Cornea 20(8): 859-863, 2001
Evaluation of Donor Tissue With a
New Videokeratoscope
The Keratron Scout
Josef Stoiber, M.D., Josef Ruckhofer, M.D., Wolfgang Hitzl, Ph.D., and
Günther Grabner, M.D.
Purpose. To evaluate the percentage of corneas with an epithelial
surface quality sufficient for a reliable screening of donor eyes
with keratoconus and after photorefractive keratectomy (PRK) or
laser in situ keratomileusis (LASIK) treatment for refractive errors.
The usefulness of the computer-assisted, video-keratography sys-
tem Keratron Scout in making this determination was evaluated.
Methods. Forty eyes from 20 donors were screened within 30
minutes after enucleation and within 24 hours postmortem. At first
a meticulous slit-lamp evaluation of the corneal surface and stroma
was performed; thereafter eight pictures per eye were taken with
the Keratron Scout, and an ultrasound pachymetry reading of the
corneal center was taken. “true curvature,” algorithm-based color
maps were used for analysis. Eptithelium was not removed,
because all corneas were suitable for transplantation. Balanced salt
solution was used to keep cornea moist. The low intraocular
pressure regularly found in postmortem eyes was raised to within
normal ranges by intravitreal injection. Corneas were classified
according to the integrity of their epithelial surface, which influ-
ences the regularity of the topography maps. Results. The quality
of the images acquired varied, depending mostly on the quality of
the epithelium. Regular topography patterns were found in 15 eyes
(37.5%); in 14 eyes (35%), minimal epithelial roughness or
sloughing in just one quadrant of the cornea was detected. Mod-
erate to severe epithelial irregularities or defects were found in
nine eyes (22.5%). Screening for abnormal shape was possible in
90% of the tested eyes, where no changes caused by prior refrac-
tive surgery or keratoconus were apparent. Conclusion. The post-
mortem quality of the epithelial surface allows screening for kera-
toconus or refractive procedures in the majority of donor eyes.
Video-keratography with the Keratron Scout seems to offer a sen-
sitive and quick method for this purpose, thereby adding an addi-
tional safety feature to eye banking in view of the rapid develop-
ment of corneal refractive surgery.
Key Words: Topography-—Cornea-—Keratoconus-—PRK-—
LASIK-—-Epithelium..
Screeening donor eyes for keratoconus (KC) and previous PRK
or LASIK treatment is becoming more and more important as
Submitted February 21,2001. Revision received July 9, 2001. Accepted
July 21, 2001
From Landesklinik fuer Augenheilkunde und Optometrie, Landesklin-
iken Salzburg, Muellner Haupstrasse 48, 5020 Salzburg, Austria.
Address correspondence and reprint requests to Dr. J. Stoiber, Land-
esklinik fuer Augenheikunde und Optometrie, Landesklinik Salzburg.
Muellner Haupstrasse 48, 5020 Salzburg, Austria. E-mail: j.stoiber@lks.at
859
significantly more than 1 million Lasik procedures are performed
per year on a world wide basis, with the number still rapidly
growing. Eyes that have undergone these procedures are clearly
unsuitable for transplantation, and the clinical changes caused by
these procedures are barely detectable by stlit-lamp examination
even immediately after surgery, if at all. The major requirement
for a sufficiently reliable screening by computer-assisted video-
keratography (CAVK) is a corneal surface of sufficient quality for
obtaining reproducible surface maps.
In this eye-bank study, we evaluated and now propose the use of
a score to reflect epithelial surface integrity. In this study, we also
tested the usefulness of the newly released CAVK system Keratron
Scout (Optikon 2000, Rome, Italy), for donor-eye screening.
MATERIALS AND METHODS
Forty eyes from 20 donors were enucleated with great care for
the complete preservation of the epithelium within 24 hours post-
mortem (which is the usual time frame in our eye bank). The 12
o’clock position on each eye was marked by suturing the rectus
superior muscle. In no case was epithelium removed because all
corneas were suitable for transplantation. Fifteen donors were
male, five female. The mean age of the donor was 61.7 years, with
an age range of 7–88 years. The mean time from death of the donor
to enucleation was 15.4 hours (± 5.6 h). The corneal surface and
stroma were examined with a hand-held slit lamp, and epithelial
defects and other corneal pathology were noted in detail. The low
intraocular pressure regularly found in postmortem eyes was raised
to within a normal range by injecting sterile, balanced salt solution
(BSS) into the vitreous cavity. An eye pressure of approximately
22 mm Hg was aimed for and carefully checked with applanation
tonometry (Fig. 1), with great care taken to not induce epithelial
irregularities or defects. Balanced salt solution was used to keep
the corneas moist before corneal topography was performed. The
whole procedure was performed under sterile conditions to main-
tain asepsis and suitability for transplantation.
Videokeratographic Analysis
Screening of all eyes was performed within 30 minutes after
enucleation and immediately after raising the intraocular pressure.
An “OR trolley” model of the Placido-based corneal topography
system Keratron Scout (Optikon 2000), which allows measure-
860 J.STOIBER ET AL.

