CA-100 Instruction Manual Sw Ver 1.3

Table of Contents 1

STARTING THE CA-100 PROGRAM ....................................................................1-1

2

PATIENT FILE ARCHIVE ......................................................................................2-1 2.1 2.2 2.3 2.4 2.5 2.6 2.7 2.8

3

ADDING A NEW PATIENT ....................................................................................2-1 SELECTING A PATIENT.......................................................................................2-1 DESELECTING A PATIENT ..................................................................................2-2 PATIENT FILES ..................................................................................................2-2 CHANGING A PATIENT’S FIRST AND LAST NAME ...................................................2-2 DELETING A PATIENT ........................................................................................2-3 SEARCHING FOR A PATIENT ...............................................................................2-3 ARCHIVE BACKUP .............................................................................................2-3

EXAM ARCHIVE ....................................................................................................3-1 3.1 3.2 3.3

CREATING NEW EXAMS .....................................................................................3-1 DISPLAYING AN EXAM FROM THE EXAM ARCHIVE ................................................3-2 DELETING AN EXAM FROM THE EXAM ARCHIVE ...................................................3-2

4

IMAGE GALLERY..................................................................................................4-1

5

ACQUIRING IMAGES FROM THE KERATOSCOPE............................................5-1 5.1 5.2 5.3 5.4

6

AUTOMATIC ACQUISITION WITH KERATOSCOPE..................................................5-1 FINISHING THE ACQUISITION SEQUENCE ............................................................5-2 SAVING IMAGES INTO THE GALLERY ...................................................................5-3 IMMEDIATE PRINT..............................................................................................5-4

PROCESSING KERATOSCOPIES........................................................................6-1 6.1 6.2 6.3

7

EDITING RINGS .................................................................................................6-1 EDITING THE PUPIL ...........................................................................................6-2 EDITING THE LIMBUS .........................................................................................6-4

PUPIL .....................................................................................................................7-1 7.1 7.2 7.2.1

7.3 7.3.1 7.3.2 7.3.3

8

IMAGE ACQUISITION ..........................................................................................7-1 PUPILOMETRY ..................................................................................................7-2 Menu ....................................................................................................................7-3

PUPILOGRAPHY ................................................................................................7-4 Decentralization ...................................................................................................7-5 Speed...................................................................................................................7-5 Percentile .............................................................................................................7-6

TOPOGRAPHICAL MAP .......................................................................................8-1 8.1 8.2 8.3 8.4

9

OPTIONS ..........................................................................................................8-1 MENUS .............................................................................................................8-2 FULL SCREEN DISPLAY OF KERATOSCOPIES .....................................................8-12 USING THE MOUSE POINTER AND CROSSHAIR ON THE MAP ...............................8-12

MAP COMPARISON ..............................................................................................9-1 9.1 9.2

10

CHOOSING MAPS FOR COMPARISON ..................................................................9-1 DIFFERENCE MAP .............................................................................................9-2

CONTACT LENSES.............................................................................................10-1

10.1 10.2

CONTACT LENS SIMULATION ............................................................................10-1 AUTOFIT ........................................................................................................10-2

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10.3 10.4 10.5 10.6

MENUS ...........................................................................................................10-2 TILT ...............................................................................................................10-6 PROFILE .........................................................................................................10-7 USING THE MOUSE POINTER AND THE CROSSHAIR ON THE FLUORESCEINE SIMULATION ................................................................................................................10-8

11

TRIAL LENS DESIGN ..........................................................................................11-1

11.1 11.2 11.3 11.4 11.5 11.6 11.7 11.8 11.9 12

CORNEAL HEIGHT MAP.....................................................................................12-1

12.1 12.2 12.3 12.4 12.5 13

CREATING A NEW MANUFACTURER ..................................................................11-1 SELECTING A MANUFACTURER.........................................................................11-1 CREATING A NEW MODEL ................................................................................11-1 PROTECT MODEL ............................................................................................11-2 SELECTING MODELS........................................................................................11-3 EXPORTING MODELS .......................................................................................11-3 IMPORTING MODELS ........................................................................................11-3 DELETING MANUFACTURERS ...........................................................................11-3 DELETING MODELS .........................................................................................11-3 CORNEAL HEIGHT MAP PROCESSING ................................................................12-1 OPTIONS ........................................................................................................12-2 MENUS ...........................................................................................................12-4 HEIGHTS PROFILE ...........................................................................................12-7 USING THE MOUSE POINTER AND CROSSHAIR ON THE MAP ...............................12-7

ZERNIKE ANALISYS ...........................................................................................13-1

13.1

ZERNIKE ANALYSIS SUMMARY ..........................................................................13-1

13.1.1

13.2

13.2.1 13.2.2 13.2.3

13.3

PRINTER.........................................................................................................14-1 PRINTING THE SCREEN....................................................................................14-1 PRINTING STANDARD REPORTS .......................................................................14-1 STANDARD REPORT SETTINGS ........................................................................14-2 CREATING CUSTOMIZED REPORTS ...................................................................14-2 PRINTING CUSTOMIZED REPORTS ....................................................................14-5 PRINT TO FILE .................................................................................................14-6 PRINT TO FILE SETTINGS .................................................................................14-7

ACCESSORY FUNCTIONS .................................................................................15-1

15.1 15.2 15.3 15.4 15.5 15.6 15.7 16

Menu ................................................................................................................13-10

PRINTING.............................................................................................................14-1

14.1 14.2 14.3 14.4 14.5 14.6 14.7 14.8 15

Options ..............................................................................................................13-4 Menu ..................................................................................................................13-5 Graphs and components ...................................................................................13-7

VISUAL QUALITY SUMMARY .............................................................................13-9

13.3.1

14

Menu ..................................................................................................................13-2

ADVANCED .....................................................................................................13-3

IMPORTING FILES ............................................................................................15-1 EXPORTING FILES ...........................................................................................15-1 COMPACTING AND BACKING UP THE ARCHIVE ...................................................15-4 STATISTICS ....................................................................................................15-5 APPOINTMENT CALENDAR ...............................................................................15-5 LENSES MEASUREMENT ..................................................................................15-6 REFRACTION ..................................................................................................15-6

APPENDIX A: INSTALLATION ...........................................................................16-1

16.1

USERS WITH WITH METEOR II..........................................................................16-1

16.1.1

New Users .........................................................................................................16-1

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16.1.2

16.2

16.2.1 16.2.2 16.2.3 16.2.4

16.3 16.4 16.5 17

New users. .........................................................................................................16-5 Upgrading the system from a previous version. ................................................16-5 Installation of Direct X 8.1 .................................................................................16-6 Install FOCUS Topographer USB Drivers .........................................................16-7

SOFTWARE INSTALLATION ...............................................................................16-8 NOTE CONCERNING INITIAL PROGRAM STARTUP ...............................................16-9 CALIBRATION OF THE KERATOSCOPE ...............................................................16-9

APPENDIX B: CUSTOMIZING THE SOFTWARE...............................................17-1

17.1 17.2 17.3 18

Upgrading the system from a previous version .................................................16-1

USERS WITH USB ...........................................................................................16-5

PASSWORD ....................................................................................................17-1 SETTINGS.......................................................................................................17-1 MODIFY MENU ................................................................................................17-4

OVERVIEW OF THE CA-100 PROGRAM ...........................................................18-1

18.1 18.2 18.3 18.4 18.5 18.6 18.7 18.8 18.9 18.10 18.11 18.12 18.13 18.14 18.15

STARTING THE CA-100 PROGRAM ..................................................................18-1 ADDING A NEW PATIENT ..................................................................................18-1 SELECTING A PATIENT FROM THE ARCHIVE ......................................................18-1 DELETING A PATIENT ......................................................................................18-1 CREATING NEW EXAMS ...................................................................................18-1 DISPLAYING AN EXAM FROM THE EXAM ARCHIVE ..............................................18-2 ACQUIRING IMAGES ........................................................................................18-2 SAVING IMAGES INTO THE GALLERY .................................................................18-2 PROCESSING KERATOSCOPIES ........................................................................18-2 PUPIL .........................................................................................................18-2 TOPOGRAPHICAL MAP .................................................................................18-2 SIMULATION OF A CONTACT LENS ................................................................18-3 CORNEAL MAP HEIGHT ................................................................................18-3 ZERNIKE ANALISYS......................................................................................18-3 PRINTING ...................................................................................................18-3

INDEX ..........................................................................................................................18-1

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1 Starting the CA-100 program Welcome to the CA-100 system. To begin your work session, double click the short cut icon on the desktop or in the programs submenu at the start menu and launch the program. If it is password protected, enter your password in the window that prompts and then continue. After some seconds you will see the main screen of the CA-100 software, as shown in Figure 1.1 below.

Figure 1.1: Main screen The first screen is divided into three main sections, upper left-hand, lower left-hand and right-hand section. In the first section, upper left-hand corner of the screen, the text fields [Surname], [Name] and [Birth date] of the patient can be found, as well as the [Ø] button, clock and [Data] button. The [Ø] button opens the patients database window (see § 2.2) The [Data] button commands the lower left-hand section of the screen by alternating the info displayed between the patients personal information and the patients exam’s history (see Chapter 3) (see § 2.4) At the right-hand side of the screen, we find the gallery of images related to the selected patient. If no patient has been selected, all of the boxes will be empty.

