CLINICAL SCIENCES

White-to-White Corneal Diameter

Normal Values in Healthy Humans Obtained With the Orbscan II
Topography System
Florian Rufer, MD, Anke Schroder, MD, and Carl Erb, MD

Purpose: The corneal horizontal diameter (white-to-white) is

abnormal in diseases like microcornea, relative anterior microphthalmos, and corneal dystrophies. Because normal values are described imprecisely in the literature, the purpose of this study was to
reevaluate the horizontal corneal diameter as a scientific parameter.

Methods: The horizontal corneal diameter was measured with the

Orbscan II system in 370 right eyes and 373 left eyes of 390 healthy
white subjects aged 1080 years. There were 148 female subjects and
242 male subjects. Each measurement was repeated twice. Differences in gender, between right and left eyes, and age-related alterations were analyzed statistically.
Results: The average corneal diameter was 11.71 6 0.42 mm. The
average corneal diameter was 11.77 6 0.37 mm in males compared
with 11.64 6 0.47 mm in females. The resulting normal ranges were
11.04 to 12.50 for males and 10.70 to 12.58 mm for females. Differences in gender were not significant in the t test for independent
samples (P = 0.071). There were no statistically significant differences between right and left eyes in the t test for dependent samples
(P = 0.16). Corneal diameters decreased slightly with age.

Conclusions: With the obtained normal values, more precise

determination of microcornea and macrocornea will be possible in the
future. The horizontal corneal diameter was not significantly greater
in males than in females. Further studies are needed to show the
reasons for the age-related decrease in measurements.
Key Words: white-to-white, corneal diameter, Orbscan II, microcornea, macrocornea
(Cornea 2005;24:259261)

he corneal horizontal diameter (white-to-white) is abnormal in some corneal diseases. It is used to determine
macrocornea and microcornea. Although the normal white-towhite corneal diameter is mentioned in many book chapters,

Received for publication August 27, 2003; revision received August 26, 2004;
accepted August 27, 2004.
From the Department of Ophthalmology, Medical University of Hanover,
Hanover, Germany.
Reprints: Florian Rufer, MD, Department of Ophthalmology, University
Hospital of Kiel, University of Schleswig-Holstein, D-24105 Kiel,
Germany (e-mail: florian.ruefer@web.de).
Copyright 2005 by Lippincott Williams & Wilkins

Cornea  Volume 24, Number 3, April 2005

the average values are imprecise and vary greatly. Until now,
no measurements of the normal white-to-white corneal diameter have been published in MEDLINE. In 2002, Wang and
Auffarth1 showed that very accurate white-to-white measurements are possible with the Orbscan topography system.
Using this system, the purpose of this study was to evaluate
normal white-to-white values in 390 healthy subjects as a basic
parameter.

MATERIALS AND METHODS

For horizontal white-to-white measurements, we used
the Orbscan II system (Orbtek Inc., Salt Lake City, UT), which
is a no-contact, 3-dimensional anterior segment scanning slitbeam system. The Orbscan II system provides autodetection of
the limbus for white-to-white measurements. The maximum
resolution is 2 mm within the central corneal surface.2,3 A total
of 370 right eyes and 373 left eyes in 390 healthy white
volunteers were examined (age, 1080 years; average, 40.7 6
16.35). There were 231 male subjects and 141 female subjects.
Each measurement was repeated twice. Eyes that had undergone surgery as well as users of contact lens users or any kind
of eyedrops were excluded. Diseases of the eyes were excluded
by an ophthalmologic examination including slit-lamp examination, indirect ophthalmoscopy and pressure measurement.