FIG. 1. Measurement of eye pressure using a surgical applanation

tonometer.

ments in horizontal orientation, was used to assess corneal topog-

raphy (Fig. 2, 3).
The Placido image consists of 28 rings; 7168 points on the
corneal surface are measured, and more than 75,000 analyzed.
Image capture is triggered by an infrared (IR) beam that intercepts
the corneal vertex. Corneal geometry reconstruction is based on an
arc-step algorithm, producing “true curvature” color maps with FIG. 3. Assessment of corneal topography with the Keratron Scout.
high accuracy.1 Eight pictures per eye were taken with the Kera-
tron Scout (Optikon 2000) in all cases. The measurements were taking into consideration the slit-lamp findings), corneas were
centered on the pupil. The repeatability was tested with the “re- classified by using a score that grades epithelial surface regularity
peatability check,” an integrated feature of the Keratron Scout (Table 1). Corneas with a completely regular surface and with no
(Optikon 2000) software (Fig. 4). Images that were significantly “disturbances” in their topography maps within the 7-mm zone
out of range were discarded, if proposed by the program. One were classified as belonging to “group 0” (Fig. 5A). Corneas with
image of the remaining series of each eye was randomly selected
and used for analysis. According to topographic regularity (and

FIG. 2. “OR trolley” model of the Keratron Scout. FIG. 4. Repeatability check of the Keratron Scout.