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2 Patient files DATABASE archive 2.1 Adding a new patient To add a new patient to the patient DATABASE, type in the patient’s first and last name in the appropriate empty text field box and press the Enter button or click on the [Ø] button. The software will then ask the user for confirmation on adding the new patient; if confirmation is given, a window will appear in the centre of the screen prompting the user to enter the birth date of the new patient. The birth date is mandatory to differentiate patients having the same name. It may be entered either in the form of DD/MM/YY or DD-MM-YY. The day and month may be written using one or two digits (for ex. 01-01-60 or 1-1-60). The year may be written using two or four digits (for ex. 0101-60 or 01-01-1960). To confirm the new patient entry, press Enter or click on the [Ok] button, To cancel the new patient entry click on the [Cancel] button . After confirmation, a section will appear at the lower left-hand side of the screen, enabling the user to enter extra patient’s personal data information. This data section is divided into three parts tabs named: personal, medical, and other (see § 2.4) Each time the user enters a patient’s name that matches the name of one or more patients who are already in the patient DATABASE archive, the already existing patient’s names will be displayed on the screen. To continue click on the [New patient] button in order to confirm the addition of the new patient. 2.2 Selecting a patient There are several ways to select a patient from the patient file archive: • Type in the first and last name in the appropriate fields and press the Enter button or click on the [Ø] button. Select the patient’s name with a double click in the window that prompts up. • Type in only part of the first or last name in the appropriate fields.. Select the patient from the list as described in the previously. • Leaving the first and last name fields empty, press the Enter button or click on the [Ø] button. In this manner, a list of all of the patients contained in the patient’s DATABASE will appear. Search the list using the scroll bar on the right-hand side and double-click on a the patient’s name. The same thing may be done using the arrow keys on the keyboard and pressing the Enter button. To close the patient’s DATABASE, click on the [Cancel] button. The [New patient] button is used for the entry of a new patient in the case of an already existing patient with that same name in the patient’s DATABASE.

Figure 2.1: Selecting a patient from the archive Once a patient has been selected, at the lower left-side of the screen a list with the patients exams will automatically appear along with the gallery of images, at the right-side part of the screen, linked to the selected. To view the other existing exams and image galleries, scroll down the list of them by using the arrows on the keyboard and to select one click on it.

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2.3

Deselecting a patient

Once a patient has been selected, the arrow shown on the [Ø] button changes direction and points upwards. To cancel the selection, click on this button so that the arrow turns downwards again or click [Close patient] from the [File] menu. 2.4 Patient DATA At the upper left-side section of the screen, we find a button that changes from [Data] button to [Examination] button and vice versa when clicked, which consequently changes the content displayed at the lower left-side part of the screen. When the button is displayed as [Examination] button, it displays the patient personal Data at the lower left-side of the screen, divided into three sections: personal, medical, and other data. - The personal data includes the following: Sex Birth place Birth date Address Postcode City Province Nationality Telephone - The medical data includes the following: Healthcare number Personal doctor Case history Diagnosis of right eye Diagnosis of left eye - The other data (always relating to the patient’s data) includes the following: Marital status Profession Tax code VAT number Company name Activity Company address Any modifications made to the data are saved by pressing Enter without a prompt. The patient file closes and will be automatically replaced by the patients exams list. To delete a patient’s file and all the related data click on the [Delete] button at the bottom part of the screen.

2.5

Changing a patient’s first and last name

Figure 2.2: Changing a patient’s first and last name

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To modify or correct the first and last name of an already existing patient, select [Patient Data] from the [Edit] menu while in the patients Data file. The window shown in Figure 2.2 will then appear. 2.6 Deleting a patient To delete a patient’s file from the Database archive, open the patient’s file and click on the [Data] button and then at the bottom of the screen click on the [Delete] button. Note: Deleting a patient’s file will also delete all exams and associated images and its related movies. 2.7 Searching for a patient By clicking in the [Search] command located in the menu at the top of the main screen, a window will prompt up with various search options. At the top of the Search window we find three boxes from which to define an specific search criteria. To choose and define the search criteria, click at the arrows buttons located on the right side of the boxes and from the drop-down list of options that appears at each box scroll and select the desired option by clicking with the mouse at the desired highlighted option. Then click on the [Add] button. The chosen search criteria will appear in the box located at the bottom of the window.

Figure 2.3: Window for choosing search criteria. To add additional search criteria, click on the [And] button and repeat the procedure described above and to enter alternative search criteria, click on the [Or] button and repeat the procedure described above. To delete the chosen search criteria, click on the [Reset] button. To start the search, click on the [Search] button. To close the window, click on the [Exit] button. Once the search is completed, a list of patients who satisfy the search criteria will appear on the main screen along with a scroll bar named [Active search]. This bar will allow the user to scroll through the list of patients and view the files for the selected patients. Once the desired patient file has been found, the user will be able to view the patient’s exams (see § 3.2). To end the Search, click on the [End Search] command located in the menu at the top of the main screen Archive Backup The backup of the Database archive is always automatically executed when the user closes the program.

Figure 2.4: Path for the backup of the archive

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The archive is duplicated and copied in the following way: the first time the program runs, it creates the BackUp folders structure path shown in Figure 2.4 and at closing time the “eye.mdb” file is saved in the directory folder “BackUp\BackUp1”. The next time after that the program is run and then closed, the archive inside “BackUp1” will be moved into “BackUp2” and the current “eye.mdb” file in use will be saved inside the “BackUp1” folder. The third time after that the program is run and then closed, the archive file inside “BackUp2” will be moved into “BackUp3”, the archive file in “BackUp1” will be moved into “BackUp2” and the current “eye.mdb” file in use will be saved inside “BackUp1”. . For each subsequent execution of the program, the back up files “eye.mdb” will be moved from folder to folder, a new copy the updated archive file saved and the oldest eliminated. In this way, inside folder “BackUp1” there is always the most recent version of the archive, in “BackUp2” the previous one and in “BackUp3” the oldest one.

2-4

3 Exam Database archive An unlimited number of exams may be associated to each patient. These exams are defined according to the type of exam and execution date. 3.1 Creating new exams To create a new exam for a patient, select an existing patient or add a new patient as described in Chapter 2. Once this has been done, inside the exams list box click on the [New] button located in the lower left-hand corner or press Enter. To cancel the exam, while highlighted, click on the [Delete] button (see Figure 3.1).

Figure 3.1: List of exams relating to a patient The new exam is listed according to the type of exam and execution date. The type of exam appears automatically depending on the program settings (see § 17.3). In the Exam Type pulldown menu list shown below in Figure 3.2, it is possible to change the definition of the type of exam by typing it directly inside the [Exam Type] text box, as well as the exams date in the [Exam Date/Time] text box. Once a new exam has been created, at the lower left-hand side of the main screen the exam data section becomes active and includes the following text boxes:

Figure 3.2: Exam box

Exam Date/Time The date and time displayed are by default the same as the operating system. However, these values may be changed by selecting the corresponding text box.

3-1

Exam Type The default exam type depends on the program settings which may be modified using the [Modify] menu on the main screen (see § 17.3). When a list of exam types is available, it is possible to chose the type of exam among those that have been previously entered by clicking on the [È] and then on the name of the exam that appears on the list. The various exams may be entered using the [Modify] menu on the main screen (see § 17.3). Diagnosis Free text insertion box. Group Choose a group by clicking on the [È] button and then clicking on the name of the group from the list. The various groups may be entered using the [Edit] menu on the main screen (see § 17.3). Description Scrollable free text insertion box allowing the user to scroll through the text. Any changes made to the exam data are automatically saved when the exam section is closed. Depending on the program settings, any of the three buttons below may be present in the lower part of the main screen. Topography Allows the user to open the window used to acquire keratoscopies. Pupillography Allows the user to open the window to acquire pupil sequence. In the same window is present a [Refraction] button that allows you to access a section for insertion of refraction data. Summary: to perform a new corneal map the user has to select a patient, create new “Corneal Topography” exam or select an existing one, then push the

button.

3.2 Displaying an exam from the exam archive To display an exam from the exam archive, simply scroll down the list of exams (see Figure 3.1) using the mouse or the arrows on the keyboard. the exam is highlighted, the images and the movies related to that exam will appear in the gallery section located on the right-hand side of the main screen. 3.3 Deleting an exam from the exam archive To delete an exam from the exam archive, select the exam and click on the [Delete] button (see Figure 3.1). A message will appear asking confirmation to delete. Note: Deleting an exam also deletes all related images and movies.

3-2

4 Image gallery Whenever an exam inside the exam archive is accessed, as described in § 3.2, the image and movie previews related to the selected exam will be shown in the gallery section at the right-hand side of the main screen (see Figure 4.1). Each gallery may contain a maximum of 64 images which may be scrolled through by using the arrow buttons located at the bottom of the section. Images marked with a red “T” have been acquired with the topographer but they have not been processed. To process and display their corneal map the user has to double-click the image. Then the editing result’s window is shown and it is possible to display keratoscopies (see Chapter 6). Images marked with a white “T” have been already processed; to display the corneal map, or fluoresceine simulation, the user has to double click in the image. Pointing to an image in the gallery and clicking the right mouse button will open a shortcut menu containing the following options: Information’s Opens a window where it is possible to enter the information relating to the image (or movie): • Short description: maximum of 10 characters. This description is shown under the image. To see the other descriptions, the user needs to open the window; • Description: Free text box; • Time elapsed: Function used for the Eye Image module; • Calibration: Is used to calibrate linear distances; • Eye examined: Choose the button for either the right or the left eye. To confirm the choices, click on [Ok]. To cancel the insertion of information, click [Cancel]. Display This is equivalent to double-clicking on the preview. On images it opens the viewer described in Chapter 6, for movies it opens the movie player (see Errore. L'origine riferimento non è stata trovata.). Put in Exposition Inserts the image in the Exposition described in Chapter Errore. L'origine riferimento non è stata trovata.. This menu item is not available for movies. Insert from disk Opens the window shown in Errore. L'origine riferimento non è stata trovata. .allowing the user to insert an image from a disk to the gallery The imported image has to be in one of the supported formats (TIF, BMP, JPG, TGA, etc.). It is possible to choose the specific location within the gallery as to where to insert the image as well as to preview it before importing it else clicking on the [New] button automatically places the image in the first empty position inside the gallery. Information concerning the dimension of each image is displayed. The [Apply] button is used when the user wants to continue inserting more images. The [Ok] button is used when the user is finished inserting images into the gallery and wants to close the import window.

