Practical

Accurate optical biometry using the

IOLMaster Carl Zeiss Meditec
The primary aim of biometry is to allow the selection of the correct intraocular lens power to
achieve the desired refractive result after cataract surgery. The refractive aims of cataract
surgery must be discussed with the patient in terms of their requirements, expectations and
what is achievable and available.

atient satisfaction with cataract

surgery and implantation of an
intraocular lens (IOL) is influenced by
the resulting refractive state. Therefore, it is
of great importance to make a correct calculation of the pre-operative refractive power
of the eye, which depends on the power of
the cornea and the lens, the position of the
lens and the axial length of the eye.
When IOL surgery started in the late 1970s
the standard procedure, based on the timehonored Gullstrand schematic eye, was to
add +19D to the pre-surgery refraction. This
works well in emmetropic patients. Later,
the calculations were refined and based on
ultrasound A-scan measurements, together
with keratometry for calculation of the
refractive power of the cornea. The current
technique relies on partial coherence interferometry, first described by Fercher and
Roth in 1986. Incidentally, the first medical
application of this technique was ophthalmologic biometry.
This method is fast, comfortable for the
patient, and provides precise, accurate
and repeatable measurements, resulting in
greater efficiency, improved accuracy and
overall performance (Drexler et al, 1998;
Lam et al, 2001; Santodomingo-Rubido et al,
2002; Lee et al, 2008)
The aim of the current paper is to describe
how to perform optical biometry and to
provide some tips and guidelines. Currently
there are several equipments for biometry

on the market, one example is the LENSTAR

LS 900 (Haag-Streit, Koentitz/Switerland), another is the IOLMaster (Carl Zeiss
Meditec). The latter equipment is described
in this paper, mainly from the operators
perspective, and all comments reflect the
authors personal opinion.

What is biometry, and

why do we do it?
As can be read from the guidelines for cataract
surgery from the Royal College of Ophthalmologists (RCO), the primary aim of biometry is to allow the selection of the correct
IOL power to achieve the desired refractive
result after cataract surgery. Biometry is an
essential step before cataract surgery. The
refractive aims of cataract surgery must be
discussed with the patient in terms of their
requirements, expectations and what is
achievable and available (Royal College of
Ophthalmologists, 2010).

Biometry is an examination procedure

that involves the application of statistical
analysis to biological data. These data are
acquired by the operator, using the instrument, and the data quality is important for
the results of the analysis.
The IOLMaster (Figure 1) became available in September 1999 and was the first
automatic non-invasive optical biometry
system. It is a non-contact, all inclusive
technique which uses infra-red laser (780
nm) to provide precise measurements of the
axial length, the curvature of the cornea, the
anterior chamber depth, the width of the iris,
and with the latest IOLMaster 500, also the
pupil diameter (IOLMaster Online Manual,
2011). The evolution of the IOLMaster
reflects the development of software, which
has provided improved results. With the
release of the new IOLMaster 500 all patients
can be measured if the Accutome ultrasound
synergy is purchased. It is difficult to refer to

Figure 1. Patient examined with the IOLMaster 500.

Lyn Millbank

DOBA (Australia), is Orthoptist Ramsay

Healthcare Fulwood Hall Hospital, Preston,
Lancashire, and at iSight Drayton Clinic
Southport. Clinical Trainer Ophthalmic
Systems Carl Zeiss UK

4

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Practical
all the different versions of software for each
scenario, therefore, the reader is advised to
consult the manual provided to work within
the limitations of the model used in clinic.

What information does

biometry provide?
For calculation of the correct power of the
IOL for a cataract patient, the optical biometer measures the axial length (AL), the
corneal curvature (Ks), the anterior chamber
depth (ACD), the horizontal diameter of the
iris; white to white (WTW) and with the
IOL Master 500, also the pupil diameter.
For an overview of the calculations and the
normal values see Table 1.

