data (G.S., P.B., K.J.H., T.O.); ods in phakic and pseudophakic eyes. J Cataract Refract Surg.
drafting of the manuscript (G.S.); critical revision of the manuscript 2003;29:89-94.
(C.C., S.P., P.B., M.C., K.J.H., T.O.); statistical expertise (G.S.); admin- 19. Rabsilber TM, Khoramnia R, Auffarth GU. Anterior chamber
istrative, technical, or material support (K.J.H.); supervision (P.B.) measurements using Pentacam rotating Scheimpflug camera.
J Cataract Refract Surg. 2006;32:456-459.
20. Shankar H, Taranath D, Santhirathelagan CT, Pesudovs K.
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