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Figure 4.1: Window used to import an image from other patients Insert from gallery Allows images and movies to be imported from the gallery of other patients For an image it opens the viewer described in Chapter 6, for a movie the movie player (see Errore. L'origine riferimento non è stata trovata.). Copy Image Allows an image or a movie to be copied from one position in the gallery to another.

Figure 4.2: Copy image Select the destination position in the gallery, click on the [Apply] button and the image (or movie) will copy itself into the selected gallery position. To return to gallery click on the [Ok] button after the copy has been executed. Delete image Allows the user to delete an image or movie from the Gallery and therefore from the corresponding patient file. Send to Allow the user to send an image or a movie by e-mail.

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5 Acquiring images from the keratoscope To acquire an image from the keratoscope, select a patient and create a new corneal topography exam or select an exam from the exam list to which new images will be added. Then click on the to open the window used to acquire images. The window will be different depending on the used video keratoscope selected (fixed or “Focus”), frame grabber and selected options from the [Settings].

5.1 Automatic Acquisition with Keratoscope In order to acquire in automatic mode, you have to select the check box option button for “Automatic Acquisition” in the [CA-100] tab from the [settings] window at the [File] menu at the top of the screen. In Figure 5.1. is displayed the “Automatic Acquisition” window environment. The live sequence is at the center of the window, while the galleries at the right and at the left are used to show the previews of the acquired images during the current session. When you start the acquisition procedure it’s necessary to specify the eye, and this can be done in different ways: With Focus: • Pushing the button (right eye) or (left eye) under the live window. • Pushing the button “R” or “L” which are next to the base of the video keratoscope handle. With Fixed: • Pushing the button (right eye) or (left eye) under the live window. • Pushing the joystick button. Now the acquisition sequence can start: the system makes a beep, above the live sequence image the selected eye radio button will be shown selected and the corresponding button of the selected or ) will become red at one of the bottom corners. To guide the user on moving the eye ( instrument in the correct direction to go through the perfect focus position the system provides visual signals and sounds help’s. The visual signals are colored arrows next to the live window: a red arrow turned up suggests to bring the instrument nearer to the eye, while a blue arrow turned down suggests to bring the instrument away from the eye. At the same way, a series of beeps with high tonality alerts to bring the instrument nearer, while a series of beep with low tonality alerts to bring the instrument farther away. The acquisition procedure can end in two ways. In the first case (manual) the user stops the acquisition using the same buttons described for the starting. The second way is completely managed by the system which automatically checks instant by instant if the necessary conditions for the acquisition are verified (crossing of the perfect focus position, low decentralization of the pointing cross, slow movement); when all the conditions have been satisfied the system stops the acquisition sequence and save the corresponding image.

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Figure 5.1: Acquisition window. As soon as the acquisition procedure stops, the corresponding button of the selected eye return grey and the preview of the acquired image will be displayed in the gallery. There are two kinds of acquisition options: if [Precision] is selected the system requires a little more time to perform the acquisition, but the result is very precise; otherwise select the option [Speed] when the acquisition is performed in critical condition (for example when the patient can’t keep the eye open for the time of the acquisition), the acquisition will be faster and precise enough. Only in cases where you use the “Focus”, to make the system work correctly, it’s recommended to execute the calibration buttons of the acquisition in the video keratoscope. To do this, place the instrument over a uniform background (for example a with paper) until you visualize a completely gray image, click on the [Set buttons] button and follow the indications displayed at the bottom of the screen. It’s recommended to acquire more than one image for the same eye, so you’ll be able to choose the best out of more than one. It’s possible to acquire up to 16 images within a session.

5.2

Finishing the acquisition sequence

To end the image acquisition sequence, click on the [Exit] button. All of the acquired images will then be displayed for each eye (left or right) in groups of 1, 4 or 8 (left or right): the number of images to be displayed on the window may be chosen by clicking on one of the three buttons located in the [Zoom] section at the top right of the window as shown in Figure 5.2. Use the and buttons to scroll through the captured images. Pushing the button starts a new acquisition session that will erase previous pictures.

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Figure 5.2: Sequence of the acquired keratoscopies. To magnify the images double-click on them. To the right of the magnified image, the [+] will appear which, when clicked upon, will display crosshairs corresponding to the centre of the objective of the video camera. This allows the user to determine whether or not the image is centered (see Figure 5.3). To return to the view of all of the images in the sequence, double-click anywhere on the image. With automatic acquisition: • A colored label at the top left of each image reports the kind of acquisition; “A” for automatic and “M” for manual (if the acquisition sequence was interrupted with a manual stop). • In the middle right part of the screen a measure sample of the standard deviation is reported for each eye. • The images can be displayed in two different ways: chronological (in the order in which they heve been acquired) or according to the standard deviation (the first is the closer to the mean value of curvature of the sample, the last is the farthest). The colored border of the image means the class of acquisition according to the standard deviation (green if the image is near enough to the mean value, red if the curvature is steeper than 0.25D, blue if the curvature is flatter than 0.25D in respect to the mean value). 5.3

Saving images into the gallery

At the bottom part of the screen in the acquisition window (see Figure 5.2 and Figure 5.3), the user will see a series of small boxes representing either the various positions or groups in the gallery. The user may scroll through these boxes using the arrow buttons. To save the keratoscopies to be processed, move the mouse pointer on top of the chosen image , click and keep pressed the left mouse button (the mouse pointer will change shape) and drag the image to the desired location in the Gallery (the mouse pointer will again change shape) and release the left mouse button to save it in that location. The new image will overwrite any image

5-3

that was already present and the user will see the new image displayed in the chosen position. On the new position, the user will see a thumbnail drawing of an eye indicating that the position in the gallery is no longer empty.

Figure 5.3: Keratoscopy acquisition window Clicking on the [Process] button allows the keratoscopy to be processed. Any images that haven’t been saved into the gallery may not be processed and are lost once the acquisition window gets closed. 5.4

Immediate print

After saving into the gallery the captured keratoscopic images you will be able to print the standard report directly from the grabbing environment (right panel [Immediate print] bottom, in Figure 5.2). Immediate print buttons ([OD / OS], [OD] and [OS]) are disabled at start-up and only become active after saving the images in the gallery during the grabbing session. For example, the saving of the first keratoscopic image of the right eye enables the [OD] button; saving of the first keratoscopic image (attention to not keep the exact same position) of the left eye enables the [OS] and [OD / OS] buttons. The [OD / OS] Button print’s a left vs right eyes standard report; the [OD] button print’s the standard right eye report; [OS] button print’s the standard left eye report. Pushing the [Set] button displays the “ Standard Report Settings” window (see §14.3).

5-4

6 Processing keratoscopies Clicking on the [Process] button located below each saved keratoscopy in the images capture window (see Chapter 5) begins the elaboration of the corresponding image. It is also possible to open the Elaboration window by double-clicking inside the images marked with a red “T” (see Chapter 4) in the gallery. The program recognizes the position of the keratoscopic rings reflected on the cornea and individuates the jumps in brightness between bright and dark rings and vice versa. The identification of the rings is highlighted on the keratoscopy by the superimposition of red and green points which allow the user to see if the program recognizes the rings correctly. Some of the rings may not be correctly identified because of interference due to irregularities, corneal opacity, or shadows generated by the eye lashes or the nose. For this reason, it is always necessary to check the identification of the rings before elaborating the topographic map so as to make any needed corrections manually using the editing commands. It is possible to act on the identification of the rings, the pupil, and limbus by clicking on the corresponding buttons inside the [View] box, located in the upper right-hand corner of the window. 6.1 Editing rings The reconstruction of the rings is carried out after the system has automatically found the points. To determine and set the editing rings parameters, use the buttons located on the right-hand side of the window. (see Figure 6.1 below):

Figure 6.1: Editing the rings [Ring points] box • [Add] to add points; • [Remove] to remove points; • [Rem. all] to remove all of the points. The buttons may be chosen by clicking on them with the left mouse button. The arrows on the keyboard may also be used to choose the [Remove] and [Add] buttons: • Press on the [Å] arrow to [Remove] points; • Press on the [Æ] to [Add] points. [Ring] box • Buttons numbered from 1 to 24 correspond each one to one of the rings. • Use the [Change] button to reposition a selected ring.

