Purpose: The Bausch & Lomb Zywave uses Shack-Hartmann aberrometry to determine wavefront aberrations of the human eye and provide an estimate of refractive error. We investigated the effect of pupil size on the repeatability and validity of refractive errors estimated by the Zywave and the repeatability of higher-order aberrations.
Methods: Twenty-three subjects were measured with the Zywave under natural and cycloplegic conditions on two occasions separated by at least one week. Refractive error was also measured using a Nidek ARK-700A autorefractor. At one visit, a cycloplegic subjective refraction was performed. Measured ocular wavefront aberrations were expressed as the polynomial coefficients from a least-squares fitted fifth-order Zernike polynomial expansion over three, five and seven millimetre diameters. Repeatability and validity were evaluated by calculating the difference between pairs of refractive estimates or Zernike terms, determining the mean and standard deviation of these differences and calculating the 95% limits of agreement (LoA = mean +/-1.96 x SD).
Results: The repeatability of refractive error estimated by the Zywave was better than that of the Nidek autorefractor for both manifest and cycloplegic conditions. Manipulating the pupil size on the Zywave from three to seven millimetres changed the mean cycloplegic spherical equivalent from -1.91 D to -2.60 D, a shift that was negatively correlated with spherical aberration. As expected, the magnitude of the Zernike coefficients increased with increasing pupil diameter, as did their corresponding 95% LoA. The 95% LoA decreased for higher-order terms but the magnitude of the terms and the variation between subjects also decreased with increasing order. To compensate for these factors,the ratio of the SD between sessions to the SD across subjects was calculated. The ratios were lowest for second-order terms (less than 0.08 for 7.0 mm pupil), intermediate for the C4,0 spherical aberration term (0.14) and third-order terms (approximately 0.25) but approached and exceeded 1.0 for many fourth- and fifth-order terms.
Conclusions: The Zywave provides valid and repeatable estimates of refractive error. We attribute the myopic shift for larger pupils to the eye's spherical aberration. The repeatability of the Zernike terms measured with the Zywave was acceptable for the second-order and spherical aberration terms but for other higher-order terms, the variation between sessions may exceed the variation between subjects indicating unacceptable repeatability. This may have important ramifications for wavefront-guided LASIK.