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The IOL Power Calculation

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605 views120 pages

The IOL Power Calculation

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Mardika Family
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© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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THE INTRAOCULAR LENS POWER CALCULATION

Gede Pardianto (Ed.) ANAK SUDARTI FOUNDATION


i
THE INTRAOCULAR LENS POWER CALCULATION

The Intraocular Lens Power Calculation

Copyright c 2022. Anak Sudarti Foundation. All rights reserved.


No part of this publication maybe reproduced or copied in any form, or by any means, without
prior written permission from the publisher.

For humanitarian purpose, each author has privilege rights to reprint or reproduce the whole
book without any modification, sell the book in very low price, or share it for free.

Edited by Gede Pardianto

Layout and cover by Muhammad Hakiki


The book cover is a tribute design in cherish, respect, honor, and salute of Balinese Frangipani,
Batik Gajah Oling from Banyuwangi East Java, and Batik Batak Toba from North Sumatra.

Printed by CV Manhaji Medan Indonesia

National Library of the Republic of Indonesia - Indexed


ISBN 978-623-6763-50-6
e-ISBN 978-623-6763-51-3 (PDF)

bit.ly/ISBNTheIntraocularLens

Printed in the Republic of Indonesia

ii Gede Pardianto (Ed.)


THE INTRAOCULAR LENS POWER CALCULATION

“ This book is dedicated to God, our patients, teachers,


students, colleagues, and beloved families.
Gede Pardianto (Ed.)
” iii
THE INTRAOCULAR LENS POWER CALCULATION

Anak Sudarti Foundation


Registered in the Ministry of Justice and Human Rights of the Republic of Indonesia

Reg. No: AHU-0034552.AH.01.04. Year of 2015


TIN (NPWP): 75.063.539.3-111.000

The Foundation is non-profit which strives to foster the development of education,


knowledge charity, and humanitarian service

Support system:
Yayasan Anak Sudarti (Anak Sudarti Foundation) Bank Mandiri (Indonesia, SWIFT
Code: BMRIIDJA) Account No. 1050012350207

iv Gede Pardianto (Ed.)


THE INTRAOCULAR LENS POWER CALCULATION

Foreword

Cataract is the biggest cause of blindness in the world. As life


expectancy continues to increase, so does the likelihood of getting
cataract for everyone on Earth. However, we must be grateful that the
blindness caused by cataract can be handled thanks to the ever-growing
knowledge, skill, and technology in the field of ophthalmology, which
includes the Intraocular Lens (IOL) technology.
The development of IOL plays a huge role in the countermeasures
needed to treat blindness due to cataracts. With time, the IOL technology
allows us to move from restoring the visual function to fixing the visual
function, and beyond.
Today, the need for an excellent visual function following a cataract operation is even
bigger. To respond to that need, there has to be a comprehensive effort in every aspect of
operating and handling cataracts, which includes putting the appropriate IOL, especially in
terms of its power.
As we move forward, IOL Power Calculation continues to hold a crucial role. We hope that
this book could provide a significant contribution to the management of cataracts and to the
achievement of a better visual function for every cataract patient around the world.
We also hope that this book could play a major role in helping millions of patients to
be able to work and be productive again. That way, it could generate positive impacts on
the socioeconomic status of many families, which may allow their children to have more
opportunities towards higher and better education to reach a brighter future.

Nila F. Moeloek (Professor)


Former Minister of Health
Jakarta, Indonesia

Gede Pardianto
Foreword (Ed.) v
THE INTRAOCULAR LENS POWER CALCULATION

Preface
The history of Intraocular Lens (IOL) power calculation commenced as
soon as ophthalmologists began to implant IOLs and discovered that not
everyone needed the same IOL power (+20 Diopters was tried) and large
refractive surprises occurred when that was attempted. Additionally, because
we initially had non-foldable IOLs requiring sutured large incisions, almost
always made at 12 o’clock, surgeons rapidly discovered that it took a long time
for refractive stability and patients developed a progressive drift to against
the rule large astigmatic errors. However, a -5.00 +4.00 x180 refractive error
was a lot better than +11.00 +5.00 x180, a not unusual refractive error after
intracapsular cataract extraction. So, as soon as IOL implantation began to
become popular, in the 1970’s, ideas for better IOL power calculations proliferated. Ultrasound became
available in the early 1980s, followed by shrinking incisions. Optical biometry appeared in the early
2000s, and the era of finally having a chance to leave patients close to emmetropic postoperatively
began. New biometers and topographers appeared, and increased accuracy was achieved accompanied
by increased machinery cost. The pace of change escalated and the drive to emmetropia raced
forward. Numerous papers emerged and the knowledge of biometry began to become extensive and
fragmented in the 21st century, requiring progressively increasing effort to sort out.
Dr. Gede Pardianto recognized that the majority of ophthalmologists were not positioned
to assemble the information required to make informed decisions about how they were going
to pursue biometry optimally in their practices, and also wondered, in all but the most affluent
countries, how they were going to pay for the technology needed to achieve excellent results.
Recognizing this important gap, Dr. Pardianto has brilliantly assembled here, in a single
volume, what is now needed to understand concepts and achieve excellent biometric results
and has provided reasonable conjectures of where we are headed in newer areas. I am honoured
to have been asked to contribute to this book. One huge laudatory goal of Dr. Pardianto is his
intention to make the book available at a very reasonable cost, so all will have access to this
resource. The book purports to be a source of otherwise scattered information and hopes to
provide historic background and solid reliable information on questions we all have. No book
is ever the last word, but this is a great place to acquire the understanding to perform biometry
intelligently and confidently in the vast majority of patients.

Steve A. Arshinoff (Professor)


Toronto, Canada

vi Gede PardiantoPreface
(Ed.)
THE INTRAOCULAR LENS POWER CALCULATION

Gedefrom
Note Pardianto
Minister(Ed.)
of Health vii
THE INTRAOCULAR LENS POWER CALCULATION

The Editor’s Page

Please allow me to cherish and express my appreciation to my best


friends – fellow contributors, and publisher for their hard work and
commitment to make this book project into reality. This is our humble
contribution to the effort for helping the people against blindness.
Hopefully our readers will take advantage of this book to help
them achieve a better vision for their patients around the world. For
indeed, millions of our patients await the opportunity to see and work
again through the gentle work of our hands.
I hope this book will be a kind of useful legacy for humanity.

Gede Pardianto
Medan, Indonesia

viii Gede Pardianto


The Editor’s(Ed.)
Page
THE INTRAOCULAR LENS POWER CALCULATION

Table of Contents

Title Page
Copyright Page
Dedication
Foreword ________________ v
Preface ________________ vi
Keynote Address from Minister of Health ________________ vii
The Editor’s Page ________________ viii
Table of Contents ________________ ix
List of Figures ________________ x
List of Tables ________________ xi
List of Abbreviations ________________ xii
List of Contributors ________________ xvi
How to cite the entire book ________________ xviii
Chapter 1. History of Optical Biometry ________________ 1
Chapter 2. What was Known About Biometry and IOL Power Calculation?_______ 11
Chapter 3. Intraocular Lens Power Calculation Formulas ________________ 25
Chapter 4. IOL Power Calculation in Standard Eyes and for Immediately Sequential Bilateral
Cataract Surgery ________________ 33
Chapter 5. IOL Power Calculation in Special Situations ________________ 43
Chapter 6. Toric IOL Power Calculation and Managing Residual Astigmatism __________ 75
Chapter 7. IOL Power Calculation for the Bag-in-the-Lens (BIL) Implantation Technique ___85
Acknowledgements ________________ 95
About the Editor ________________ 96
Index ________________ 97

