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10.5005/jp-journals-10025-1105
A New Tomographic Method of Staging/Classifying Keratoconus: The ABCD Grading System
Original Article
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Fig. 1: An example of subclinical keratoconus. The BAD display on the left shows advanced keratoconus with a prominent posterior
ectasia, highly abnormal pachymetric progression and a final ‘D’ > 8 standard deviations from the norm in spite of a normal anterior
surface and normal anterior indices shown on the right topometric display
Fig. 3: Sample of the Belin/Ambrosio enhance ectasia display. The left side of the map shows anterior and posterior elevation with a
standard 8.0 mm BFS and the enhanced reference surface. The right side shows the corneal thickness analysis and the pachymetric
progression graphs
Fig. 4: Standard anterior elevation map on the left in the cornea with a prominent ectasia and the depiction of the exclusion zone on
the right (in red)
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Fig. 6: A comparison of the posterior elevation maps in an eye with moderate keratoconus. The map on the left uses the standard BFS,
while the map on the right uses the enhanced reference surface. The enhanced reference surface map shows significantly greater
elevation values
Fig. 7: A comparison of anterior elevation in a normal eye with the standard reference surface (left) and the enhanced reference
surface (right). There is minimal elevation difference between the maps
quality. If any single eye was flagged, both eyes were RESULTS
removed from analysis resulting in 672 eyes/336 patients.
A total of 672 eyes of 336 ‘normal’ patients were analyzed.
As opposed to the previously described normative data
There were 52% females/48% males with an average age
which was based on the standard 8.0 mm BFS, the new of 44.9 years (25–75). Anterior and posterior ROC values
data reported corneal thickness at the thinnest point were 7.65 ± 0.236 mm/6.26 ± 0.214 mm respectively and
and radius of curvature for the anterior surface (ARC) thinnest pachymetry values were 534.2 ± 30.36 mm (Table 3).
and posterior surface (PRC) for a 3.0 mm zone centered Comparing anterior curvature values to AK staging
on the thinnest point. The 3.0 mm zone was chosen as yielded 2.67, 5.47, 6.44, > 6.44 standard deviations for
this is the exclusion zone size utilized in the BAD soft- stages 1 to 4 respectively. Comparative pachymetric values
ware for most keratoconic corneas. The normative data yielded 4.42, 7.72, > 7.72 standard deviations for stages
generated from this database was then used to develop 2 to 4 respectively (AK criteria has no pachymetric value
a classification system which approximated stages 1 to 4 for stage 1). Posterior staging uses the same standard
on the AK system for anterior data and corneal thickness, deviation gates as generated for the anterior data (Table 4).
but added a stage 0, representing more ‘normal’ values.
Once the anterior data gates were established, similar
STAGING
gates based on the standard deviations derived from the The goal of our study was to propose a new classification/
anterior surface were utilized for the posterior surface. staging system that both addressed the deficiencies of the
Table 3: Values for anterior and posterior radius of curvature posterior data and thinnest point pachymetry, but this
and thinnest point information could be available from any commercial
Anterior radius Posterior radius Corneal thickness tomographic unit (i.e. Scheimpflug, slit-scanning, OCT).
of curvature of curvature at thinnest What is not currently available is the radius of curvature
(mm) (mm) point (mm)
at a specific diameter (3.0 mm) surrounding the thinnest
Mean 7.65 6.26 534.2
point. We feel this is critical to better reflect the true
Median 7.64 6.25 533
STD 0.236 0.214 30.36 ectatic region, and this software modification can easily
Range 6.89–8.66 5.61–6.93 454–614 be added to other systems other than the one used in our
study (Oculus Pentacam).
AK system, utilized current imaging capabilities, be inde- The greatest hindrance to a clinical adoption is the
pendent of a specific imaging device, be clinically user lack of familiarity ophthalmologist have in using radius
friendly, convey meaningful anatomic and functional of curvature instead of diopters. Radius of curvature
information and, in the future, may have the potential to is typically used in contact lens fitting and spectacle
be utilized to determine ectatic progression. To this end, design but fewer ophthalmologists fit contacts than in
we propose a new staging system that is similar to the the past. Radius of curvature was selected to allow the
approach taken by the Spaeth angle classification where same measurement of both the anterior and posterior
each anatomic component is independently graded.50 surfaces as radius of curvature is independent on index of
The new grading system named ABCD looks at the ante- refraction. The posterior corneal surface is a negative lens
rior radius of curvature (A), posterior radius of curvature with a low power due to the cornea/aqueous interface.
(B for back surface), corneal pachymetry at thinnest (C), Reporting the true dioptric power of the posterior cornea
Distance best-corrected vision (D), and adds a modifier would be even less intuitive. For ease of adjustment, the
(–) for no scarring , (+) for scarring that does not obscure posterior surface power is shown as an anterior power
iris details and (++) for scarring that obscures iris details equivalent using the same radius to diopter conversion
(Table 5). commonly used for anterior surface keratometry.
This grading system is relatively simple to use and has Diopters = 337.5/radius of curvature (mm)
the advantage of grading each component independently, A sample application of the new ABCD grading
recognizing subclinical disease, and adding a stage 0 to system is shown in Figure 8. The BAD display shows mild
better reflect an absence of possible disease. The grading to moderately advanced keratoconus with a final ‘D’ of
system is dependent on tomography to produce both 4.88. The anterior changes are relatively minor with an
Table 4: Comparable values for anterior and posterior radius of curvature and thinnest point
AK criteria Comparable ARC Comparable PRC Comparable thickness
Stage I Avg K < 48.0 D < 2.63 STD > 5.70 mm
> 7.05 mm
Stage II Avg K < 53.0 D < 5.47 STD > 5.15 mm 4.42 STD
Apical thickness > 400 mm > 6.35 mm > 400 mm
Stage III Avg K > 53.0 D < 6.44 STD > 4.95 mm 7.72 STD
Apical thickness > 300 mm > 6.15 mm > 300 mm
Stage IV Avg K > 55.0 D > 6.44 STD < 4.95 mm < 300 mm
Apical thickness < 300 mm < 6.15 mm
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Fig. 8: Sample of the ABCD grading in mild to moderate keratoconus. The ARC is 7.34, the PRC 5.88 and the thinnest pachymetry
470. There is no corneal scarring and the visual acuity is 20/30+. The final staging is A0/B1/C1/D1–
Fig. 9: Sample of moderately advance keratoconus. The visual acuity is decreased to 20/40+ and there is not corneal scarring. The
final classification is A2/B2/C1/D1–
average K of 7.34 mm (46.0 D). The corneal thickness map Figure 9 depicts a more advanced cone, but again the
shows a thinnest reading of 470 mm with a slight inferior- posterior surface changes are more severe. Visual acuity
temporal displacement. Both the posterior surface and is 20/40+ and there is no visible corneal scarring. The
pachymetric progression show greater change with a ABCD classification in this example would be A2/B2/C1/
central posterior radius of curvature of 5.91 mm. The D1–.
cornea exhibited no scarring and the patients BDVA OS The third example (Fig. 10) is a case of markedly
was 20/30+. The ARC and PRC taken from the 3 mm advanced keratoconus with mild scarring and a best
zone centered on the thinnest point were 7.34 and 5.88 corrected vision of 20/200. The classification would
respectively. The ABCD classification (Table 5) for this be A4/B4/C2/D3+. The ‘+’ indicating mild corneal
cornea would be A0/B1/C1/D1–. scarring.
Fig. 10: Sample of markedly advanced keratoconus with a best-corrected visual acuity of 20/200 and mild apical scarring. The final
ABCD grade would be A4/B4/C2/D3+
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