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Selecting/deselecting rings To select or deselect a ring, point the cursor near one of its points and click with the right mouse button or click on the corresponding numbered button at the right-hand side of the window. It is also possible to select a ring using the numbers on the keyboard: for the rings having two-digit numbers, type in the figures quickly; for rings having one-digit numbers, type in the figure and wait a moment. Once a ring has been selected, it is possible to select the previous or following ring using the arrow keys on the keyboard: pressing the [Ç] key will select the following ring; pressing the [È] key will select the previous ring. When a ring is selected, the corresponding numbered button becomes active by being pressed inwards and the points on the ring are linked together in a solid blue line. When a ring is selected, the add or delete buttons will only apply to that specific ring. Removing points To remove points, click on the [Remove] button located in the [Ring Points] box. Move the mouse pointer to the keratoscopy image. Then click and keep pressed the left mouse button. This will cause a small green square to appear on the pointer: to delete points, move the small green square over the points to be deleted. Clicking on one of the three squares located at the bottom center part of the window changes the size of the green square depending on the desired extension of the points to be deleted. If only one ring is selected, only the points on that ring will be deleted. Adding points A ring must be selected before points may be added to it. Using the procedure described above, select a ring and then click on the [Add] button in the [Ring Points] box. Then move the mouse pointer to the selected ring and to the point where the system was unable to find the points automatically. The reconstruction of the ring can only be carried out if there is sufficient information to do so. Repositioning entire ring In some cases, it may be determined that a ring was not located at the position it should have been assigned. For example, opacity in the central cornea may prevent the first rings of the keratoscopy from being reflected. In this case, the software may erroneously consider the first ring that it identifies in the keratoscopy as being ring number 1. To obtain a correct elaboration of the topographical map, the rings will have to be renumbered until each of the rings occupies the real position to which it has been assigned. If the periphery of the cornea is intact, the rings may be repositioned in the correct way by assigning the number 24 to the last ring on the keratoscopy. The numbers assigned to the inner rings will be updated accordingly. To change the position of the rings, proceed as follows: • select the ring that occupies the incorrect position using the procedure described above; • click on the [Change] button in the [Ring] box (the ring number will turn red), • click on the number button corresponding to the new position that the ring is to occupy. Once this has been done, all of the rings will be repositioned according to the new position of the selected ring. Any rings that move outside the 1 to 24 range will be lost.

6.2 Editing the pupil Clicking on the [Pupil] option in the [View] box will allow the user to edit the pupil. There are two ways to edit the pupil: [Manual] and [Automatic], which may be selected by clicking on the corresponding buttons. Manual editing Clicking on the [Manual] button, will display a set of commands on the right-hand side of the window as shown below in the Figure 6.2. One of the options, [Freehand] or [Polygonal], must be chosen in order to draw on the pupil either by freehand or in segments. If the [Freehand] option is chosen, the user may draw a straight red line by clicking and maintaining pressed the left mouse button. When the left mouse button is released, the software will convert the red line into a yellow ring that corresponds to the

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drawing made. If the [Polygonal] option is chosen, each time the left mouse button is pressed, a segment is drawn on the pupil. Double-clicking on the left mouse button will terminate the procedure. In both cases, it is possible to smooth out the drawing of the pupil to a greater or lesser extent by using the scroll bar located on the right-hand side of the window. The [Redraw] must be clicked after each smoothing modification.

Figure 6.2: Manual (polygonal) editing of the pupil The four arrow buttons located under the scroll bar allow the user to position the contour of the pupil in four directions. Automatic editing Clicking on the [Automatic] button will display a set of commands on the right-hand side of the window as shown below in the Figure 6.3 below. A rectangle must be drawn around the area where the pupil is located. This is done by clicking and maintaining the left mouse button on the keratoscopy and moving the mouse until the rectangle contains the entire pupil area. When the left mouse button is released, the system will automatically generate a representation of the pupil. It is possible to use the scroll bar located on the right-hand side of the window to change the dimensions of the area where the program will look for the pupil: in this case, the pupil dimensions will change only if the program finds other points that may be assimilated to the contour of the pupil.

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Figure 6.3: Automatic editing of the pupil The four arrow buttons located under the scroll bar allow the user to position the contour of the pupil in four directions.

6.3 Editing the limbus Clicking on the [Limbus] option in the [View] box will allow the user to edit the contour of the iris. Clicking and maintaining the right mouse button while moving the mouse pointer over the keratoscopy, allows the user to change the dimensions of the limbus. Clicking on the left mouse button positions the contour of the iris on the eye. The [Map] button displays the color map of the cornea (see Chapter 7). The [Exit] button closes the Edit window and returns the user to the main screen.

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7 Pupil 7.1

Image Acquisition

To proceed with the acquisition of the images in Pupilometry, select a patient and click on the button or choose the item [Grab Pupil ] from the [Topography] menu in the upper part of the main window. This way you enter the “live” environment window shown in Figure 7.1.

Figure 7.1: Acquisition Before executing the acquisition it is necessary to do certain preliminary actions. After having ready the patient, select the eye from which an image will be acquired and set the instrument so it can visualize the eye in the live window. For the instrument to be set correctly, the reference cross should coincide with the center of the pupil and it should be in focus by moving the instrument backwards and forwards until reaching the optimal focus position. In this conditions the pupil is in a phototropic condition. Choose the kind of exam you want to record: dynamic (sequence from photopic to scotopic condition), fixed photopic, fixed mesopic, or fixed scotopic. At this point, it is possible to start the image acquisition sequence by clicking and maintaining pressed the button in the joystick until the pupil becomes scotopic for the dynamic or continue pressing until reaching for the other kind of acquisitions. In the dynamic acquisition mode, when pressing the button in the joystick, the light of the instrument shuts off to stimulate the pupils dilatation. During the acquisition the instruments the reference cross should be kept the closest to the pupils center as possible. At the end of the acquisition the program elaborates the image and creates automatically the exam. It can happen that in the image sequence there isn’t enough information present to individuate the pupil (as an example if the eye were semi-close): in that case the user can eliminate permanently the image or recuperate it by setting manually the missing parameters (pupil outline, fixing point).

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After the end of the acquisition, the pupillometry window displays the results of the acquisition. During acquisitions in controlled light condition (scotopic, mesopic and photopic), when closing the window, the saved images sequence will be reduced to only three images; the images with the minimum, mean and maximum diameter values will be chosen and saved. It is very important at this phase, before saving, to eliminate the images that present artifacts or winking. 7.2

Pupilometry

To access the pupilometry window environment it is necessary first to have done a Pupilometry and then chose [Pupil] in the menu item in the main window, or in the Color map, or in the Zernike analysis summary, or in the Advanced Zernike or in the Visual Quality summary. In cases where the patient hasn’t undergone a pupilometry, it will be disabled. Also while inside a map, the menu item to access this section will be activated only if a pupilometry exam of the eye exist of it. As an example, if you are in the right eye topographic map, but the pupilography has been done only to the left eye, the menu item [Pupil] will be disabled. The window (see Figure 7.2) contains an image of a patients eye in which the outline and the center of the pupil is shown in red and the fixing point in green.

Figure 7.2: Pupilometry You can choose the type of acquisition by clicking on one of the buttons at the right side of the window (scotopic, mesopic, photopic and dynamic) and you can select the left or right eye through the option button at the upper right-side box. At the [Sequence Images] box placed at the bottom left-side of the window we find a scrollable bar to choose the image to be visualized. At the left side of the bar two numbers indicate; the number of the image visualized and the second the total number of images that make up the pupilometry images sequence. Each time that a new image is selected, it is visualized and the outline of the pupil, the pupil center and the fixing point are updated. In the [Diameter Pupil] box placed at the bottom center-part of the window the scroll bar serves to visualize the dilatation/contraction of the pupil upon the variations of the diameters media. The extremes of the scrollable bar are the minimal and maximum values of the diameters media of the pupils measured in all the images from the sequence. By selecting a new diameter the program updates automatically in the current eye image the outline of the pupil and its center; also at the

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right side of the scrollable bar it is displayed the selected diameters value and the polar coordinates of the corresponding pupil with respect to the fixing point. At the bottom right-side part of the window is displayed the reports of the mean value and the standard deviation of the pupil diameter of the acquired sequence. 7.2.1 File

Menu Save By selecting this item, a window will be displayed allowing the user to export an image to a disk in a format that is readable by other software programs. Close This command closes the Pupilometry window.

Edit Pupil editing This item enables the manual reconstruction of the pupil outline after the system has automatically found the points. In order to determine what needs to be done, use the buttons located on the right-hand side of the window (Figure 7.3): • [Add] to add points; • [Remove] to remove points; • [Rem. all] to remove all of the points. By clicking on one of the three buttons with the squares inside, the size of the green square changes depending on the desired extension of the points to be deleted. The [Close] button ends the editing procedure. The buttons may be selected by clicking on them with the left mouse button.

Figure 7.3: Pupil editing To remove points, click on the [Remove] button and place the mouse pointer over a point. Then click and maintain pressed the left mouse button. This will cause a small green square to appear on the pointer: to delete points, move the small green square over the points to be deleted. To add points, click on the [Add] button and place the mouse pointer over the section where the system was unable to find the points automatically and press the left mouse button. The reconstruction of the ring can only be carried out if there is sufficient information to do so. Fixation point This item sets the manual fixation point. To set a new position select [Fixation point] from the menu, move the mouse pointer to the expected point, press the left mouse button and select again [Fixation point] menu. Image Gallery By clicking on this voice a new window appears as the one shown in Figure 7.4.