GedeofPardianto
Table Contents (Ed.) ix
THE INTRAOCULAR LENS POWER CALCULATION

List of Figures

Figure 1. Interference pattern caused by the light reflected at the cornea and retina ____ 2
Figure 2. A-Scan acquired with PCI ________________ 3
Figure 3. B-Scan acquired with SS-OCT ________________ 5
Figure 4. Toric IOL aligned with the IntelliAxis Refractive Capsulorhexis axis mark which
was created using the LENSAR femtosecond laser by using preoperative data.
________________ 77
Figure 5. Zeiss Callisto display showing precise alignment of a toric IOL. Note that corneal
marks are not necessary and therefore aren’t seen. ________________ 78
Figure 6. A treatment algorithm for residual astigmatism after toric IOL placement. (LRI:
Limbal Relaxing Incision) ________________ 79
Figure 7. The effects of a misaligned SN6AT9 AcrySof Toric IOL (Alcon, Fort Worth, TX).
________________ 80
Figure 8. Data entry and results page from the Toric Results Analyzer (freely available at
astigmatismfix.com) ________________ 81
Figure 9. Diagram of the double rhexis implant, illustrating the central optical part sur-
rounded by its haptic. The two oval-shaped anterior and posterior haptics are ori-
ented perpendicular to each other to ensure optimal IOL stability. The side view
of the implant shows the characteristic groove in which the two capsules will be
placed. (1. Optics, 2. Groove, 3. Posterior Haptic, 4. Anterior Haptic, 5. Mark of
Orientation) ________________ 88
Figure 10. A- “bag-in-the-lens” lens implant positioned in the double rhexis, where the epi-
thelial cells of the lens are captured in the peripheral portion of the remain-
ing capsule and therefore cannot migrate to the pupillary axis. B- conventional
implantation scheme of the lens in the capsular bag ‘in the bag’ showing the
epithelial cells of the lens in the equatorial region and on the posterior capsule.
________________ 89
Figure 11. Assembling of different postoperative images after BIL implantation at different
postoperative times up to 1 year postoperatively. Visual axis remains clear in all
eyes provided the BIL is properly implanted. ______________ 91

x Gede Pardianto (Ed.)


List of Figures
THE INTRAOCULAR LENS POWER CALCULATION

List of Tables

Table 1. Variables required by commonly used equations ________________ 36


Table 2. Recommendation of formulae to use with varying ocular parameters ____ 38
Table 3. Devices that can be used to measure Biometric Parameters _____________ 40
Table 4. Refractive prediction errors (PE) according to the five formulas in eyes with three
stages of KCN (in D) ________________ 52
Table 5. Percentage of eyes with three stages of keratoconus with a refractive PE within
±0.5, ±0.75, and ±1 D ________________ 52
Table 6. Treatment Methods of Residual Astigmatism ________________ 78
Table 7. Loss of Refractive Power Upon Toric IOL Rotation ________________ 80
Table 8. Rotating a Toric IOL ________________ 82

Gede
List Pardianto
of Tables (Ed.) xi
THE INTRAOCULAR LENS POWER CALCULATION

List of Abbreviations

AAO American Academy of Ophthalmology


ABMD Anterior Basement Membrane Dystrophy
AC IOL Anterior Chamber IOL
AC Anterior Chamber
ACCC Anterior Continuous Curvilinear Capsulorhexis
ACCP Average Central Corneal Power
ACD Anterior Chamber Depth
ACP Average Corneal Power
AI Artificial Intelligence
AL Axial Length
ALK Automated Lamellar Keratoplasty
ALP Actual Lens Position
APACRS Asia Pacific Association of Cataract and Refractive Surgeons
AQD Aqueous Depth
A-Scan Amplitude Mode Scan
ATR against-the-rule astigmatism
AVD Anterior Vitreous Detachment
AXL Axial Length
BIL bag-in-the-lens
B-Scan Brightness Mode Scan
BUII Barrett Universal II
CCC Continuous Curvilinear Capsulorhexis
CCP Central Corneal Power
CCT Central Corneal Thickness
CD Corneal Diameter

xii Gede
ListPardianto (Ed.)
of Abbreviations
THE INTRAOCULAR LENS POWER CALCULATION

CEDOF Continuous Extended Depth of Focus


CMAL Cooke Modified Axial Length
CT Corneal Thickness
CXL Corneal Collagen Crosslinking
D Diopter
DALK Deep Anterior Lamellar Keratoplasty
DMEK Descemet Membrane Endothelial Keratoplasty
DSAEK Descemet Stripping Automated Endothelial Keratoplasty
EBMD Epithelial Basement Membrane Dystrophy
EKR Equivalent Keratometry Readings
ELP Effective Lens Position
ESCRS European Society of Cataract and Refractive Surgeons
etc Etcetera
EuReCCa European Registry on Childhood Cataract
EVO Emmetropia Verifying Optical
FDA Food and Drug Administration
FD-OCT Fourier-Domain Optical Coherence Tomography or Frequency-Domain
Optical Coherence Tomography
FLACS Femtosecond Laser Assisted Cataract Surgery
HWTW Horizontal white to White
ICL Implantable Collamer Lens
ICRS Intrastromal Corneal Ring Segments
ILM Inner Limiting Membrane
ILP Internal Lens Position
iOCT intraoperative Optical Coherence Tomography
IOL Intraocular Lens
ISHF Intrascleral Haptic Fixation
ISO International Organization for Standardization
IWA Intraoperative Wavefront Aberrometry
KCN Keratoconus
LASIK Laser in-situ Keratomileusis
LECs Lens Epithelial Cells
LF Lens Factor
LIB lens-in-the-bag

Gede
List Pardianto (Ed.)
of Abbreviations xiii
THE INTRAOCULAR LENS POWER CALCULATION

LT Lens Thickness
mm millimeter
OCT Optical Coherence Tomography
OLCR Optical Low Coherence Reflectometry
ORA Optiwave Refractive Analysis
OVD Ophthalmic viscoelastic devices
PCCC Continuous Curvilinear Capsulorhexis
PCI Partial Coherence Interferometry
PCO Posterior Capsule Opacification
PE Prediction Errors
PEARL-DGS Postoperative spherical Equivalent prediction using ARtificial intelligence and
Linear algorithms by G. Debellemanière, D. Gatinel, and A. Saad
pIOL Phakic Intraocular Lens
PK Penetrating Keratoplasty
PKA Posterior Corneal Astigmatism
PMMA Polymethyl methacrylate
PPCCC Primary Posterior Continuous curvilinear capsulorhexis
PRK Photorefractive Keratectomy
PVDF Polyvinylidene Fluoride
RA Residual Astigmatism
RBF Radial Basis Function
RGP Rigid Gas Permeable
RK Radial Keratotomy
RPE Retinal Pigment Epithelium
SA Spherical Aberration
SB Scleral Buckle
SD-OCT Spectral-Domain Optical Coherence Tomography
SE Spherical Equivalent
SF Surgeon Factor
SIA Surgery-Induced Astigmatism or Surgically-Induced Astigmatism
Sim-K Simulated Keratometry
SMILE Small Incision Lenticule Extraction
SNR Signal-to-Noise Ratio
SRK Sanders-Ritzlaff-Kraff

xiv Gede
ListPardianto (Ed.)
of Abbreviations
THE INTRAOCULAR LENS POWER CALCULATION

SS OCT Swept-Source Optical Coherence Tomography


TCP Total Corneal Power
TCRP Total Corneal Refractive Power
TD-OCT Time-Domain Optical Coherence Tomography
TK Total Keratometry
TRF Telomere Restriction Fragments
UGH uveitis-glaucoma-hyphema
USG Ultrasonography
UV-A Ultraviolet-A
WTR with-the-rule astigmatism
WTW White to White

Gede
List Pardianto (Ed.)
of Abbreviations xv
THE INTRAOCULAR LENS POWER CALCULATION

List of Contributors

1. ARSHINOFF, Steve A. (Professor)


Department of Ophthalmology and Vision Sciences, University of Toronto
Toronto, Ontario, Canada