Learning how to
perform biometry using
the IOLMaster
Read instructions, attend
courses, ask colleagues

Start by reading the manual carefully (available in several languages) and also attend

a recognized course which has practical

workshops with hands-on time. Cascade
training is not ideal and may result in
poorly understood concepts being passed
on incorrectly.
If you work in the UK you should be
aware of the RCO guidelines for cataract surgery (2010), which can be used as
a guide to writing departmental protocol
along with the ophthalmologists direction.
Every clinic should have an instruction and
a departmental protocol for biometry, read
it. Always ask a colleague to perform biometry on yourself to enable you to understand the workflow and ensure good patient
instruction.

Familiarize yourself with the

normal values, so you know what
to expect
It is important to understand why you are
doing biometry and to be familiar with the
average values in normal eyes in order to
troubleshoot when differences or unusual
measurements are produced (see Table 1).

Perform examinations in both

eyes
You should always perform measurements
in both eyes even if the patient has already
undergone cataract surgery in one eye. This
will help to confirm measurement results
alongside the type and status of the eyes.
You can expect the measurements of both
eyes to be similar unless clinical or refractive information indicates otherwise.

Calibration
Do not forget to always check the calibration of the equipment every day see the
manual section for Test Eye.

How to prepare for the

examination
Take the time to prepare the patient properly, starting with an explanation of what
you are intending to do, and why. Request
a copy of the patients current spectacle
prescription and, if possible, the pre-cataract spectacle prescription this may help
explain unexpected measurement in the

Table 1. Parameters measured

Measurement
What is measured

6

Normal value
mean (range)

Beware

Notes

Axial length (AL)

Uses partial coherence
23.5 mm

interferometry to
(2226)

measure from tear film

to retinal pigment

epithelium (RPE)

Expect longer eyes if myopic,

shorter if hyperopic
Myopic shift may occur in
dense cataract
Staphyloma may be
present in high myopia

Adjust AL
settings if
measuring
other than
phakic eye

Corneal curvature
Distance between
4244D
(Ks)
reflected infrared
(Expect steeper in

images projected onto
hyperopes and flatter

the cornea
with myopes)

Prior refractive Sx,

Keratoconus or corneal
pathology must be
considered
Refractive index

Refractive power
of cornea approx
43D
Corneal thickness
approx 0.5 mm

Anterior chamber
Distance between the
3.24 mm
Do not measure ACD on
depth (ACD)
anterior vertex of the
(Varies, may be
IOLMaster in pseudophakia

cornea and the anterior
shallower if dense
or aphakia

vertex of the natural lens
cataract, high hyperopia
Ks are required before ACD

or glaucoma)
measurement can be taken

Average lens
thickness approx
4.63 mm
Refractive power
of lens approx
20D
ACD required for 
Haigis and Haigis 
L formula

White to White
Horizontal diameter of
12 mm
(WTW)
the iris
(11.512.5)

Provides distance
of visual axis
from centre of
iris

If anterior chamber IOL

required and is too large
it will bulge and cause
damage, if too small it will
not be effective

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Practical
case of myopic shift induced by the cataract.
Access the patients ophthalmic history to
account for any out of range measurements.
Prior refractive surgery will alter the Ks and
if this information is ignored the chances
are that the outcome will lead to a refractive
surprise. Patients who have had refractive
surgery have high expectations. However,
they do not always volunteer the information and may not consider they have had
surgery.
Do not measure patients with known
retinal detachments or macula oedema
because optical biometry measures the
AL along the visual axis from the tear film
to the retinal pigment epithelium (RPE)
using partial coherence interferometry. If,
for example, macular pathology is present,
a double peak can occur in the AL and the
value may be variable and imprecise (Kojima
et al, 2010).
Ideally biometry should be performed
before dilating drops are instilled and before
tonometry or pachymetry is performed
(Royal College of Ophthalmologists, 2010),
because the shape of the cornea will be
changed and the Ks may be inaccurate. If
the patient wears contact lenses consult
departmental protocol or refer to RCO guidelines (Royal College of Ophthalmologists,
2010) and inform the patient to remove
contact lenses accordingly in the appointment letter. Contact lenses will also affect K
measurements.
For axial lengths from 22.50 mm to
26.00 mm, and central corneal powers
ranging from 41.00 D to 46.00 D, almost
any modern IOL power calculation formula
will give good outcomes. Based on certain
indications (e.g. axial lengths and/or
corneal powers outside the normal range,
previous surgery or laser treatment) the
IOLMaster uses different formulae to make
the correct calculations. Table 2 shows the
formulae and the parameters needed for
every formula, together with the constant
that is used. Normal values for the different
parameters are given in Table 1.