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Figure 7.4 Pupil images galery With the arrow buttons you can view the complete sequence of images. You can delete an image by dragging and dropping it into the trash can by or by clicking on the right button of the mouse and selecting the voice [Delete] from the menu. In “dynamic” mode acquisition, you can edit the pupil edge by selecting the voice [Edit] from the mouse menu. Delete Delete’s current image. Delete pupilometry Delete’s whole Pupilometry Options Pointing cross If selected (√) shows the blue pointing cross in the centre of the image. Coordinates Indicates the type of coordinates (cartesian or polar) used to represent the pupil centre position referred to the fixation point. Distance This command allows the user to measure a distance by drawing a line segment on the image. The measurement is reported next to the segment. To draw a line segment click on a point on the map with the left mouse button, move the mouse to the desired point and click again on the mouse button. Eye Indicates the current eye (left or right). The items are enabled if a pupilometry exist. Graphs Allow’s viewing of graphs relative to the examined pupil. 7.3 Pupilography To access this window select the [Graphs] menu in the [Pupilometry], [Color map], [Zernike Summary Analysis], [Advanced Zernike] or [Visual Quality Summary] windows.

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In the window we find three tab’s: “Decentralization”, “Speed” and “Percentile”, as you can see in the Figure 7.5. To change section click on the windows tabs. 7.3.1 Decentralization In the Figure 7.5 we see the [Decentralization] section with a case example. In this case the “ordinate” and the “abscissa” represent the Cartesian coordinates of the pupil centre with respect to the fixation point (0,0) varying the pupil diameter (ø), readable in the rectangle at the rightbottom. By using the scrollbar it’s possible to change the diameter value while viewing in the graph the relative pupil centre highlighted by a little green square. The coordinate values of the point are visible at the bottom-centre part, and the corresponding polar coordinates at the left side. When moving the mouse over the graph (the part with black background), the cursor becomes similar to a magnifying glass and by clicking repeatedly the left button of the mouse it allows you to zoom-in until you reach a zoom of 16:1. By clicking the right button it zoom-out’s. This function makes a representation always centred on the axis origin (the fixation point).

Figure 7.5: Graph folder (Absolute scale) 7.3.2 Speed In the [Speed] section, you’ll see a graph representing the trend of the pupil’s diameter against acquisition time.

Figure 7.6 Speed graph

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As shown in Figure 7.6, the graph reports in “abscissa” the second’s acquisition time and in “ordinate” the mm value, in a normalized scale between the minimum and maximum value. 7.3.3

Percentile

Figure 7.7 Percentile

The [Percentile] section shows a graph representing the statistical value of the percentile of the sample for each controlled light acquisition condition. The red line shows the value of the middle value of the sample, the blue box the range of values between the percentile at 25% and 75%, the green line the range of values between the percentile at 10% and 90% and the pink circle the values out of this range. The [Scale] can be selected [Absolute] (value between 2 to 9mm) and [Normalized] from the minimum to the maximum value of the acquired diameters.

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8 Topographical map This window below shows the coloured map of the cornea.

Figure 8.1: Topographical map To access this window, either click on the [Map] button located at the bottom of any of the keratoscopy processing windows (see Chapter 6) or open an already processed map inside an existing image gallery (see Chapter 4).

8.1 Options On the left-hand side of the screen, the user will find a set of options which determine how the map is displayed: View Map if selected (√), this option displays the map; Eye if selected (√), this option displays the image of the eye in the background; Rings if selected (√), this option displays the ring points; Pupil if selected (√), this option displays the contour and centre of the pupil. The user will also see in the following: • the horizontal and vertical decentralizing of the pupil with respect to the centre of the map (abscissas and ordinates, in mm); • the average diameter of the pupil (in mm); • the average dioptric power of a portion of the cornea having a diameter of 3 mm centred on the entrance pupil.

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At the left side of the pupil’s parameters we find a scroll bar for the pupil diameter. The scroll bar is active only if a pupilometry exist. While scrolling the bar the pupil diameter is updated and redrawn. Options Meridians if selected (√), this option draws the meridians on the display; 3 Zones if selected (√), this option draws three rings having a diameter of 3, 5 and 7 mm, centred with respect to the centre of the map; Rulers if selected (√), this option displays two rulers, one along the vertical axis and the other along the horizontal axis; Grid if selected (√), this option displays a grid with measurement units of one millimetre. Scale Absolute Klyce absolute scale: this scale always uses the same correspondence between colors and diopters in order to allow for homogeneous comparisons between the maps. In this scale, the central values ranging from 35.5 to 50.5 D vary at steps of 1.50 D (the central zone of this portion corresponds to 43 D) whereas at the extremes ranging from 9 to 35.5 D and from 50.5 to 101.5 D. The values vary at steps of 5 D. Normalized This scale is calculated automatically according to the values of minimum and maximum curve of the cornea under examination. This scale allows a more appropriate resolution for each map; however, depending on the difference between the minimum and maximum, the scale is not constant and does not allow direct comparisons to be made between two different maps. Adjustable With this scale, it is possible to enter a desired middle value as well as the step between one value and the following one. Type the values in the boxes or scroll through the drop-down list. Click on the [Apply] button in the lower left-hand corner of the window to view the map with the selected scale. This scale may be used to compare various maps even without using the absolute scale, which in some cases may not have the appropriate resolution. In fact, it is sufficient to select the same middle value and step to compare different maps without any difficulty.

8.2 Menus The top menu bar in the topographical map window is described below from left to right as follows: Images Information This command opens a dialog box which allows the user to enter and/or modify information regarding the image being displayed. Save This command saves the modifications made to the image, overwriting the original image located in the gallery and keeping the image at the same position. Save in Position This command opens a dialog box which allows the user to save the image in another position in the gallery without losing the initial image. In this manner, it is possible to save the modified image without losing the initial image. It is therefore possible to have the keratoscopy, the color map of the cornea, and several different fluoresceine images all relating to the same eye in different positions in the gallery; another possibility would be to reprocess a keratoscopy and also keep the previous map.

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Figure 8.2: Saving images in the Gallery If the [Save] command is used instead of the [Save in Position], all of the data needed to display the keratoscopy or any other type of map or fluoresceine simulations will be saved anyway, although it will be necessary to reprocess the data. Using the [Save in Position] command to save images in different modified positions in the Gallery, however, creates a repetition of data that takes up disk space. We therefore suggest that the [Save in Position] command only be used when strictly necessary in the event that very significant modifications have been made to the image. It serves no purpose, for example, to keep an axial map and a local map of the same eye in two different positions in the Gallery since it is a simple matter to go from one map to the other by just reprocessing the data. Figure 8.2 below shows the window which is used to save images to different positions within the Gallery. In the upper right-hand corner of the window, the user will see a small box displaying the image to be saved. On the left-hand side of the window, the user will see in groups of eight the various positions in the Gallery. To save the image, place the mouse pointer on the small box and press on the left mouse button (the mouse pointer will change shape) then drag the image to the desired location in the Gallery (the mouse pointer will again change shape) and release the left mouse button to save it in that location. The new image will overwrite any image that was already present and the user will see the new image displayed in the chosen position. Save colorimetric scale (options) Select this command (9) to save the colorimetric scale located next to the image; Interpolation This command allows the user to obtain the data missing from the map by means of interpolation. The reconstructed data is limited to the availability of sufficient nearby data; Reprocess This command reprocesses the keratoscopy from the beginning. Therefore, if the points of the ring, the pupils, or the limbus images have been edited, the modifications will be lost; Editing ring points

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This command allows the user to make modifications to the pupil, limbus, and points of the ring (see Chapter 9), without losing previously made modifications; Exit This command closes the viewing window of the coloured map of the cornea and returns the user to the main screen. Keratometrics Sim K This command provides a simulation of the readings that would be obtained by using keratometer. The selected zone therefore has an extension that varies according to the curvature of the measured cornea. The user is able to see the steeper and flatter meridians on the map together with the corresponding simulated keratometric data; Meridians This command allows the user to see the steeper and flatter meridians on the map within the zones 3mm, 5mm and 7mm of the cornea, with the corresponding keratometric data, forcing the axis to be perpendicular to each other; Emimeridians This command allows the user to see the keratometric data for each semimeridian. The commands [Sim K], [Meridians] and [Semimeridians] are mutually exclusive and only the command which is marked with the (9) symbol is displayed. Once one of these options is activated, the values are displayed at the bottom in the window (see Figure 8.3 (a), (b), (c)) in the boxes called [3mm Zone] ([Sim-K]), [5mm Zone] and [7mm Zone]. If [Sim-K] command is selected (see Figure 8.3 (a)) curvature values in the steeper (the red one) and flatter meridians (the blue one), steeper and flatter meridians (@), middle curvature value (AVG), cylinder (CYL) and axis (@) are displayed. In the right of the [SimK] panel corneal eccentricity is displayed. To set asphericity parameter (e, SF, p, Q) use [Asphericity] menu. If [Emimeridians] command is selected (see Figure 8.3 (b)) the curvature values are displayed with the corresponding meridian in the boxes called [3mm Zone], [5mm Zone], [7mm Zone].