McMaster University, Hamilton


Ontario, Canada

Ben Gurion University of the Negev


Be’er Sheva, Israel

Airlangga University
Surabaya, Indonesia

2. DHAWLIKAR, Nisha S.
New York Eye and Ear Infirmary of Mount Sinai
New York City, New York, USA

3. DAI, Yi Ling
New England Eye Center
Tufts Medical Center, Tufts University
Boston, Massachusetts, USA

4. FINDL, Oliver (Professor)


Vienna Institute for Research in Ocular Surgery (VIROS)
Department of Ophthalmology, Hanusch Hospital, Vienna, Austria

President of the European Society of Cataract and Refractive Surgeons (ESCRS)

5. GUPTA, Rishi
University of Ottawa Faculty of Medicine
Ottawa, Ontario, Canada

xvi GedeList
Pardianto (Ed.)
of Contributors
THE INTRAOCULAR LENS POWER CALCULATION

6. HUGHES, Kate V.
New England Eye Center
Tufts Medical Center, Tufts University
Boston, Massachusetts, USA

7. KRAMER, Brent
Duke Eye Center, Duke University
Durham, North Carolina, USA

8. NENNING, Magdalena
Vienna Institute for Research in Ocular Surgery (VIROS)
Department of Ophthalmology, Hanusch Hospital, Vienna, Austria

9. PARDIANTO, Gede
Sabang Merauke Eye Center (SMEC) at Medan
Medan, North Sumatra, Indonesia

10. RAO, Naveen K. (Professor)


Tufts University School of Medicine
Boston, Massachusetts, USA

11. SAVINI, Giacomo


G.B. Bietti Foundation I.R.C.C.S.
Rome, Italy

Studio Ocullistico d’Azlegio


Bologna, Italy

12. TASSIGNON, Marie-José (Professor)


University Hospital of Antwerp, Antwerp University,
Antwerp, Belgium

Former President of the European Society of Cataract


and Refractive Surgeons (ESCRS)

Gede
List Pardianto (Ed.)
of Contributors xvii
THE INTRAOCULAR LENS POWER CALCULATION

How to cite the entire book:

Pardianto G, editor. The Intraocular Lens Power Calculation. Medan: Anak Sudarti Foundation. 2022.

Free Maestro Lectures videos:

bit.ly/maestrolectures

Free copy of this book:

bit.ly/TheIOLPowerCalculation

xviii Gede
How Pardianto
to cite the entire(Ed.)
book
THE INTRAOCULAR LENS POWER CALCULATION

Chapter 1
History of Optical Biometry
Magdalena Nenning, Oliver Findl

As the demands for advanced technologies and techniques related to cataract surgery have
grown over the years, so did the patient’s expectations for an optimal refractive outcome,
which can only be achieved with a precise calculation of intraocular lens (IOL) power. For this
purpose, different IOL power formulae have been developed and all of them require an accurate
assessment of preoperative biometry. The most essential part is the measurement of the axial
eye length (AL), as imprecise AL values are responsible for 54% of postoperative refractive
errors. While ultrasound has been commonly used for biometry purposes in the past, more
precise biometry systems have been developed over the years that are nowadays considered the
gold standard for ocular biometry.1-3 The following chapter will give an overview of the history
of biometry and the methods currently available.

Ultrasound biometry
Ultrasound biometry was first introduced in 1956 and has been the gold standard for AL
measurement for many years, with two different methods available.2,4
Contact applanation biometry requires the ultrasound probe to directly be in touch
with the cornea during measurement. A high frequency sound wave is used to traverse the
various structures of the eye, while it is partly reflected back towards the probe at every
media interface, providing information about the distance between the probe and the media
interface, which is how the AL can be determined. However, the indentation of the cornea
resulting from this method leads to lower AL values and therefore an overestimation of the
IOL power.
A more accurate method is immersion ultrasound biometry, as the compression of the
globe is avoided by placing a saline immersion bath between the probe and the cornea.1,5,6
Both methods use relatively long, low resolution wavelengths (10 MHz) to facilitate
penetration even through dense media, however, they do so at the cost of a low resolution.
Another disadvantage of ultrasound biometry is that inconsistent measurements may be
commonly faced, either due to the fact that retinal thickness may vary in the central retina or
due to measurements that are performed slightly off-axis.1,5,6

Gede Pardianto (Ed.) 1


THE INTRAOCULAR LENS POWER CALCULATION

Partial coherence interferometry (PCI) by the use of broadband superluminescent


In 1986, partial coherence interferometry diodes, allowing to measure not only the AL,
(PCI) was introduced for the purpose of ocular but also the dimensions of the cornea and
biometry,7 while the concept itself dates back anterior chamber.7
to the 1970s.8 The infrared light beam emitted by the
Fercher and coworkers in Vienna, superluminescent diode had a wavelength
Austria, illuminated the patient’s eye with a of approximately 780 nm, a high spatial
long-coherence Helium-Neon laser beam and coherence and a very short coherence length.
analyzed the reflections from the cornea and The spectrum of colors was broader than those
the retina, which formed an interferogram of lasers, which made the measurement more
consisting of circular interference fringes. sensitive. A Michelson interferometer was used
(Figure 1) By placing an interferometer within to split the beam into a direct and a delayed
the laser beam, the optical path length between beam by means of two mirrors, one being
cornea and retina could be determined. (See fixed and one being moveable. The two beam
also Chapter 2) components were reflected at every media

Figure 1. Interference pattern caused by the light reflected at the cornea and retina7

No contact with the eye and hence, interface and the reflections were detected
no anesthesia was required for this method, by and superimposed on a photodetector. An
however, a higher resolution could be overlapping of the reflected beams indicated
achieved.7,9 One practical problem that an identical total path length and resulted in
remained was to provide a high spatial an interferogram at the observation plane.1,10,11
coherence and a very low temporal coherence, When aiming to measure the AL, the reflections
which were conditions required for the from the anterior corneal surface and the
measurements. The first lasers, used until retinal pigment epithelium were analyzed
1985, were dye lasers that were not sufficiently and their optical distance was assessed by
stable, followed by multimode semiconductor determining the mirror positions at the point
lasers whose spectral bandwidth was not high of interference.10 The interference pattern
enough. Later, the resolution could be improved obtained resembles the signal of ultrasound

2 Gede
Chapter 1: History Pardianto
of Optical (Ed.)
Biometry
THE INTRAOCULAR LENS POWER CALCULATION

A-scans, but the resolution (approximately 12 Zeiss Meditec AG) was the first commercially
m) and precision (0.3 to 10 m) is much higher. available PCI instrument introduced for
The precision depends on the coherence length anterior segment biometry purposes.14,15
of the light source: the shorter the coherence Moreover, the PCI technique was refined to
length, the higher the accuracy.1,10,11 measure distances deviated by the visual
As the results obtained with this method axis, at arbitrary angles. Applied in a fully
refer to optical distances, they need to be computerized scanning instrument, horizontal
converted to geometrical distances by dividing and vertical directions can be scanned to gain
them by the group refractive index of the topographic and tomographic images as well
traversed media (cornea, aqueous humor, lens as cross-sectional images and thickness maps
and vitreous).1 (Figure 2) shows an A-Scan of a of different fundus structures.10
myopic eye, acquired as described above. The
Optical Low Coherence Reflectometry
optical length of the eye can be read off the
(OLCR)
signal peak (33.56 mm) and the geometrical
length of the eye of (24.78 mm) can be OLCR based devices use a technology
calculated.11 similar to PCI, as they involve a Michelson

