1040-5488/03/8001-0036/0 VOL. 80, NO. 1, PP. 36–42 OPTOMETRY AND VISION SCIENCE Copyright © 2003 American Academy of Optometry ORIGINAL ARTICLE A Method to Predict Refractive Errors from Wave Aberration Data ANTONIO GUIRAO, PhD and DAVID R. WILLIAMS, PhD Laboratorio de Óptica, Departamento de Física, Universidad de Murcia, Campus de Espinardo Murcia, Spain (AG), Center for Visual Science, University of Rochester, River Campus, Rochester, New York (DRW) ABSTRACT: We explored the impact of the eye’s higher-order aberrations on subjective refraction comparing two classes of methods for estimating refractive state, one based directly on the wave aberration defined in the pupil plane and another based on the retinal image plane. The method defined in the pupil plane chose the sphere and cylinder that either minimized the wave aberration root mean square or minimized the sum of all the spherical and cylindrical components in the wave aberration. The method defined in the image plane chose the sphere and cylinder that optimized an image-quality metric such as the Strehl intensity ratio, the entropy and the intensity variance of the point-spread function, the volume under the modulation transfer function, or the volume under the contrast-sensitivity function. All these methods were compared in a population of six eyes for which we measured both the wave aberration with a Shack-Hartmann wavefront sensor and the subjective refraction under identical conditions. Pupil plane methods predicted subjective refraction poorly. The mean absolute error of the prediction, in spherical equivalent, was about 0.5 D (range, 0.1 to 0.8 D) and increased with increases in higher-order aberrations. However, for all the retinal image plane methods, the mean error between predicted and subjective refraction was about 0.1 D (range, 0 to 0.25 D). The reliability of the method based on the image-quality optimization was further confirmed in a large population of 146 eyes. In conclusion, higher-order aberrations influence the amount of sphere and cylinder required to correct vision. The results indicate that subjective refraction can be predicted from the eye’s optics alone by optimizing computed retinal image quality. (Optom Vis Sci 2003;80:36–42) Key Words: aberrations, subjective refraction, objective refraction, refractive errors, image-quality metrics, retinal image quality number of objective techniques (retinoscopy, autorefrac- objective methods may not properly take higher-order aberrations tion, and photorefraction) can be used to measure the into account. For example, it has been shown that there can be a spherical and cylindrical refractive errors of the human eye. significant degree of uncertainty in photorefraction measurements A 13 Because they are much faster than subjective refraction, they are when the spherical aberration of the eye is considered. Aberra- attractive alternatives to performing a subjective refraction. Objec- tions also influence the retinoscopic measure.14 An increase with tive refraction is not only useful but often essential, for example, age of the error between subjective refraction and autorefraction when examining young children and patients with mental or lan- has been found,15 which could arise from the fact that higher-order guage difficulties. However, a major concern is whether these ob- aberrations increase with age.16, 17 Some autorefractors may some- jective methods correctly estimate the best subjective refraction of how incorporate the effect of higher-order aberrations by, for ex- the observer. The limitations of autorefractors in accuracy and ample, maximizing the contrast of a target imaged on the retina. repeatability are well known. For example, there are discrepancies However, it is more often the case that they base their estimate on between autorefractive and subjective measurements,1 especially a smaller pupil size than is used in the subjective refraction, which with astigmatism2 or when the degree of ametropia is large.3 In underestimates the role of higher-order aberrations. general, patients prefer the clinician subjective refraction to autore- Thus, there is a need to develop an objective method to estimate fraction.4 Also, retinoscopy and autorefraction usually disagree to refraction that takes into account the effect of the eye’s higher- some extent.5 The eye has higher-order aberrations beyond defo- order aberrations. These aberrations can now be measured quickly, cus and astigmatism,6–12 and one possible reason for the lack of accurately, and repetitively, for instance, with a Shack-Hartmann agreement between subjective and objective methods is that some sensor.18 This paper addresses the question of how to compute the Optometry and Vision Science, Vol. 80, No. 1, January 2003 Predicting Refractive Errors from Wavefront Aberration Data—Guirao & Williams 37 subjective refraction from these wave aberration