Conclusion
Today, with sophisticated IOL power calculations, about 90% of cases fall within 1.0
D and 99.9% within 2.0 D of their targets,
assuming optimized conditions. Prediction is more accurate in long eyes and less

accurate in short eyes. The calculation and

selection of appropriate IOL power are
among the most significant tools in refractive
surgery today (Olsen, 2007).
Optical biometry using the partial coherence interferometry with, for example, the
Zeiss IOLMaster has become synonymous
with measurement precision, simple operation and excellent outcomes. Although the
IOLMaster is easy to use it is important to
understand the procedure and technique
and that the measurements are applied
to modern formulae using optimized A

Constants. Further discussion on formulae

and A constants will be addressed in future
IJOP
IJOP publications.

Conflict of interest: the author is a part time

employee of Carl Zeiss UK, but the paper
was not commissioned by the employer.
The author is grateful to Burkhard Wagner
Product Group Manager, Cataract and
Refractive Diagnostics, Carl Zeiss Meditec
for providing necessary information and
the images.

Table 2. Formula and indications

Formula

Requirements

A constant

Haigis
AL K1 K2 ACD
a0 a1 a2


Hoffer Q
AL K1 K2

Indications
All lengths of eyes if 
each of the three A 
constants optimized

pACD (personalized
Short eyes <22 mm
ACD)

Holladay 1
AL K1 K2
sf (surgeon factor)

Axial length 24
26mm

SRK/T
AL K1 K2
A constant

Average to longer
eyes

Haigis L
AL K1 K2
aO a1 a2

Patients who have 

undergone refractive 
surgery for myopia 
or hyperopia

Phakic IOL
K1 K2 ACD WTW pre op

refraction back vertex

distance target refraction

A constants preloaded
on IOLMaster
according to lens
selected by surgeon

Anterior IOL in

addition to natural
lens-refractive
procedure

Prior refractive
surgery clinical
history method

According to the
formula to which the
recalculated Ks
are applied

Patients who have

previously had
refractive surgery

AL pre op average Ks
pre-op refraction Stable
post-op refraction
Corneal vertex distance

Prior refractive AL hard contact

According the formula
sugery contact lens (CL) power CL base to which
lens method
curve. Refraction with CL. remeasurement

Refraction without CL
of the Ks is applied

Patients who have

previously had
refractive surgery.
Least accurate 
approach for prior 
refractive surgery 
patients

Readers of the International Journal of Ophthalmic Practice are

invited to contribute. If you wish to discuss an idea prior to submission contact the Editor, Georgina Grell: [email protected]. Author guidelines can be found on the website: www.
ijop.co.uk.

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Practical
Measurement procedure

Axial Length (AL) (keyboard shortcut A)