Figure 2. A-Scan acquired with PCI11

As in the IOL Master, the PCI method interferometer and provide A-scan images as
is used for AL measurement, however, central a result. They use a laser diode infrared light
corneal thickness, anterior chamber depth with a wavelength of 820 nm. The first device
(ACD) and lens thickness can also be measured introduced was the Lenstar LS900 (Haag-Streit
with high precision.12,13 The AC Master (Carl AG, Switzerland), followed by the Aladdin

Gede Pardianto
Nenning (Ed.)
M, Findl O. 3
THE INTRAOCULAR LENS POWER CALCULATION

(Topcon, Japan). All measurements, including with digital processing of signals of multiple
central corneal thickness and lens thickness, measurements. By superimposing multiple
can be obtained simultaneously, without the scans, the signal of true peaks, although each
need for realignment. There is no clinically of them low in amplitude, it is enhanced, while
relevant difference in the results of both two peaks of random background noise cancel
methods.16-18 (See also Chapter 2) each other out. With this technique, the rate of
acquisition failure could be reduced to 4.7%.19
Evolution of PCI Another approach to be used in optical
Optical biometry is preferred over biometry became available with the introduction
ultrasound biometry, as it has significantly of optical coherence tomography (OCT).
improved the accuracy of AL measurement.
However, one important drawback of OCT based biometry
conventional PCI technology as opposed to The term OCT was first introduced in
ultrasound is its failure of measurement when 1991, when low-coherence reflectometry was
it comes to dense opacities of the cornea or the further developed to obtain not only one-
lens.19 The signal-to-noise ratio (SNR), which is dimensional (A-Scan), but two-dimensional
the ratio of the interference signal amplitude (B-Scan) images.1,7,27 For this purpose, multiple
relative to the background noise amplitude, longitudinal scans were generated by an
is used to quantify the accuracy of PCI, with incorporated scanning mechanism with higher
high SNR values reflecting a higher quality speed and subsequently combined to form
of the results. The SNR should account for at a two-dimensional map.28 The opportunity
least 2.0 in order to confirm the reliability of to gain B-Scans was a major development
the measurement.20,21 Therefore, any opacity in in ophthalmic imaging. When applying the
the media traversed by the laser can impair the technology of OCT for biometry purposes, a
result, particularly dense cataracts.19 The overall longitudinal cross section through the entire
rate of SNR values below 2.0 for conventional length of the eye can be achieved, which is
PCI varies from 8% to 20%.22-25 In those cases of particularly interesting in pseudophakic eyes
acquisition failure, ultrasound biometry has to in order to measure postoperative ACD, or in
irregular cataracts, or eyes with phakic IOLs.
be performed to gain AL readings.19
In order to overcome this problem, Time-domain OCT
software and hardware upgrades of the
The first OCT devices developed used
commonly used biometers have been
time-domain detection. A beam splitter
developed.18 The first approach to increase the
splits a low-coherence light source into two
SNR was to use averaging of consecutive scans.
components, one of them being directed to the
In this method, structural elements, which
tissue sample and the other one being directed
have been hidden under the noise floor, became
to a reference mirror. The reflected and
visible by diminishing all noise variance, backscattered signals from both interferometer
including shot noise. Nonetheless, the signals arms are detected by a photodetector.28
remained low in amplitude.26 To enhance the
In time-domain Optical Coherence
signals, in a second approach, the composite
Tomography (TD-OCT), the position of the
scan was introduced in a software upgrade
reference mirror is changed during the
(version 5.0) of the IOL Master 500. This method
process and the photodetector only senses
combines averaging of consecutive scans
interferometric signals when the distance of

4 Gede
Chapter 1: History Pardianto
of Optical (Ed.)
Biometry
THE INTRAOCULAR LENS POWER CALCULATION

the two arms is the same so that the reflections available. In Swept Source OCT (SS-OCT), a
reach the detector simultaneously.27 At the Fourier transformation is applied to convert
event of interferometry, the amplitude as well the interferogram, similar to FD-OCT. A
as the corresponding position of the reference rapidly tunable narrowband swept laser is
mirror is scanned so that every interference used, which emits different wavelengths, one
peak during the scan can be associated with at a time, and therefore divides the light into a
the location of the reflections from the tissue spectrum without the need of a spectrometer.33
sample.27,28,29(p12 ff) Each laser frequency marks a unique time
delay and every time the laser is swept, a
Spectral-Domain OCT photodetector records the interferogram
In Spectral-Domain Optical Coherence generated by the light waves returning to the
Tomography (SD-OCT), first introduced in device.32 (See also Chapter 2)
2006 and also known as Fourier-Domain Whereas in TD-OCT, the acquisition
Optical Coherence Tomography (FD-OCT)
speed is limited by the modulation of the
or Frequency-Domain OCT, the position
reference arm length, in SS-OCT it only
of the reference mirror remains the same
correlates to the frequency at which the
during image acquisition. A spectrometer,
light source is swept, enabling much higher
a charge-coupled device (CCD) with an
scanning rates (40 to 110 times faster).28,30,32
array of photodetectors, is used instead of
As opposed to FD-OCT, in the setting of SS-
a photodetector. It detects all frequency
OCT the spectrum of wavelengths is not
components of the interference pattern,
detected simultaneously, but rather one single
with each photodetector being sensitive to a
wavelength after another, which avoids signal
certain range of frequencies. The location of
roll off and enhances the depth range. Hence,
the signal can be determined by analyzing
different ocular structures can be imaged at
the interference pattern, i.e. the spacing of
the same time without changing the focus
the fringes and their amplitude. The resulting
of the device.28 Furthermore, the higher
interferogram is converted to a frequency
wavelength of SS-OCT results in deeper tissue
domain spectrum by Fourier transformation.
Similar to TD-OCT, multiple A-Scans are penetration, as light scattering occurs to a
generated and combined to B-Scans.28,30,31(p261),32 smaller degree, so it is superior to SD-OCT in
cases of retinal hemorrhages, exudates or in
Swept Source SD-OCT imaging structures beyond the retinal pigment
With the introduction of the IOL Master epithelium.28,32-34 (Figure 3) shows a B-Scan
700 (Carl Zeiss Meditec AG) in 2012, the first obtained with the IOL Master 700, visualizing
swept source version of SD-OCT became the measurement of the AL.35

Figure 3. B-Scan acquired with SS-OCT35

Gede Pardianto
Nenning (Ed.)
M, Findl O. 5
THE INTRAOCULAR LENS POWER CALCULATION

Intraoperative OCT biometry. Preoperative measurements can


The main source of postoperative now be carried out with greater precision,
refractive errors are imprecisely predicted which, together with newer IOL power
values of the postoperative IOL position calculation formulae and lens designs,
or the postoperative ACD, respectively.6,36 contributes to satisfactory postoperative
Modern IOL power formulae incorporate the refractive outcomes. In the majority of cases,
so-called effective lens position (ELP), which the target refraction can be accomplished in
is the position of the implanted IOL after a range of ±0.5 Diopters (D), however, as it
surgery predicted by preoperative biometrical is still not achieved in every patient, further
measurements.37,38 However, a more precise research is still required.44
way to predict the postoperative IOL position is
to use OCT intraoperatively to measure the ACD References
of the aphakic eye.39,40 1. Drexler W, Findl O, Menapace R, Rainer G, Vass
The first intraoperative Optical C, Hitzenberger CK, Fercher AF. Partial coherence
interferometry: a novel approach to biometry in
Coherence Tomography (iOCT) device,
cataract surgery. Am J Ophthalmol. 1998;126(4):524-
introduced in 2001, was a handheld probe that
534. doi:10.1016/S0002-9394(98)00113-5.
utilized a TD-OCT system.41 Later on, both SD-
2. Fontes BM, Fontes BM, Castro E. Intraocular
OCT and SS-OCT systems were used to increase
lens power calculation by measuring axial length
measurement speed and to allow for larger
with partial optical coherence and ultrasonic
field-of-views and higher sampling densities.42
biometry. Arq Bras Oftalmol. 2011;74(3):166-170.
By providing a handheld OCT device, image
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acquisition could be accomplished in supine
3. Goto S, Maeda N, Noda T, Ohnuma K, Koh S, Iehisa I,
position as well as in sterile settings for the
Nishida K. Comparison of composite and segmental
first time, so with this development, the way
methods for acquiring optical axial length with
for iOCT was paved. However, one practical
swept-source optical coherence tomography. Sci
problem was motion induced artefacts and Rep. 2020;10(1):4474. doi:10.1038/s41598-020-
also, the method was uncomfortable as it 61391-7.
required pauses during surgery. Therefore,
4. Hitzenberger CK, Fercher AF, Juchem M.
the devices were mounted on conventional
Measurement of the axial eye length and retinal
operating microscopes and later permanently thickness by laser Doppler interferometry. In:
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allow for real-time imaging during surgery.43
5. Lee AC, Qazi MA, Pepose JS. Biometry and
Nowadays, modern iOCT systems can be intraocular lens power calculation: Curr Opin
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6. Olsen T. Sources of error in intraocular lens power
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position measured intra-operatively may be
7. Hitzenberger CK, Drexler W, Leitgeb RA, Findl O,
used in fourth-generation power formulae Fercher AF. Key Developments for Partial Coherence
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virtual ELP.38 (See also Chapter 2) Human Eye Made in Vienna. Investig Opthalmology
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important developments in the field of optical 19362.