measurements. constitutes a “best image.” From geometric ray tracing, the answer is Such a method would be useful, not only for prescribing spectacles that the best image would correspond to a plane where the size of the and contact lenses, but especially for refining refractive surgery, spot is at a minimum. However, the spots determined geometrically where the possibility to re-treat an eye is limited. do not accurately reflect the point-spread function (PSF), which must In this article, we describe a procedure that calculates the com- be calculated based on the aberrated wavefront and the diffraction of bination of sphere and cylinder that optimizes different image- the light at the exit pupil. The distribution of light in the actual optical quality metrics based on the distribution of light in the computed image is usually very different from the image predicted geometrically. retinal image. The method yields an optimum image that is corre- Another candidate for the best image plane is the plane where lated with the subjective best retinal image. Experimental results the root mean square (RMS) of the wave aberrations is minimum. are presented that compare the subjective refraction in a popula- The higher-order aberrations may be combined with lower-order tion of subjects with the objective refraction showing the reliability aberrations, which is known as “balancing.” One of the main prop- and accuracy of the method. erties of the popular Zernike polynomials is that they represent 0, Ϯ2 balanced aberrations. Second-order polynomials, Z2 , represent defocus and astigmatism. For instance, spherical aberration is bal- Higher-Order Aberrations and the Eye’s Refraction 0 Ϯ2 Pupil Plane Metrics anced with defocus in the Zernike term Z4; the terms Z4 are bal- anced with astigmatism, etc. The aberration balancing may lead The diagrams in Fig. 1 show an example of the image formation by one to assume incorrectly that a minimum RMS of the aberrated a myopic eye with and without higher-order aberrations. Without wavefront produces the best image. Hence, the RMS of the wave aberrations (Fig. 1a), all the rays would focus on the paraxial plane, and aberration is commonly used as a measure of how aberrated an eye then the refraction of the eye would be calculated from the spherical is. A fact that has supported that use is that the RMS correlates, for negative lens required to displace the focal plane to the plane lying on small aberrations, with another popular metric also used as a crite- the retina. However, due to aberrations (Fig. 1b), the rays passing rion of image quality, the Strehl intensity ratio, defined as the ratio through the edge of the pupil converge at a focus that is not coincident of the peak irradiance in the PSF to the peak irradiance in a dif- or even coaxial with the paraxial focus. This simple example shows fraction-limited system. A large value of Strehl ratio indicates good how the distribution of rays in different planes produces images with image quality. For small aberrations, Strehl ratio and RMS of the different quality. The refraction of that eye should be the one required wave aberration are inversely proportional: when the Strehl ratio is for displacing a plane of “best image” to the retina. Two well-known maximum, the RMS is minimum. Several equations have been simple cases are the case of the least confusion plane for an astigmatic derived to express this relationship19; one of the best known is eye corrected only for defocus and the case of the extra focus required ␲ to best correct an eye that has spherical aberration. Similarly, other 2 S ϭ expͫ Ϫ ͩ RMS)2ͬ (1) higher-order aberrations also play a role, affecting not only the focus ␭ correction but the correction of astigmatism as well. Thus, the best where S is the Strehl ratio and ␭ is the wavelength. The eye’s wave image is not necessarily achieved by correcting the defocus and astig- aberration is usually decomposed in the variance-normalized matism corresponding to the paraxial approximation, which neglects Zernike base after being measured: the effects of higher-order aberrations. A pertinent question is what ϭ ͸ m m WA cn Zn (2) n,m (See Thibos et al.20 for the double-index Zernike coefficient order- ing). An advantage of that is that the RMS of the wave aberration can then be obtained easily from the Zernike coefficients as 2 ϭ ͸ m 2 RMS (cn ) (3) n,m Thus, any correction of the refractive errors of the eye could be determined by setting to zero the corresponding Zernike coeffi- 0, Ϯ2ϭ cients: c2 0. But, again, the image analysis based on diffrac- tion of the wavefront shows the failure in general of that idea. When aberrations are large, a maximum in Strehl ratio can be obtained with nonoptimally balanced aberrations21, 22 (i.e., not a minimum in the RMS). More concretely, when the RMS of the wave aberration is larger than about 0.15 wavelengths, Equation 1 is no longer valid.