The Zeiss IOLMaster uses a Michelson interferometer (Hill, 2003)
to measure the axial length from the tear film to the RPE along the
visual axis and will after five AL measurements produce a composite
signal (Monz, personal communication). Unless there is pathology
or refractive differences you can expect the AL measurement to be
similar between eyes.
Start by occluding the eye not being examined. This is particularly
helpful with squint patients and high ametropia to ensure central
fixation. The signalnoise ratio (SNR) will be displayed simultaneously on the ALM screen as a value. This value is a gauge of the
quality of measurement. Measurements with an SNR between 1.6
and 1.9 appear with an exclamation mark (!) after the reading and
the message Borderline value! This will occur with dense cataracts
as the pathway of the light is challenged. Borderline value! does
not necessarily mean that the reading is incorrect and must be
rejected. It is an indication to check axial length measurements for
plausibility and consistency and compared with the reading.
Readings in the series of measured values that deviate from the
internally calculated composite value by more than 50 m are
shown in red and marked multiple peaks. If the SNR is below 1.6,
no reliable axis length can be determined from the single measuring
signal. In this case dashes -- are shown. If the uncertain values are
determined to concur with the other readings, the readings marked
Borderline value! should also be accepted as valid axial lengths.
Do not delete any single measurements, e.g. only because they
have a very low SNR or no axial length measurement could be determined (SNR with ! or --). Such signals can contain usable information on AL for use in the calculation of the composite signal (Zeiss
IOLMaster manual and tutorial).
When measuring eyes with dense cataract, moving the measuring
spot around the reticule and defocusing the spot increases the
chances of getting light through the cataract to the RPE.
Patients spectacles may be worn for AL measurement, which may

Figure 2. The anterior chamber depth (ACD) screen

8

lead to higher SNR and increased accuracy of measurement along

the visual axis.
The IOLMasters version 3 to 5 will only allow 20 AL measurements
per eye per day. However, the IOLMaster 500 will allow repeated AL
measurements for up to 8 hours.
Check that the obtained measurements are reproducible and that
they fit with the type of eye being measured, i.e. longer AL if the eye
is myopic, and shorter in hyperopia.
Remember to change the AL settings for anything other than
phakic eyes by using the AL settings at the top of the screen. In the
IOLMaster 500 this may be done on the new patient screen or on
the dual mode screen.
Keratometry (Ks) (keyboard shortcut K or with IOLMaster
500 access dual mode by pressing A)
The corneal curvature (Ks) is determined by measuring the distance
between reflected infrared images projected onto the cornea. The
Ks are measured in mm and then converted into dioptres. Ensure
that the correct refractive index is in use. Check in case other users
may have changed this.
Be aware that K measurements will be altered by refractive surgery.
1D difference in K values corresponds to 1D difference in final IOL
power calculation
Ask the patient to blink or close the eyes for a few seconds to
improve tear film. Always revert to manual mode if pathology
prevents good measurement (this may be done by pressing M on
the keyboard).
Five internal K measurements are taken within 0.05 secs. By taking
3 K measurements the average Ks are provided from a total of 15
measurements.
Anterior chamber depth (ACD) (keyboard shortcut D)
The ACD is determined as the distance between the optical sections
of the crystalline lens and the cornea produced by lateral slit illumination, thus the corneal thickness is included (Figure 2). This is the

Figure 3. The white to white (WTW) screen

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Practical
most difficult measurement on the IOLMaster, although software
version 5 and the IOLMaster 500 has automated mode for ACD
with traffic light aid.
Note that the Haigis, Haigis L and Holladay 2 formulae all require
accurate measurements of ACD.
Do not measure ACD using the IOLMaster in patients with pseudophakia or aphakia because the alignment is based on reflection
from the lens structure.
White to white (WTW) and pupil diameter (PD) (keyboard
shortcut W)
The WTW is determined from the image of the iris. Ensure that the
patient keeps the eye wide open and maintains fixation on the target
light.
WTW provides useful information when an anterior chamber IOL is
required. This enables calculation of the size, not the power, of the
IOL to be inserted into the anterior chamber. The WTW provides
the distance of the visual axis from the centre of the iris (Figure 3).

Data analysis: IOL calculation

When all required measurements have been performed go to the

IOL calculation page (keyboard shortcut I). The IOL calculation page
provides a choice of formulae for standard cataract procedures as
well as formulae offering a solution for IOL power calculation on