(a) Sim-K

(b) Emimeridians

(c) Meridians

Figure 8.3: Keratometrics values If [Meridians] command is selected (see Figure 8.3 (c)) curvature values in the steeper and flatter meridians, steeper and flatter meridians (@), middle curvature value (AVG), cylinder (CYL) and axis (@) are displayed in the boxes called [3mm Zone], [5mm Zone], [7mm Zone]. The values shown on the map and on the [3mm Zone] ([Sim-K]), [5mm Zone] and [7mm Zone] panels are reported in the unit of measurement chosen from the [Curvature] menu (millimetres or diopters). Indexes Keratoconus Screening This command opens a panel which indicates whether the eye being examined has a topography which is compatible with the keratoconus (see Figure 8.4 below). The evaluation of compatibility of the topography with the keratoconus is based on 4 indexes:

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Figure 8.4: Keratoconus screening system KA: Apical curvature. This index represents the power of the apical cornea. If the eye topography is compatible with the keratoconus or the keratoconus is suspect, moving cursor on the KA parameter and left button clicking draws the apical cornea on the map. AGC: Apical Curvature Gradient. It means average difference per length unit of the corneal power reference to apical power. AGC high values (bigger than 2 D/mm) show a possible compatibility with keratoconus. SI: Difference between average power of two circular areas centred on the vertical axis of the rulers, one on the bottom hemisphere and one on the one on the top of the cornea. SI is a vertical asymmetric index: positive values means top hemisphere more curved than bottom one, and vice versa. Kpi: Keratoconus Probability Index. For the indexes KA, AGC, Kpi the values falling within two standard deviations from the average of the normal population are considered as being normal and are highlighted in green; values falling within two and three standard deviations from the average of the normal population are considered as being suspect and are highlighted in yellow; values which exceed the three standard deviations from the average of the normal population are considered as being anomalous and are highlighted in red. There are three possible conclusions which may be drawn from the combined evaluation of these three indices, namely: the eye topography is not compatible with the keratoconus (green); the keratoconus is suspect (yellow); the eye topography is compatible with the keratoconus (red). If the eye topography is compatible with the keratoconus or the keratoconus is suspect, in the lower part of the panel geometric parameters value of the keratoconus are shown: A: keratoconus area (mm²). D: keratoconus average diameter (mm). r, ø : barycentric keratoconus polar coordinates (mm, °). RND: roundness. Moving cursor on the geometric parameters of keratoconus, these are highlighted in yellow and cursor change its shape. Left button clicking draws the choose parameter on the map. Curvature gradient This command displays a panel showing the information relating to the curvature gradient of the eye along a segment of a line (see Figure 8.5). The curvature gradient shows to what extent the curvature of the cornea increases or diminishes for each millimetre of movement along a given segment that has been arbitrarily chosen by the user. To draw a line segment, click the left mouse button on a point on the map. The arrows on the keyboard allow the user to position this point precisely. To draw the line segment, move the mouse to the desired point and click on the mouse button again. The data relating to the curvature gradient changes as the mouse moves along the screen. The two points may then be moved in a precise manner by using the arrows on the keyboard. Pressing on the “1” key for point 1 and on the “2” key for point 2 selects the points. In the window showing the curvature gradient for each of the two selected points, P1 and P2, the user will see the curvature, expressed in diopters (P), and in mm

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(r), as well as the respective position of the two points, expressed in terms of distance from the centre (d) and meridian (g). In addition, the P1-P2 box shows the difference in curvature between the two points, expressed in diopters (P) and mm (r), the length of the segment (d), the curvature gradient expressed in diopters per millimetre (D/mm) and expressed in millimetres of curvature per mm of movement (mm/mm).

Figure 8.5: Curvature gradient To close the curvature gradient panel, deselect the corresponding option from the [Indices] menu. Corneal asphericity The window is composed by two folders (Eccentricity and Peripheral degrees) which specify the corneal asphericity. The Corneal Asphericity window could be invoked also from fluoresceine simulation and Corneal Height Map environments. In both cases, as in the topographic map, the user should choose Asphericity Corneal menu item. Eccentricity As you can see from Figure 8.6 the panel is divided into four parts. The top-left rectangle (Main meridian asphericity (8mm)) contains three lines: in the first line (blue) you can read the apical radius (Ro) and the asphericity (e) along the flattest meridian (@); in the second line (red) there are the same parameters calculated along the steepest meridian; in the third line (black) there are the average values of the apical radius (Rom) and of the asphericity (em). The parameter calculations are based on a circular area centered in the center of the rings with diameter= 8mm.

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Figure 8.6: Corneal asphericity (Eccentricity) The top right rectangle (Main Meridian Asphericity (4.5mm)) contains the same parameters as in the top left one but the diameter of the circular area is 4.5mm. The bottom left rectangle (Keratoconus Asphericity) contains the apical radius (Ro) and the asphericity (e) of the conus if the eye topography is compatible with the keratoconus or the keratoconus is suspect, else this rectangle. The bottom right rectangle contains two parameters: the corneal asphericity referred to pupillar surface (4.5mm) and the surface irregularity (RMS). The last parameter measures the difference between the current cornea curvature and related aspherical best fit surface. In every panel curvature and asphericity values are formatted according to the settings chosen with the items [Curvature] and [Asphericity] present in the [Options] menu. Peripheral degrees The table describes the corneal asphericity at the different peripheral degrees. (see Figure 8.7.

Figure 8.7: Corneal asphericity (Peripheral degrees) The first four rows of the table describe the parameter values examined along the nasal, temporal, inferior and superior emimeridian. The next two rows (horizontal and vertical) represent respectively the average between nasal and temporal parameter values and between inferior and superior parameter values. The last row contains the general parameter averages. The first two columns show the analyzed meridian and the apical radius along that meridian. The successive rows (10°, 15°, 20°, 25°, 30°) indicate the eccentricity value or the sagittal radius at the various peripheral degrees.

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Keratorefractive Indices Selecting this option a new window appears which supplies the information relative to the Keratorefractive Indices (see Figure 8.8).

Figure 8.8: Keratorefractive Indices Astigmatism 3 mm: corneal toricity express in diopters in a corneal area of 3 mm of diameter, centered in the corneal vertex; 5 mm: corneal toricity express in diopters in a corneal area of 5 mm, of diameter, centered in the corneal vertex. Average Pupillar Power Average dioptrically power of a 3mm diameter corneal portion centered in the entrance pupil. Asphericity medium asphericity area in a cornea with 4.5 mm of diameter, centered in the middle of the pupil. The parameter use to represent the asphericity of the cornea (e, SF, p, Q) can be set through the voice [Aspheric] in the menu [options]. Spherical aberration Longitudinal spherical aberration from a corneal area with a 4.5mm in diameter, centered in the middle of the pupil. Express in diopters. Curvature Irregularity Standard deviation of the instant curvature with respect to a best fit aspheric surface, calculated for a cornea with 4.5mm of diameter, centered in the middle of the pupil. It is express in diopters. Asimmetry The medium instant curvature of the flattest corneal hemisphere area with 4.5 mm of diameter, centered in the middle, is indicated in blue, and the medium curve of the curviest part of the corneal hemisphere in red. The SAI ( Surface Asymmetry Index), represents the index of surface asymmetry of a corneal area with 4.5 mm of diameter, centered in the middle of the pupil, calculated as the average of the difference between the instant curvature along the semi-meridians of each meridian. As regards to the Asphericity, Spherical Aberration, Irregularity of the Curvature and the Assymetry (SAI), the values compress between two deviations from the standard average of the normal population are considered normal and visualize in green; values compress between two and three deviations from the standard average of the population are considered suspicious and visualize in yellow; while values compress above

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three deviations from the standard average of the normal population are considered anomalous and visualize in red. Optical Zone Decentralization This is the distance in mm between the optical zone centre and the corneal vertex and the pupil centre. First it is required to draw in the map three points joined to the optical zone border. Then you can stretch the drawn circumference to fit exactly the zone of treatment. The panel (see Figure 8.9) shows the result during the operation in Cartesian or polar coordinates. Moreover it is shown the dimension and the eccentricity of the optical zone.

Figure 8.9 Optical Zone decentralization Color Map Axial if selected (9), this option displays the axial map; Instantaneous if selected (9), this option displays the local map; Axial + Instantaneous if selected (9), this option displays the axial map along with the local map; Zernike analysis Allows to enter in the Zernike summary window (see chapter 13); Transparency this option allows the user to draw on the map with the eye being visible in the background as a transparency; Numerical Values if selected (9), this option displays the curvature values on the map, expressed in diopters or millimetres depending on the unit of measurement chosen from the [Options] menu. If the map is not visible, the values take on the colors of the step to which they belong; Curvature Profiles This command opens and closes the window that allows the user to draw the curvature profiles, as shown in Figure 8.10 below.

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Figure 8.10: Curvature profiles It is possible to view the profiles of two meridians at the same time. When the user opens this window for the first time, the steepest and flattest meridians will be displayed as indicated by the Sim-K processing. To view the profiles of other meridians, the user needs to specify the values of these meridians in degrees (from 0 to 180) in the appropriate boxes and then click on [Redraw]. In the upper section of the window, the user will see the graph of the specified meridians. In the lower section of the window, the user will see the difference between the two meridians in absolute value, that is, the corneal toricity with respect to the axes. The [Zoom] button cuts the steps on the Y-axis of the graph so as to highlight the smallest variations in curvature. Comparison This option opens the window allowing the user to compare 2 or 4 maps or calculate the differences between two maps (see Chapter 9). Contact Lenses This option takes the user to the fluoresceine simulation window (see Chapter 10). Options Distance This command allows the user to measure the distances by drawing a line segment on the image. The measurement is reported next to the segment. To draw a line segment, click the left mouse button on a point on the map. The arrows on the keyboard allow the user to position the point precisely. To draw the segment, move the mouse to the desired point and click on the mouse button again. The two points may then be moved in a precise manner by using the arrows on the keyboard. Pressing on the “1” key for point 1 and on the “2” key for point 2 selects the points. Asphericity This command sets (9) the current asphericity parameter (e, SF, p, Q). Curvature Diopters This option displays the map in diopters; Millimetres This option displays the map in millimetres. The selected option is marked with a (9) symbol. Paint Color This command allows the user to choose to have the line segments that are drawn on the image appear in black or white. Export file

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It opens a window, shown in Figure 8.11, which allows to choose the name and the location where to save the file.