Cornea, Vol. 20, No. 8, 2001

 EVALUATION OF DONOR TISSUE
an irregularity in just one quadrant were classified as group 1”
(Fig. 5B). Corneas with irregularities in two quadrants were con-
sidered “group 2” (Fig. 5C). Those showing irregularities in three
quadrants were “group 3” (Fig.5D), and corneas with a completely
irregular topography or an irregularity in the corneal center were
classified as “group 4” (Fig. 5E). Two observers (J.S. and J.R.)
classified each topography map separately and independently. In
cases of disagreement between these observers, final scoring was
achieved by a joint review of the topography map.
Topography maps were then categorized as “normal,” “myopic
laser surgery suspect” (displaying central flattening with associ-
ated midperipheral steepening), “hyperopic laser surgery suspect,”
or “keratoconus suspect” (the latter two displaying excessive cen-
tral corneal steepening).
Pachymetry
Central corneal thickness was measured by ultrasonic pachym-
etry (DGH 2000, DGH Technology Inc., Exton, PA, U.S.A.). Mea-
surement was performed 10 times per eye, and the mean value was
taken for analysis.
Statistical Analysis
To detect significant differences for the comparison of the five
score groups, the ANOVA model was applied with a type I error
rate of 5%.2 It is well known that multiple comparisons demand
the use of a type I error rate adjustment to protect against an
increase in the overall type I error rate.2 The p value adjustment
was done with the Bonferroni-method for each table to end up with
a reasonable overall type I error rate of 5%.3 Hence the result of
one t test was considered as statistically significant, if and only if
the corresponding p value was less than 0.05/3.3 To find a relation
among different pairs of variables (age, postmortem time, pachym-
etry), the corresponding correlation coefficients were computed.
RESULTS
The 15 corneas displaying a regular epithelial surface were con-
sidered to belong to group 0. Fourteen corneas with just minor
irregularities were categorized as belonging to group 1. Four cor-
neas were classified into group 2, three corneas into group 3, and
four corneas into group 4 (Fig. 6). Of the latter, in one pair of
donor eyes (61-year-old male donor, enucleation 14 hours post-
mortem), analysis of corneal topography was impossible because
of bullae in the epithelium; in another eye the optic nerve was cut
too short making it impossible to “normalize” the intraocular pres-
sure. The corneal topography abnormalities correlated with the
epithelial defects noted by the slit lamp. There was no statistically
significant correlation between the epithelial regularity score and
age of the donor or time from death to enucleation. Mean pachym-
etry was 732 ± 76 mm. No statistically significant correlation could
be found between central corneal thickness and donor age or time
from death to enucleation.
861
Condition of corneal surface allowed reliable screening with
CAVK in 36 eyes (corneas of group 0, 1, 2, 3). The mean simu-
lated K-reading of all eyes was 43.64 (±1.54) D, and the mean
astigmatism was 1.26 (±0.91) D. The mean simulated K reading
was 44.3 (±1–47) D in group 0, 43.15 (±1.57) D in group 1, 42.29
(±0.81) D in group 2, and 43.99 (± 1.14) D in group 3. Mean
astigmatism was 0.89 (±0.61) D in group 0, 1.18 (±0.81) D in
group 1, 2.54 (±1.16) D in group 2, and 1.94 (±0.95) D in group 3.
Analysis of topography maps showed neither excessive corneal
steepening typical for KC nor central flattening with associated
midperipheral steepening, which is typically found after myopic
laser surgery.
DISCUSSION
Keratoconus, a chronic noninflammatory corneal thinning dis-
order leading to scarring and progressive thinning, has a reported
incidence between 54.5 and 230 per 100,000 in the general popu-
lation. 4 Although late stages of the disease process certainly may
be detected by the established routines of an eye bank, early cases
of KC may not easily be identified. Several authors have proposed
an undetected KC in the donor cornea as an explanation for a
“recurrence” in the graft.5–8
With the increasing number of refractive procedures worldwide,
there is growing concern that refractively altered corneas will
make their way into eye banks. Because the morphologic changes
after a LASIK or PRK procedure in most cases are barely detect-
able by slit-lamp examination in the living eye and probably even
less so in the postmortem cornea, there is an substantial risk of
including such a cornea in a transplantation schedule.9
Todd et al. tried to project the effect of refractive procedures on
the future corneal donor pool. They calculated that by 2020 almost
50 million Americans might have undergone laser vision correc-
tion, which would at that time exclude one in four potential
donors, considering the demographic overlap between donors and
refrac-tive patients.10
Several authors have reported the use of various CAVK-systems
for donor-eye screening.11–14 This is the first report on the use of
the Keratron Scout (Optikon 2000) in an eye bank. The main
advantage of this system is its high degree of accuracy resulting
from its arc-step algorithm and the high number of measured and
analyzed points.1 The possibility of performing measurements in
the horizontal orientation makes screening of an enucleated eye
much easier, because no globe-fixing devices are needed. In ad-
dition, the scout topographer is obtainable as a battery-operated
hand-held model, which makes it feasible to perform screening for
abnormal shapes in the morgue before any surgical step is taken,
with the exception of pressurization of the globe. This is an im-
portant innovation because many eye banks do not enucleate the
whole globe but prefer in situ excision of the corneoscleral disc.
The most important criterion for a reliable screening by CAVK
is the quality of the epithelium. Because corneal transplantation is
preferably performed with an intact epithelial layer, screening
methods should leave the corneal surface intact, and avoiding
abra-sion of the epithelium.
Several factors can adversely affect the postmortem quality of
the epithelium, causing an irregular corneal surface, e.g. lagoph-
thalmus leading to a localized dryness of the surface, or postmor-
tem edematous changes in the epithelium increasing the risk of
Cornea, Vol. 20, No. 8, 2001
862 J.STOIBER ET AL.