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Chapter 1: History Pardianto
of Optical (Ed.)
Biometry
THE INTRAOCULAR LENS POWER CALCULATION

8. Ivanov AP, Chaikovskii AP, Kumeisha AA. New method cataractous eyes. Clin Ophthalmol. Published
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2 laser instruments for measuring axial length: 26. Szkulmowski M, Wojtkowski M. Averaging
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coherence tomography. Science. 1991;254(5035):1178- of the aphakic eye for intraocular lens power
1181.doi:10.1126/science.1957169. calculation. Br J Ophthalmol. 2015;99(1):7-10.
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optical coherence tomography measurements doi:10.1080/09500340.2017.1366567.

8 Gede
Chapter 1: History Pardianto
of Optical (Ed.)
Biometry
THE INTRAOCULAR LENS POWER CALCULATION

Authors:

Magdalena Nenning

Financial Disclosure: None

Oliver Findl

Financial Disclosure:

- He is a scientific advisor to Alcon, Carl Zeiss Meditec AG,


Croma, Johnson & Johnson, and Merck.

How to cite this chapter:


Nenning M, Findl O. History of Optical Biometry. In: Pardianto G, editor. The Intraocular Lens Power
Calculation. Medan: Anak Sudarti Foundation. 2022; 1-9.

Gede Pardianto
Nenning (Ed.)
M, Findl O. 9
THE INTRAOCULAR LENS POWER CALCULATION

10 Gede Pardianto (Ed.)


THE INTRAOCULAR LENS POWER CALCULATION

Chapter 2
What was Known About Biometry
and IOL Power Calculation?
Gede Pardianto

Biometry of ocular surface


Biometry is the method of applying mathematics to calculate the ideal intraocular lens power
of the eyes. The process depends upon devising mathematical terms to describe the factors that
contribute to the variations among different individuals, in order to determine the intraocular
lens power and assemble them into an equation that can yield an accurate result for the vast
majority of patients. Therefore, it relies on a collection of methods to determine each term
in the equation. Corneal Topography is the study of the shape of the corneal surface, while
the Corneal Tomography produces and evaluates a three-dimensional section of the cornea.
Corneal tomography is deployed for the examination of the anterior and posterior surfaces of
the cornea, along with corneal pachymetric mapping.1
Keratometry is an assessment of the refractive state of the anterior corneal surface and
measures the anterior radius of the corneal curvature, expressed in millimeters (mm). This is
generally translated into the more familiar Dioptric (D) power maps. In terms of keratometry,
K1 represents the flattest meridian whereas K2 represents the steepest meridian of the anterior
corneal surface. These are generally orthogonal, or close to orthogonal and if so are described
as regular, enabling the Average Corneal Power (ACP) to be determined mathematically by
(K1 + K2)/2 D.2
The White-to-White (WTW) or Horizontal White-to-White (HWTW) describes the corneal
diameter represented by the horizontal distance between the borders of the corneal limbus.3,4
Central Corneal Power (CCP) refers to the power of the cornea, found by measuring the radius
of the corneal anterior surface curvature from a central area with a predetermined diameter,
generally approximated to be 3 mm, to represent an average pupil diameter.4,5 Combined Surface
means combining the anterior and the posterior surfaces of the cornea into one hypothetical
representative surface that requires certain assumptions about the ratio of the anterior and
posterior radii of curvature. For a given ratio, the approximated representative corneal refractive
index, which is smaller than the refractive indices of the corneal material and aqueous humor, is
calculated. This approximated representative corneal refractive index differs for each Intraocular

Gede Pardianto (Ed.) 11


THE INTRAOCULAR LENS POWER CALCULATION

Lens (IOL) Power Calculation formula.6 dioptric power. Posterior cornea contributes
Previously, the standardized Refractive Index an average of about 0.3 D of against the rule
was usually taken as 1.3375, the geometric ratio astigmatism. If the surgeon only calculates
of posterior/anterior corneal curvature was the anterior surface of the cornea, it can
accepted as 0.822 and the Corneal Thickness affect the result of refractive surgery to
at 500 μm.7 correct astigmatism. Failure in calculating
Meanwhile, some calculate that the amount of posterior corneal astigmatism
the refractive index of the cornea is can result in overcorrection of eyes that have
1.3315.8 Simulated Keratometry (Sim-K) with-the-rule astigmatism (WTR) or under-
measurements characterize the corneal correction of eyes that have against-the-rule
curvatures in the central 3-mm area. It is astigmatism (ATR).10,11
obtained from the anterior corneal curvature
using the 1.3375 index.9 The steep Sim-K Biometry of the Eyeball
reading is the steepest meridian of the cornea. The Axial Length (AL or AXL) is the
The Total Corneal Refractive Power (TCRP) distance from the corneal tear film surface to
or Total Corneal Power (TCP) value is the posterior interference peak for the device
calculated by using the refractive index of air under consideration. For ultrasonography this
(1.000), cornea (1.376) and aqueous humor corresponds to the anterior retinal surface,
(1.336) using Snell's law without relying on whereas for optical biometry it corresponds
any prior assumptions. More recently, the to the retinal pigment epithelium (RPE)/
ray tracing method is performed through both Bruch’s membrane (AL-RPE).12,13 AL can also
corneal surfaces to calculate the TCRP or TCP. be defined as the linear distance between
Equivalent Keratometry Reading the corneal surface and the inner limiting
(EKR) is obtained from 1.0 to 7.0 mm corneal membrane (ILM) or AL-ILM. Since IOL Power
diameters. The EKR value at 4.5 mm was Calculation formulas were developed earlier
determined to be the most closely matched to using ultrasound, the AL-ILM, each AL-RPE
conventional K values.7-10 optical biometric measurement is converted
to an AL-ILM by subtracting the retinal
Astigmatisms are categorized
thickness, which is assumed to be 300 μm in
into corneal keratometric and internal
all eyes.13
astigmatisms. The result of the unequal
curvature along both of the two principal The Anterior Chamber Depth (ACD)
meridians of the anterior cornea generates refers to the distance between the anterior
corneal keratometric astigmatism. surface of the cornea and the anterior surface
Internal astigmatism is created by the of the lens.14,15 Previously, some journals
components of refractive astigmatism behind mentioned that ACD represents the distance
the cornea. The Total Corneal Astigmatism between the corneal endothelium and the
is meticulously measured by the sum of anterior capsule of the crystalline lens.14-16
anterior and posterior surfaces.10 The toricity However, a letter to the editor countered that
of the posterior corneal surface represents definition represents Aqueous Depth (AQD)
more than that of the anterior corneal and not the ACD, which includes the thickness
surface. The posterior surface is steeper of the cornea centrally.17,18
than the anterior one, as it has a smaller Effective Lens Position (ELP) is
radius of curvature, yielding a negative defined as the distance from the cornea to the