Figure 8.11: Export file By default the proposed file name begins with the letters of the patient surname followed by some figures established to have a name quite always different also for the same patient. It’s possible to choose between different exportation protocol (Standard,xyz,etc..). If the chosen protocol is “Standard”, there are two possible formats in which the data file could be exported: “txt” format (text file) or “dat” format (binary file). On the right you can select the data to export between: Elevations Axial curvatures Instantaneous curvatures For the curvatures it’s possible to choose the measure unit between diopters and millimeters. You can export only one kind of data in a time. The data to export can be choose among the following: patient data; annotations; sim-k; corneal diameter pupil; refraction. In the [Notes ] square you can write a brief comment. Push [Ok] to start the exportation. Index exportation It opens a new window to export in a text file the indexes of the patient which are selected in the list. For each exportation a line is added to the text file maintaining the data of the previous exportations. There are two ways of exportation. The first is to enter in the window and push the button [Export]. The second one is to select before the option [Automatic exportation], which allows to execute the exportation directly from the Topographical map window simply pushing the selected key (F6, F7 or F8). To create an exportation file click on the button [New], select the desired indexes and chose the file name To open an existing exportation file click on the button

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[Load] and make the selection. To modify the settings of the exportation file push [Edit], select the desired indexes and save. To simplify the select/deselect operations of the indexes there are the buttons [Sel All] and [Desel All]. The indexes are grouped by affinity in the [Indexes] list; to view the indexes for a particular class select the corresponding item in the list. Laser exportation According to the enabled laser selected in the folder [Laser] of the [Setting], a list of laser is reported. Clicking on the menu voice the specific laser exportation window is opened. Print Select printer this command opens a window allowing the user to select a printer; Print customized report this command opens a window allowing the user to print a previously saved customized printout report. (see § 14.5 and § 14.6); Standard report settings this command opens a window allowing the user to choose the information that he or she would like to have printed along with the topographical map, as described in § 14.4; Print standard report this command allows the user to print a standard report, as chosen by the [Standard Report Settings] command (see § 14.3); Print screen this command allows the user to open the print screen window (see § 14.2). Print to file settings It opens the window described in paragraph 14.8 to set the options for the print to file function. Print to file If this menu item is selected (9) pressing the key chosen in the [Print to file settings] window the user can capture the screen or only the active window and save it in a file (for more details see paragraphs 14.7 and 14.8).

8.3 Full screen display of keratoscopies Quickly double-clicking the left mouse button on any point on the map will display the keratoscopy relating to that map in full-screen mode. The user may print this image by going to the corresponding menu on the top left portion of the screen. Double-clicking the left mouse button again will bring the user back to the window showing the color map of the cornea.

8.4 Using the mouse pointer and crosshair on the map Clicking the left mouse button anywhere on the map will place the crosshair on that point. This crosshair will remain on that point regardless of where the mouse is moved. At this point, the crosshair may be moved by using the arrows on the keyboard. Clicking once more on the left mouse button will align the crosshair with the mouse pointer again. The crosshair is linked to a series of data which relate to every single point of the map, and which are displayed at the bottom of the screen: Power: curvature of the cornea, expressed in diopters (D); Radius: curvature of the cornea, expressed in millimetres (r); Distance: distance of the point from the centre of the map, expressed in mm (d); Depth: height of the point with respect to the tangent plane at the vertex of the cornea, expressed in µm (z); Meridian: meridian upon which the point is found, expressed in degrees (g).

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9 Map Comparison To open the Map Comparison window, click on the [Comparison] menu located in the Color Map window. 2 or 4 maps will be loaded and displayed at the same time. All of the values of the corresponding points of each map may be seen by moving the mouse pointer over any given map. In the comparison phase, the normalized scale is deactivated. The [Comparison] menu offers various options: Between 2 map This option allows the user to select 2 maps from the gallery and compare them; Between 4 maps This option allows the user to select 4 maps from the gallery and compare them; Change map number... (available only during comparisons) this option allows the user to substitute one of the maps being compared; Difference Map This option allows the user to choose two previously processed and saved maps from the gallery to obtain a difference map. The chosen option is marked with a (9) symbol.

9.1 Choosing maps for comparison Whenever the user wishes to compare 2 or 4 maps or display a difference map, a window will open allowing him or her to choose from among all of the maps saved in the gallery relating to all of the patients in the archive. The window allowing the user to choose the maps for comparison is shown in Figure 9.1 above. In the upper left-hand corner, the user will see a list of patients: select a patient by clicking the left mouse button on the patient’s name. In the upper right-hand corner, the user will see a list of exams relating to the selected patient. Select an exam by clicking the left mouse button on it. At this point, if there are any topographical maps relating to the selected exam, these will appear as and buttons located on thumbnails in their respective positions in the gallery. Use the the right-hand side of the window to scroll through them. At the bottom of the window, the user will see either 2 or 4 blank positions (depending on whether the user has chosen to compare 2 or 4 maps). To select the maps for comparison, simply drag and drop the desired images in the gallery to the blank positions: move the mouse pointer to the desired image. Then press and maintain the left mouse button (the pointer changes shape) and move the mouse pointer to the new position (at the bottom of the window). When the mouse pointer changes shape again, release the left mouse button (this completes the drag and drop procedure).

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Figure 9.1: Choosing maps for comparison To remove an image from the comparison position, drag and drop the image in the dustbin located in the lower right-hand corner of the window. Click on the [Ok] button to confirm the removal or on the [Cancel] button to cancel it.

9.2 Difference Map After having completed the procedure described above, the user may generate a difference map which will display three maps on the screen (see Figure 9.2 below): the two upper maps are the maps that the user chose to compare, whereas the lower map shows the difference in curvature for each point between the upper two maps. On the left-hand side of the difference map, the user will see the colorimetric scale relating to each difference value. There are two scroll bars allowing the user to change the middle value and step of the scale, in a manner similar to that used to change the parameters in the adjustable scale in the color map of the cornea (see § 8.1).

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Figure 9.2: Difference map To close the Map Comparison window, deselect the chosen option ([2 maps], [4 maps], [Difference map]) by clicking on the option marked with a (9) symbol. This will return the user to the window showing the color map of the cornea.

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10 Contact lenses The window used for fluoresceine simulations may be opened by going to the [Contact Lenses] menu in the Color Map window . To view the fluoresceine simulation of a lens, use the commands located on the left-hand side of the window (see Figure 10.1 below).

Figure 10.1: Fluoresceine contact lens simulation

10.1 Contact lens simulation Simulation of a predefined lens Select a manufacturer from the drop-down list of predefined names which appears when clicking on the [È] button located to the right of the [Manufacturer] box. For the selected manufacturer will be found automatically (AutoFit procedure) the lens that better fit the current cornea. After calculation the resulting fluoresceine simulation for the selected lens model is shown; the geometrical parameters of the lens model are displayed on the left of the window. To add / remove manufacturers and models in AutoFit procedure see Chapter 11. Clicking on the [È] button located to the right of the [Model], [Diameter] or [Toricity] / [Inverion] boxes, Autofit procedure is also execute. The software will propose an initial base curve that may be modified by scrolling through the drop-down list of predefined values which appears when clicking on the [È] button located to the right of the [Base Curve] box. It is possible for the user to create and modify the [Manufacturer] and [Model] drop-down lists by selecting the [Trial Lens Design] command from the [Lenses] menu at the top of the

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Contact Lenses window or by going through the [Topography] menu on the main screen (see Chapter 11). If the user clicks on [Redraw] menu, or push the button [Redraw], the software will draw a fluoresceine simulation for the selected lens model. Simulation of a customized lens For simulation of a customized lens, choose the [Customized] option from the [Model] drop-down list; it will then be necessary to select the type of lens to work with from the [Lens type] drop-down list as described above. At this point, and depending on the type of lens selected, the user will have to enter the parameters of the lens to be simulated. The software automatically adjusts the total diameter (∅t) according to the extension of the optic zone and peripheral curve of the lens. If the total diameter is changed manually, the software will automatically adjust the diameter of the optic zone, leaving the extension of the peripheral curve unchanged. The fluoresceine simulation is drawn by clicking on [Redraw], or pushing the button [Redraw].

10.2 AutoFit AutoFit procedure found automatically lenses that better fit the current cornea. To display best manufacturer lenses (see Figure 10.2 (a)) press [Manufacturer] button ([AutoFit] panel) on the left of the window. To display best archive lenses (see Figure 10.2 (b)) press [Archive] button ([AutoFit] panel) on the left of the window.

(a)

(b) Figure 10.2: AutoFit list: Manufacturer (a) and Archive (b). To select and display a lens from AutoFit list, scroll down using the scroll bar on the right hand side of the list and double click the left mouse button on the model’s name. After double click the resulting fluoresceine simulation for the selected lens model is shown; the geometrical parameters of the lens model are displayed on the left of the window. To add / remove manufacturers and models in AutoFit procedure see Chapter 11.