References

lens calculation after

Chen YA, Hirnschall N, Findl
refractive surgery for
O (2011) Evaluation of
myopia: Haigis-L formula.
2 new optical biometry
J Cataract Refract Surg
devices and comparison
34(10): 165863
with the current gold
standard biometer. J CataHaigis W (2007) A-constant
ract Refract Surg Jan 17:
optimisation is worth it.
[Epub ahead of print]
EUROTIMES dec:10
Drexler W, Findl O, MenaHill WE (2003) The
pace R et al (1998) Partial
IOLMaster. Techniques in
coherence interferometry: a
Ophthalmology 1(1): 627
novel approach to biometry
Holladay
JT, Prager TC, Ruiz
in cataract surgery. Am J
RS, Lewis JW, Rosenthal
Ophthalmol 126: 52434
H (1986) Improving the
Fercher AF, Roth E (1986)
predictability of intraocOphthalmic laser interular lens power calculaferometer. Proc SPIE 658:
tions. Arch Ophthalmol
4851
104: 53941
Haigis W (2008) Intraocular

patients who have previously undergone refractive surgery (Table 2).

Ensure that the appropriate formula has been chosen for the length
and type of eye, including prior refractive surgery (Royal College
Ophthalmologists, 2010). For ALs and central corneal powers within
the normal range (Table 1), most modern IOL power calculation
formulae will work. However, for eyes outside this range, studies
have shown that the newer generation of formulae, such as Holladay
2, or Haigis (with properly optimized a0, a1 and a2 constants) are
better choices (Lee et al, 2008; IOLMaster Online Manual, 2011).
Finally, select identity of the operating surgeon. Be aware that the
target refraction does not default back to Plano if you have typed in
a different target for the previous patient.
Look at the highlighted refractive power for right and left eye and
ensure it fits with the type of eye you have measured. Check that
the A constants have been optimized for optical biometry (Haigis,
ESONT)
Then click on the PRINT IOL CALCULATION button. A printout of the
measurements should also be provided. It contains useful information for the surgeon and makes it possible to check the biometry
results retrospectively.
Write comments by hand on the printout if there is anything of note
to help the surgeon choose the best IOL power to gain the target
outcome for the patient. If comments are typed in they will not
always be noted by the surgeon.

IOLMaster Online Instruction

Manual V.5 http://doctorhill.com/zeiss_iolmaster/
iolmaster-manual.htm
(accessed 22 January, 2011)

axial length and anterior

chamber depth measurements from the IOLMaster.
Ophthalmic Physiol Opt
21: 47783

Olsen T (2007) Calculation of

intraocular lens power: a
review. Acta Ophthalmol
Scand 85(5): 47285. Epub
2007 Apr 2

Kojima T, Tamaoki A,
Yoshida N, Kaga T, Suto
C, Ichikawa K (2010)
Evaluation of axial length
measurement of the eye
using partial coherence
interferometry and ultrasound in cases of macular
disease. Ophthalmology
117(9): 17504. Epub 2010
May 14

Lee AC, Qazi MA, Pepose

JS (2008) Biometry and
intraocular lens power
calculation. Curr Opin
Ophthalmol 19(1): 137.
Review

Royal College of Ophthalmologists (2010) Cataract Surgery Guidelines

September 2010 http://
www.rcophth.ac.uk
(accessed 22 January, 2011)

LENSTAR LS900 http://

www.haag-streit.com/
products/biometry/lenstarls-900r.html (accessed 22
January, 2011)

Lam AK, Chan R, Pang

PC (2001) The repeatability and accuracy of

Monz, Ludwin CEO Carl

Zeiss Meditec, personal
communkation8 Nov 2010

Santodomingo-Rubido J,
Mallen EA, Gilmartin B,
Wolffsohn JS (2002) A new
non-contact optical device
for ocular biometry. Br J
Ophthalmol 86: 45862

Key points
Selection of the correct IOL power to meet individual patient expectations is crucial.
It is important to have knowledge of the structures measured in biometry and to be aware of average measurements of the eye.
Ensure you have relevant clinical and refractive information about the patient prior to performing biometry.
It is important to use optimized A constants for each individual IOL being applied to the biometry measurements.
It is recommended to use third or optimally fourth generation formulae to calculate IOL power. However, this decision is made by the operating surgeon.

Optical biometry Axial length measurement Keratometry Anterior chamber depth measurement White to
white measurement Optimized A constants Modern IOL calculation formulae

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