mechanical damage. Enucleation of the donor eye should be per-

formed with great care so as not to induce scratches or warpage on
the epithelium.
We found it critically important to constantly moisturize the
corneal epithelium with fluid before topography was performed to
achieve a “smooth” surface. The lubricant should reduce the
“roughness” of the postmortem epithelial surface; however, its
viscosity should not preclude the detection of specific details of
the topography. We found balanced salt solution appropriate for
this purpose.
With the proposed “epithelium regularity score,” a cut-off point
has to be set to distinguish between safely usable corneas and those
with an irregular corneal surface that would lead to unreliable
screening. We believe that safe screening seems to be possible in

Cornea, Vol. 20, No. 8, 2001

 EVALUATION OF DONOR TISSUE
eyes with a “score 2,” whereas in corneas with irregularities in
three quadrants, each case must be decided on an individual basis.
Topography maps of “score 4” corneas are clearly not useful for
these screening efforts.
As the eye pressure regularly and rapidly is diminished to low
levels after death, the globe loses its shape with the cornea col-
lapsing. It is therefore mandatory to reestablish a near-normal eye
pressure for these screening purposes when using a placido-based
topography system. This can be achieved by injecting balanced
salt solution into the vitreous cavity under sterile conditions to
main-tain suitability for transplantation. Furthermore, tonometry
should not result in damage of the epithelial surface. Systems that
use a piezoelectric pressure transducer for intraocular pressure
measure-ment would be ideal but usually are not available to a
standard eye bank. The careful use of a hand-held sterilized
surgical applanation tonometer seems to represent an acceptable
alternative.
Mean central corneal thickness in our sample was 732 mm,
which is similar to the pachymetry results of other studies.11 Be-
cause of the irregularity of the swelling, one cannot deduce pre-
operative corneal thickness from postoperative pachymetry find-
ings. Therefore postenucleation central corneal pachymetry find-
ings alone cannot be the only criteria used to discriminate
“normal” from “refractive” or “keratoconic” corneas with their
characteristic central corneal thinning over time. The relatively
low numbers in each group may account for the inability to find a
statistically significant correlation between pachymetry results and
the time from death to enucleation in this study. Several authors
analyzed the influence of corneal swelling on corneal topography,
and their results must be taken into consideration to assess the
validity of postmortem topography. This is quite important, be-
cause false-positive and false-negative screening results should be
minimized.
Ousley et al.15 and Simon et al.16 found corneal steepening in
corneal topography of de-epithelialized eye-bank eyes after dehy-
dration with dextran, but changes were clinically relatively small
(<1D). Maloney found flattening of cadaver corneas of 0.02 D for
every 10 mm of thickening.17 Because the epithelium was removed
before corneal topography was evaluated in the three studies men-
tioned, the results could not be completely compared with those in
our study, in which the epithelial layer was left in place. Other
authors found no significant topographic changes after experimen-
tally induced corneal edema in living subjects.18
Screening donor corneas for KC and refractive corneal surgery
with CAVK would add an additional safety feature to the existing
screening procedure including slit-lamp examination, blood
863
screening, review of donor case histories, microbiologic studies,
and evaluation of endothelial cell density. This system easily
could be installed in any eye bank and could be handled by
technicians. We have shown that the Keratron Scout (Optikon
2000) could become a useful tool for this screening purpose, but
additional studies and tests are needed to determine the
postmortem sensi-tivity and specificity in detecting those eyes that
already have undergone ablative refractive procedures.
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