12 Gede
Chapter 2: What was Known About Biometry and IOL Pardianto
Power (Ed.)
Calculation?
THE INTRAOCULAR LENS POWER CALCULATION

anterior surface of the IOL 3 months after the This value at some points differs from one
surgery, plus the distance to the principal point surgeon to another. It was firstly designed as
or central point of the principal plane of the lens constant for Holladay 1 formula and now
IOL. In other words, ELP refers to the distance can be used to achieve better ELP results.22 As
from the anterior corneal vertex to the principal surgeon techniques become more and more
point of the IOL, correctly implanted, 3 months consistent over time, surgeon factors should
after surgery. The ELP is very important to have less value.
predict the postoperative IOL position within The Lens Factor (LF) describes the
the eye. ELP is crucial, because if the final IOL distance between the iris plane and the
position is closer to the cornea, it produces second principle plane of the IOL (in the thick
myopia, and if the posterior is closer to the lens model). It was firstly designed as a lens
principal point, hyperopia.18,19 Actual Lens constant for Barrett Universal formula and
Position (ALP) refers to the physical distance used together with AL and K, the LF to predict
measured from the anterior corneal surface the ELP.23
to the anterior IOL surface. Meanwhile the
The International Organization for
Internal Lens Position (ILP) is defined as
Standardization (ISO) Standard or ISO
the physical distance between the posterior
Permitted Tolerance has aided by setting
corneal surface and the anterior IOL surface.19
standards for IOL manufacturing tolerances:
The Lens Thickness (LT) is measured
a. Power 0 to <15 D, permitted tolerance is
as the distance from the anterior capsule apex
±0.3 D.
to the posterior capsule apex of the crystalline
b. Power >15 to <25 D, permitted tolerance
lens.20
is ±0.4 D.
IOL Factor in Biometry c. Power >25 to <30 D, permitted tolerance
is ±0.5 D.
IOL Factor is mostly known as the lens
constant. It is a feature used to achieve a d. Power >30 D, permitted tolerance is ±1.00
particular refractive aim by considering the D.24
IOL type, material, design, shape, and in-vivo The current standard for toric IOL from
seating in the capsular bag or other designated the American National Standards Institute is
location (AC etc.), usually around 4 to 6 weeks approved as ANSI Z80.30-2010. It regulates
after surgery. optical and mechanical properties, labeling,
The A-constant or ACD-constant lens is biocompatibility, sterility, shelf life, and
a specific value for each IOL and is unitless; clinical investigation standards for toric IOLs.
it depends on multiple variables, including the The guideline for toric IOLs:
IOL material, the refractive index, style, shape, a.
Total dioptric spherical power and
and the predicted position of the lens within cylindrical power error should be less than
the eye. It was firstly designated as the A lens or equal to 0.30 to 0.50 D for most power
constant for the Sanders-Ritzlaff-Kraff (SRK) ranges.
formula, specified by manufacturer, and used b. The combined angular error of the toric
in order to achieve higher rates of accuracy.21 marks and the orthogonality between
The Surgeon Factor (SF) is the specific meridians of toricity should be 5º or less.
distance from the pseudophakic anterior iris c. The rotational stability of a toric IOL is a
plane to the principal plane of the thin IOL. change of 5º or less in rotation for at least

Gede Pardianto
Pardianto G. (Ed.) 13
THE INTRAOCULAR LENS POWER CALCULATION

90% of eyes on consecutive visits spaced at The No-History method is a viable


least 3 months apart.25 alternative for performing IOL Power
Calculation after myopic LASIK when
Innovation and Engineering in Biometry the patient’s refractive surgery data is not
Ray tracing is a method for calculating available.31
the path of a single ray of light through a given Artificial Intelligence (AI) leverages
optical system. As a ray passes through an computers and machines to mimic the
optical system, starting at a given point and problem-solving and decision-making
at a specified angle relative to the system's capabilities of the human mind.32 Artificial
optical axis, it is refracted at each optical “know-how” refers to science and engineering
surface, causing the ray to change direction.26,27 which allow the manufacturing of intelligent
In terms of ray tracing, a Paraxial Ray is a ray machines to understand and mimic human
which is close to the optical axis of the system. intelligence.33 AI is the cutting-edge technology
Alternatively, a Real Ray or “finite ray” means and engineering-based statistical model to
a ray that is traced without requiring paraxial solve problems. It will become progressively
approximation.28 important in the future.
The C-constant refers to the ratio
of the distance between the center of Types of Biometry (See also Chapter 1)
IOL and the preoperative anterior lens capsule The Ultrasonographic (USG) Biometry
relative to the preoperative crystalline lens or Ultrasound Biometry plays an important
thickness. It is useful to predict the IOL position role in IOL Power Calculations. It uses an
or ELP from the preoperative dimension and ultrasonic scanning mode display (A-Scan or
position of the natural crystalline lens, where Amplitude Mode Scan/Display) that gives
the empty capsular bag will encapsulate and a 1 (one) dimensional measurement, such as
fixate an in-the-bag implanted IOL. In other AL,34 and B-Scan or Brightness Mode Scan/
words, the C-constant is related to where Display display that gives a two dimensional
exactly in empty capsular bag the IOL will image.34,35 B-Scan plays important role in the
rest.29 IOL Power Calculation in eyes with AL greater
Total Keratometry (TK) is a tool that than 26 mm.
combines the unique telecentric keratometry USG Biometry is enhanced by using
measurement of the anterior corneal surface the immersion technique that is defined
with the measurement of the posterior corneal as a technique where an ultrasound probe
surface.4 is firmly fixated in a shell that is filled with a
Central Topography is a tool that takes balanced salt solution. It provides A-Scan
the anterior refractive powers to evaluate measurement to be taken through the shella
the corneal topography, and to detect any water bath, instead of touching the cornea
visually relevant central corneal asymmetries directly, thereby eliminating typically 0.14 to
by averaging the topographic data of 3.4 – 5.4 0.28 mm corneal compression that occurs with
mm diameter of central cornea with 3-zone the contact or applanation technique and can
keratometry on corneal radii of 6 – 11 mm. lead to erroneous measurements, because the
Meanwhile, the Average Central Corneal compression applied by different technicians
Power (ACCP) is defined as the average of the to different patients is variable, and therefore
mean powers of the central cornea.4,9,30 cannot be mathematically accounted for. For