RESULTS
The white-to-white distance in all eyes was 11.71 6 0.42 mm.
The average in males (age, 42.7 6 16.6 years) was 11.77 6
0.37 mm. Standard error of the mean was 0.024. Thus, the
resulting normal range for males was 11.04 to 12.50 mm (6 2
standard deviations). The white-to-white distance in females
(age, 37.5 6 15.9 years) was 11.64 6 0.47 mm. Standard error
of the mean was 0.039. The normal range for females was
10.70 to 12.58 mm. Differences in gender proved not to be
significant in the t test for independent samples (P = 0.071).
There were no significant differences between right and left
eyes in the t test for dependent samples (P = 0.16). Figure 1
shows the reproducibility of measurements. The spread of both
measurements is represented in this plot by the quartiles and
the minimum and maximum values of the variable.
The median (11.70 mm) and the 25%75% quartiles (11.50
11.90 mm) were equal in both measurements.
Figure 2 shows the relationship between corneal
diameter and age. Corneal diameter measured with the
Orbscan II system decreases slightly with age. The Pearson

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Rufer et al

FIGURE 1. Reproducibility of measurements.

product-moment correlation coefficient was r = 20.16 (P ,

0.05).

DISCUSSION
Wang and Auffarth1 showed that the Orbscan topography system provides very accurate and reproducible measurements of the horizontal corneal diameter (white-to-white). In
our study, too, the reproducibility was excellent. The medians
and 25% to 75% quartiles in both measurements were equal
(Fig. 1). The normal range of the horizontal corneal diameter
(white-to-white) is not known exactly. Mean values vary
between 11.5 and 12.5 mm in the literature.48 More accuracy
in these measurements might be a useful approximation for
sizing and producing anterior chamber intraocular lenses.911
Large corneal diameters are found in keratoconus and
lattice and granular dystrophies, whereas diameters are smaller
in Fuchs and macular corneal dystrophies.7 Naumann12
introduced the term relative anterior microphthalmos (RAM)
for eyes with a disproportionally small anterior segment. These
eyes were characterized by corneal diameters of ,11.0 mm
and a total axial length of .20 mm. The definition of
microcornea in the literature varies from horizontal diameters
,10.0 to ,11.0 mm.1317 Macrocornea is usually regarded as
greater than 12.5 mm.18
The normal range for males (11.0412.50 mm) found in
our study showed good agreement with these definitions. In
contrast, the normal range for females seemed to be wider
(10.7012.58 mm) according to our findings; however,
differences of the mean were not significant.
With increasing age, measurements of the white-towhite distance decreased as described in previous studies.8,19
The linear function was y = 11.886 2 0.004 3 age for adult
corneas. Whether this is actually due to decreasing corneal
diameters remains unclear. Widening of the limbus or the
presence of arcus senilis in age might cause inaccurate
Orbscan II measurements. Another possible explanation might
be found in demographic factors. It still remains unknown
whether the horizontal white-to-white distance changes with
height and size. As the average height of people has increased
dramatically in the past decades, a correlation between height
and white-to-white corneal diameter might be of major

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FIGURE 2. Correlation of corneal diameter and age.

influence. In 1890, Priestley Smith19 observed an average of

11.65 mm in males and 11.54 in females. In 1925, Peter20
found an average corneal size of 11.67 mm in school children
aged 5 to 16 years. The corneas of boys averaged 0.15 mm
more than those of girls. In our study, the average corneal
diameter in males was 11.77 6 0.37 mm, whereas in females
it was 11.64 6 0.47 mm. It is unknown whether these
differences result from true enlargement due to the increased
height and eye size of the population in the past century or
from differences in measuring techniques. Because we did not
evaluate height and size in our study, further case-controlled
studies are required. If the white-to-white corneal diameter
was influenced by height, this should also lead to smaller
diameters in females. Priestley Smith and Peter found slightly
greater diameters in males. In our study, greater values in
males due to differences in the mean age of both groups can be
excluded because the male cohort (42.7 6 16.6 years) was in
fact a bit younger than the female (37.5 6 15.9 years).
However, the mean values of males and females were not
significantly different, whereas the standard deviation in
females was greater.
According to our results, approximate corneal diameters
of ,11.0 mm in males and ,10.7 mm in females should be
regarded as microcorneas, whereas those .12.5 in males and
.12.6 in females should be termed macrocorneas leaving out
age just now.
Based on these data, more accurate definitions of
macrocornea, microcornea, and relative anterior microphthalmos will be possible in the future. Further studies are needed to
examine the influence of height, size, and probably age. If the
white-to-white was to decrease with time, these age-related
changes might have other implications such as increasing
glaucoma due to compacting of tissue in the angle or changes
in the corneal architecture.
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