10.3 Menus The active menus in the fluoresceine simulation window are as follows: Images The available commands are the same as those contained in the color map of the cornea (see § 8.2), except for [Interpolation], [Reprocess] and [Editing ring points], which are unavailable;

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Lenses Refraction This command opens the window shown in Figure 10.3 below. This window allows the user to compute refraction data. The refraction of the object on the spectacles is shown in the upper right-hand portion of the window. The cylinder may appear as a positive or negative value. If the refraction axis diverges more than five degrees from the keratometric axis, the software will emit an alarm signal to alert the user that the lens to be applied may be complex. Click on the [OK] button to close the window and click on [Redraw]. The lens power (P) will be displayed at the bottom left-hand corner of the window next to the total diameter (T.D.). Under the section where the refraction data is inserted, there is another section allowing the user to enter the data relating to the real diagnostic lens applied. The boxes in this section are shown by clicking on the [È] button. Two types of lenses are taken into consideration: spherical or toric. If the user clicks on the [Spheric] option, only one box will appear for the base curve and another for the power. If the user clicks on the [Toric] option, two boxes for the base curve will appear and two boxes for the power. Enter the over-refraction data and click on the [OK] button. Once this has been done, click on [Redraw]. The power of the simulated lens will be updated taking into account the over-refraction data. The section on the left-hand side of the window allows the user to compute the transposition of the refraction and over-refraction at the corneal plane. The boxes relating to the over-refraction appear only if the Diagnostic Lens section is active. To view the computed data at the corneal plane, click on the [Compute] button.

Figure 10.3: Refraction used to compute the power of a contact lens Panning If selected (9), this option allows the user to move the lens over the image. To reposition the lens, first press and maintain the left mouse button on the displayed lens (the contour of the lens will be drawn) and drag it to a new location on the in the rightimage. To reposition the lens is also possible to push the button hand bottom of the window. Releasing the mouse button repositions the lens at the new location. The modifications may be viewed by clicking on [Redraw]. The

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repositioning is shown at the bottom as a movement from the centre along the abscissas and ordinates. To deactivate the reposition function, deselect the option marked (9), or push the button . Clicking on [Redraw] after this has been done will eliminate the effects of the lens repositioning. Tilt If selected (9), this option allows the user to simulate an inclination of the lens (see § 10.4). To tilt the lens is also possible to push the button in the right-hand bottom of the window. Limbus: dimensions and repositioning If selected (9), this option allows the user to see the contours of the iris, make changes to the its dimensions, and reposition it on the image. To make changes to in the right-hand bottom of the window. The limbus iris there is also button defines the limits of the area in which it is possible to compute the contact lens simulation. It is therefore not possible to simulate lenses that are larger than the limbus nor to simulate movements of the lens that exceed this limit. To modify the dimensions of the limbus, press and maintain the right mouse button and move across the image. To move the contours of the iris, press and maintain the left mouse button and drag it across the image. To delete the limbus contour display from the image, deselect the [Limbus: dimensions and repositioning] option or push the button

.

Profile If selected (9), this option opens a window displaying the lachrymal film under the lens. (see § 10.5). To open the window is also possible to push the button . Trial Lens Design Choosing this command will open a window allowing the user to view and enter the parameters relating to the various lens models (see Chapter 11). Redraw This menu allows the user to update the display after having entered the specific values for every single parameter. Options Distance This command allows the user to measure the distances by drawing a line segment on the image. The measurement is reported next to the segment. To draw a line segment, click the left mouse button on a point on the map. The arrows on the keyboard allow the user to position the point precisely. To draw the segment, move the mouse to the desired point and click on the mouse button again. The two points may then be moved in a precise manner by using the arrows on the keyboard. Pressing on the “1” key for point 1 and on the “2” key for point 2 selects the points. Asphericity This command sets (9) the current asphericity parameter (e, SF, p, Q). Curvature Diopters This option displays the map in diopters; Millimetres This option displays the map in millimetres. The selected option is marked with a (9) symbol. Fluoresceine scale This option allows the user to choose the resolution for the fluoresceine simulation scale: Low: shows the level lines in a way similar to that used to represent the false colors on the topographical map; Medium: from 0 to 104 μ, shows a shaded representation which closely resembles the appearance of a real fluoresceine image; High: from 0 to 52 μ, highlights small variations of lens clearance.

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Corneal Asphericity Choosing this menu item the Corneal Asphericity window will be displayed with parameters about this subject. A more detailed description of the window and of these parameters is given in § 8.2. Paint Color This command allows the user to choose to have the line segments that are drawn on the image appear in black or white. Imprint lenses This command execute “Imprint lenses” program. Pupil This option shows the graphical display of the pupil on the image; Limbus This option shows the graphical display of the limbus on the image; Meridians This option displays the meridians on the image; 3 Zones This option displays three rings having 3, 5, and 7 mm diameter, centred with the centre of the map; Rulers This option displays two rulers along the vertical and horizontal axes; Grid This option displays a grid with a one millimetre step. Print The commands shown here are the same as those in the Color Map window and are described in the Chapter 14. Favourite Lenses Add to Favourite This command add to the favourite lenses the currently selected lens. Show Favourite Lenses Open the window of the Favourite Lenses list as shown in Figure 10.4. For each lens it is reported the manufacturer, the model, the total diameter and the base curve and a preview image of the fluoresceine simulation. With a double click on an image, the respective lens is opened in the [Contact Lens] main window. It is possible to view all the lenses inserted by means of the arrow buttons in the bottom of the windows. The [Delete All] button allows to eliminate simultaneously all the lenses of the favourite. To delete only a lens drag the respective image over the basket and drop it. Clicking on the [OK] button you can return in the [Contact Lenses] main window.

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Figure 10.4 Favourite Lenses window Return to Color Map This takes the user back to the window showing the color map of the cornea;

10.4 Tilt The Tilt function allows the user to simulate an inclination of the lens with a 0.1 degree step along the two main meridians determined on the basis of the Sim K. To tilt the lens, choose the [Tilt] command from the [Lenses] menu. As soon as this option is selected, four buttons will appear on the image as shown in Figure 10.5 above. Click on each of these buttons to enlarge or reduce the inclination value along that axis. To reduce the inclination of the lens with respect to the corneal surface, click on the button which is closest to the greatest fluoresceine accumulation. Click on [Redraw] to view the resulting inclination chosen by means of the tilt buttons. The Tilt function allows the user to adjust the lens position when there is excessive clearance shown in the fluoresceine simulation on semimeridian, with a marked position on the opposite semimeridian. To facilitate the determination of the Tilt needed to obtain a more homogeneous position along this meridian, it may be useful to observe the profile of the lachrymal film under the lens along that meridian. (see § 10.5).

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Figure 10.5: Lens tilt buttons The effects of the inclination on the fluoresceine simulation will be eliminated once the Tilt function is deselected.

10.5 Profile The Profile function allows the user to open a window showing the profile of the lachrymal film under the lens (see Figure 10.6). After having chosen [Profile] from the [Lenses] menu, an indicator will appear on the image. This indicator pivots on the centre of the rings and rotates with the movement of the mouse pointer. Clicking on the left mouse button will set the indicator on the desired meridian and will display a window showing the graph of the profile. Clicking again on the left mouse button will release the indicator, allowing the user to set it to a new location with a new click. The graph of the profile will be updated accordingly. The buttons [Flatter meridian] and [Flattest Meridian] in the bottom side of the window allow to line up automatically the arrow on the selected meridian.

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Figure 10.6: Profile of the lachrymal film thickness Zoom Function In the lower right-hand corner of the Profile window, the user will see the [Zoom] button. This allows the user to modify the steps in the scale so as to highlight the lens clearances. When the Zoom function is deselected (the Zoom button appears in black), the steps in the scale are 50 μm each. When the Zoom function is selected (the Zoom button appears in red), the steps in the scale are 10 μm each and the lens clearances are shown more clearly. In the second case, the peripheral clearances are such that the user will need to use the scroll bars located on the righthand side of the window in order to view the entire graph: If the user would like to have a complete view of the profile of the entire lens, we suggest that the Zoom function be deselected. Viewing the Tilt of the lens on the profile graph Observing the profile graph of the lachrymal film under the lens along the various meridians, the user will clearly see a possible inclination of the lens with respect to the cornea surface: this may facilitate the determination of the Tilt required to render the position of the lens on the corneal surface homogeneous. The user may then proceed as follows: Activate the Profile function; followed by the Tilt function; move the profile indicator along one of the two main axes on which the Tilt buttons are placed. Click on the Tilt buttons, paying attention to the effects of the chosen inclination on the profile graph; repeat the procedure for both of the meridians; click on [Redraw] only after having obtained a satisfactory profile along both of the meridians. Applanation In the Profile window, the user will see the [Applanation] function which allows the user to simulate the pressure of the lens on the cornea: clicking on the arrows next to the box will increase or decrease the applanation effect at a step of 5 μm. Positioning of the lens The procedure to view the profile of the lachrymal film has priority over the lens positioning function. If the user wishes to position the lens, the profile window must first be closed by clicking once again on the [Profile] option.

10.6 Using the mouse pointer and the crosshair on the fluoresceine simulation Clicking the left mouse button anywhere on the image will place the crosshair on that point. This crosshair will remain on that point regardless of where the mouse is moved. At this point, the crosshair may be moved by using the arrows on the keyboard. Clicking once more on the left

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