14 Gede
Chapter 2: What was Known About Biometry and IOL Pardianto
Power (Ed.)
Calculation?
THE INTRAOCULAR LENS POWER CALCULATION

optimal ultrasonic Biometry, surgeons should will be the goal for most patients and surgeons,
use the immersion vector A/B-scan technique to however some may benefit from being left
measure the refractive AL.36 (See also Chapter 1) intentionally mild myopic post-operatively
The Optical Biometry refers to rapid (or, rarely, hypermetropic), depending on
and highly accurate measurement method patient’s preference and the refraction of the
using automated non-contact and non-invasive fellow eye. Anisometropia should be arranged
technology.37 below 3D. The mono vision or intentional
post-operative anisometropia can eliminate
a. Partial Coherence Interferometry (PCI)
the need for glasses after surgery, but should
is a kind of instrument that measures AL as
be well explained to the patient in advance of
the distance from the anterior corneal apex
surgery, presenting all options to the patient
to the retinal pigment epithelium. PCI uses
and generally should be less than 3 D.43
a 780-820 nm wavelength infrared laser to
measure AL.37,38 PCI in the market includes Target refraction in terms of Spherical
IOL Master 500 (Carl Zeiss), ALScan Aberration (SA) is a bit argued. SA happens
(Nidek), and Pentacam AXL (Oculus). when incoming light rays end up focusing
at different points after passing through a
b. Swept-Source Optical Coherence
spherical lens. Positive spherical aberration
Tomography (SS OCT) uses a 1050-
has more optical power away from the optical
1070 nm wavelength swept-source to collect
axis to the periphery. Negative spherical
cross-sectional images of the entire eye.
aberration has less optical power away
The system deploys three OCT images
from the optical axis toward the periphery.44
to measure AL and ACD for every single
Spherical aberration causes a dysphotopic halo
calculation.38,39 SS OCT in the market
or a blurry image. Based on SA, the IOL Power
includes IOL Master 700 (Carl Zeiss),
Calculation should be well tuned and expected
ANTERION (Heidelberg), ARGOS (Movu),
residual SA should be carefully calculated:
Eyestar 900 (HaagStreit), and CASIA2
(Tomey). a. If SA is 0 (zero), target refraction is plano or
zero D.
c. Optical Low Coherence Reflectometry
(OLCR) is a kind of technology based on b. If SA is positive, target refraction is
interferometry which is engineered to -0.25 D for every 0.10 μm of SA.
detect and localize reflectors with an 820 c. If SA is negative, target refraction is +0.25
nm wavelength super-luminescent diode to D for every 0.10 μm of SA.45
measure AL.40 OLCR in the market includes Surgery-Induced Astigmatism or
Lenstar LS900 (HaagStreit), Aladdin Surgically-Induced Astigmatism (SIA)
(Topcon), and Galilei G6 (Zeimer). (See also refers to astigmatism that is generated as the
Chapter 1) result of surgery. SIA relates to the incision
width as the main factor, and also depends
Result of surgery upon the length, type, location, and structure
Target Refraction represents the of the incision, etc. It influences the refractive
desired refractive result of surgery in order outcome.46
to achieve best uncorrected visual acuity Residual Astigmatism (RA) refers to
for distance vision, intermediate vision and astigmatism that remains after an astigmatism
reading vision.41. Some surgeons call it Desired correcting surgery. RA can be caused by
Refraction.42 Emmetropia or zero D correction incorrect axis or rotation of a toric IOL, incorrect

Gede Pardianto
Pardianto G. (Ed.) 15
THE INTRAOCULAR LENS POWER CALCULATION

marking of the cornea, inaccurate preoperative ELP as even greater variable in IOL Power
biometry and IOL measurements, unanticipated Calculation
SIA, uncalculated posterior corneal curvature, Previously, before the 1980s, in the First
etc. Small rotational misalignments can cause Generation formulas, the ELP was A-constant
large amounts of residual astigmatism.47 value of 4 mm in every patient and every IOL,
Spherical Equivalent (SE) refers to a including Anterior Chamber IOL (AC IOL).
spherical power that is calculated by adding In the 1980s, the Second Generation formulas
the spherical (myopic or hypermetropic) used AL, a single variable predictor, as a scaling
error and 1/2 the cylindrical (astigmatism) factor to determine the ELP. In 1988, the Third
components of patient’s refractive error.48 Generation formulas incorporated two variable
predictors, AL and K to improve the accuracy
AL as main variable in IOL Calculation of the scaling factors of ELP. In 1995, the Fourth
AL plays an important role in the Generation formulas ELP had been improved
accuracy of IOL Power Calculation. A cohort by adding two more variables, pre op ACD and
study reported that the average AL in normal LT. Some newest formulas add more factors
eye increases from 16.8 in infant to 23.6 mm such as gender, Central Corneal Thickness
in adult.49 (CCT), etc. to determine ELP by using AI.53-55
Associated with ELP, the anterior shift of
What was known? IOL position increases myopia. If the surgeon
By measuring the right value of AL, decides to place the IOL in-the-sulcus during
commonly in normal adult eyes, surgeons surgery, IOL Power reduction may be needed
may choose any formulas to calculate the due to the anterior displacement of the IOL
right IOL Power to gain the best result. The relative to the plan. For example:
IOL Power Calculation formulas that may be a. Below 9 D, it may be reduced by 0 D.
accurate based on AL are (See also Chapter 3
b. 9.5-17 D, it may be reduced by 0.5 D.
and 4):
c. 17.5-27 D, it may be reduced by 1 D.
a. For AL <20 mm: Hoffer Q, and Holladay 2.
d. 27-35 D, the power may be reduced by 1.5
b. For AL 20-22 mm: Hoffer Q.
D.30 (See also Chapter 5)
c. For AL 22–24.5 mm: Holladay 1, Hoffer Q,
and SRK/T.
Why do things go wrong?
d. For AL 24.5-26 mm: Holladay 1.
So many factors lead to wrong results
e. For AL >26 mm: SRK/T. 50-52 including instruments error, index of
refraction error, and formula error. The
What if the AL measurement goes wrong? other factors are usually correlated with the
The role of AL is so important, because combination of human factors (technician or
every 1 mm error in AL measurement can patient), and technical factors, such as: people
impact postoperative refraction: in a hurry, lack of training, lack of accessible
a. Above 30 mm AL can miss 1.75 D per 1 mm guidelines, fatigue, a patient with dry eye or
b. 20-30 mm AL can miss 2.35 D per 1 mm many other eye abnormalities, lack of fixation,
mechanical failure of instrumentation, wrong
c. Below 20 mm AL can miss about 3.75 D per
A-constant selected, wrong formula used,
1 mm.50
wrong K-readings entered by hand (90 degrees

16 Gede
Chapter 2: What was Known About Biometry and IOL Pardianto
Power (Ed.)
Calculation?
THE INTRAOCULAR LENS POWER CALCULATION

out), biometry print-out stuck in wrong refine it intra operatively or postoperatively.


patient's notes, incorrectly labeled IOL, wrong In order to do “successful one step surgery”,
patient in theater, reversed IOL optic, wrong we need to do IOL Power Calculation
IOL implanted (for example: 25.5 D implanted thoroughly.65,66
instead of 22.5 D or 30 D instead of 3.00 D),
the required IOL Power not available on the The calculation should be verified by two
surgery day, etc.43 separate instruments in all cases, but
especially if:
Challenging cases a. The corneal power is less than 41.00 D, or
Some challenging cases lead to missed greater than 47.00 D.
refractive targets. Some cases could be b. There is history of previous keratorefractive
resolved by using new Biometry machines surgery.
and latest IOL Power Calculation formulas,
c. The ACP between two eyes is more than
such as: Double K Modification,56 Hoffer
0.09 D.
Double AL, SRK/Tcorrected K, Haigis L, Shammas
PL, Barrett True K, Barrett Toric, Barrett True d. The patient is not able to fixate adequately
K Toric, Barrett Rx, Abulafia-Koch, Olsen e. Corneal astigmatism is greater than 2.50 D.
(PhacoOptics), Kane, Emmetropia Verifying f. Corneal diameter is less than 10.75 mm or
Optical (EVO), Ladas AI, Hill’s Radial Basis more than 13.00 mm.
Function (Hill-RBF), Clarke Neural Network, g. The patient has a problem in cooperation
Panacea, T2, Telomere Restriction Fragments or understanding.66
(TRF), Kristian Naeser 2, Sramka, Pearl
formula from Debellemanière, Gatinel, and A second person should re-measure both
Saad (PEARL-DGS), Maloney, Wang-Koch- eyes if:
Maloney, Masket, and by add TK in some
a. The AL is less than 21.30 mm, or greater
formulas. 31,54,57-61,62 (See also Chapter 3-7)
than 26.60 mm in the fellow eye.
The Holladay IOL Consultant Program,
b. The AL is greater than 26.00 mm, and there
The ASSORT Toric Calculator, The Alcon
is a poor retinal spike or wide variability in
Calculator, The Barrett Toric Calculator,
the readings. In this case, a B-scan should be
The Toric Results Analyzer Calculator, and
performed to seek a peripapillary posterior
the Tecnis Toric Calculator play a key role
staphyloma. Simultaneously, the AL to the
in calculation of toric IOL power.11 (See also
center of the macula should be measured
Chapter 3 and 6)
by vector A-scan.
In other challenging situations, we may
c. The AL difference between the two eyes
need to perform Intraoperative optical
greater than 0.33 mm that is not correlated
refractive Biometry, intraoperative OCT
with the patient's oldest refraction.
(iOCT), Intraoperative aberrometry for IOL
power estimation and without K and AL using d. The AL measurement of one eye does not
Optical Retinoscopy.63,64(See also Chapter 1) correlate with the patient's refractive error.
This may be caused by very steep or flat
Special attention corneas.
IOL Power Calculation is a long journey. e. There’s a wide variability in individual AL
We need to do it preoperatively, and sometimes readings obtained.65,66

