Revisiting keratoconus diagnosis and progression classification based on evaluation of corneal asymmetry indices, derived from Scheimpflug imaging in keratoconic and suspect cases

Purpose: To survey the standard keratoconus grading scale (Pentacam (R) -derived AmslerKrumeich stages) compared to corneal irregularity indices and best spectacle-corrected distance visual acuity (CDVA). Patients and methods: Two-hundred and twelve keratoconus cases were evaluated for keratoconus grading, anterior surface irregularity indices (measured by Pentacam imaging), and subjective refraction (measured by CDVA). The correlations between CDVA, keratometry, and the Scheimpflug keratoconus grading and the seven anterior surface Pentacam-derived topometric indices - index of surface variance, index of vertical asymmetry, keratoconus index, central keratoconus index, index of height asymmetry, index of height decentration, and index of minimum radius of curvature - were analyzed using paired two-tailed t-tests, coefficient of determination (r2), and trendline linearity. Results: The average +/- standard deviation CDVA (expressed decimally) was 0.626 +/- 0.244 for all eyes (range 0.10-1.00). The average flat meridian keratometry was (K1) 46.7 +/- 5.89 D; the average steep keratometry (K2) was 51.05 +/- 6.59 D. The index of surface variance and the index of height decentration had the strongest correlation with topographic keratoconus grading (P < 0.001). CDVA and keratometry correlated poorly with keratoconus severity. Conclusion: It is reported here for the first time that the index of surface variance and the index of height decentration may be the most sensitive and specific criteria in the diagnosis, progression, and surgical follow-up of keratoconus. The classification proposed herein may present a novel benchmark in clinical work and future studies.