Gede Pardianto
Pardianto G. (Ed.) 17
THE INTRAOCULAR LENS POWER CALCULATION

A second person should repeat the AL distance vision and the other eye is focused
measurements, the keratometry readings, at near with -0.75 to -1.75 D of myopia. -1.50
and re-perform the IOL Power Calculations D is the mode. This technique is a low-cost
for both eyes, if: option for patients who would like to reduce
a. The difference of the IOL Power for dependence on spectacles post-operatively.69
target emmetropia is greater than 3.00 D f. Many surgeons tend to use the SRK/T
compared to the anticipated value. formula for AL >21.5 mm, and the Hoffer
b. The IOL Power difference between the two Q formula for AL <21.5 mm previously,
eyes is greater than 1.00 D. and recently many surgeons tend to use
the Haigis formula.
c. The patient had prior keratorefractive
surgery with the calculated IOL Power is g. In everyday practice, many surgeons tend to
less than +17.00 D or greater than +23.00 use SRK/T formula as well in case of myopic
D.65 long eye. (See also Chapter 5)
h.
In case of flat cornea after myopic
Some previous surgeons’ suggestions in keratorefractive surgery, some surgeons may
IOL Power Calculation use SRK/Tcorrected K, Haigis L, and Shammas PL
At some points, different cases need a formulas.70 (See also Chapter 5)
particular approach. Here are some known i. In the use of extended depth-of-focus
approaches that were previously used: (EDOF) IOL, especially after previous
a. In cases of sulcus fixated IOL or anterior keratorefractive surgery, Haigis L, and
chamber IOL, some IOL Power Calculation Shammas PL may be among the most
adjustments are needed. (See ELP in this considerable formulas.62
chapter above) j. In pediatric cases, 60-75% undercorrection
b. In the implantation of Anterior Chamber had ever been recommended. The younger
IOL (AC IOL), the appropriate A-constant the age, the greater is the undercorrection.
is used along with SRK, or SRK II formulas. Therefore, undercorrection has to be done
Other formulas to consider are Binkhorst II with care, especially in unilateral cases.
and Colenbrander-Hoffer.67 Greater undercorrection tends to lead to
c. Changing IOL with different lens constant anisometropia and amblyopia.
to different place in the eye requires a k. Some surgeons use a simple rule of thumb
change of IOL Power. For example, from a to gain target refraction in pediatric case as:
one-piece in-the-bag IOL with 118.80 lens Target refraction = 7 – age (in year)
constant to an anterior chamber IOL with l. Use of Hoffer Q, Holladay 1, and SRK/T
115.50 lens constant, requires a change of formulas may be better than SRK, and SRK
IOL Power of -3.30 D.68 (See Lens Constant in II in pediatric IOL Power Calculation.51,71
this Chapter above)
m.Extensive research has shown that Olsen,
d. A little bit myopia may be more desirable Holladay 2, and Barrett Universal II (BUII)
for patients after cataract surgery than a have the finest overall ±0.50 D outcomes
little bit of hypermetropia. accuracy in multifocal IOL implantation.
e.
Pseudophakic monovision or mini- For patients receiving a multifocal IOL, it
monovision is an option that may correct may be highly recommended to consider
a dominant eye with target refraction 0 D using one of these three formulas.72,73

18 Gede
Chapter 2: What was Known About Biometry and IOL Pardianto
Power (Ed.)
Calculation?
THE INTRAOCULAR LENS POWER CALCULATION

n. The difference in the AL between eyes 3. Hoffer KJ. Clinical results using the Holladay 2
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Eventually, the surgeon needs to replace
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2020;48(6):749-756. doi: 10.1111/ceo.13760.
some reasons why the surgeon should consider
PMID:32279436.
buying a newer biometer:
5. Sónego-Krone S, López-Moreno G, Beaujon-Balbi
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6. Preussner PR, Olsen T, Hoffmann P, Findl O.
d. Need of avoiding some risks of error
Intraocular lens calculation accuracy limits in normal
(including transcription errors for online
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Study. Am J Ophthalmol 2013; 156: 1252–1260.e2. Assessment of the accuracy of new and updated
doi: 10.1016/j.ajo.2013.07.014. Epub 2013 Sep 4. intraocular lens Power Calculation formulas in
PMID: 24011524; PMCID: PMC4140419. 10930 eyes from the UK national health service.
52. Vasavada V, Shah SK, Vasavada VA, Vasavada AR, J Cataract Refract Surg. 2020; 46(1): 2-7.doi:
Trivedi RH, Srivastava S, et al. Comparison of IOL 10.1016/j.jcrs.2019.08.014. PMID: 32050225.
Power Calculation formulae for pediatric eyes. Eye. 61. Yeo TK, Heng WJ, Pek D, Wong J, Fam HB. Accuracy
2016;30:1242-1250. doi: 10.1038/eye.2016.171. Epub of intraocular lens formulas using total keratometry
2016 Aug 5. PMID: 27494083; PMCID: PMC5023817. in eyes with previous myopic laser refractive
53. Martinez-Enriquez E, Pérez-Merino P, Durán-Poveda S, surgery. Eye (Lond). 2021;35(6):1705-1711. doi:
Jiménez-Alfaro I, Marcos S.  Estimation of intraocular 10.1038/s41433-020-01159-5. Epub 2020 Aug 31.
lens position from full crystalline lens geometry: PMID: 32868880; PMCID: PMC8169843.
towards a new generation of intraocular lens Power 62. Lwowski C, Pawlowicz K, Hinzelmann L, Adas M,
Calculation formulas. Sci Rep. 2020;8:9829. doi: Kohnen T. Prediction accuracy of IOL calculation
https://doi.org/10.1038/s41598-018-28272-6. formulas using the ASCRS online calculator
54. Xia T, Martinez CE, Tsai LM. Update on Intraocular for a diffractive extended depth-of-focus IOL
Lens Formulas and Calculations. Asia Pac J after myopic laser in situ keratomileusis J
Ophthalmol (Phila). 2020;9(3):186-193. doi: Cataract Refract Surg. 2020;46(9):1240-1246.
10.1097/APO.0000000000000293. PMID: doi: 10.1097/j.jcrs.0000000000000238. PMID:
32501896; PMCID: PMC7299214. 32379087.
55. Olsen T, Corydon L, Gimbel H. Intraocular lens 63. Ianchulev T, Salz J, Hoffer K, Albini T, Hsu H, Labree
Power Calculation with an improved anterior L. Intraoperative optical refractive Biometry for
chamber depth prediction algorithm. J Cataract intraocular lens power estimation without axial
Refract Surg. 1995;21:313-319. doi: 10.1016/ length and keratometry measurements. J Cataract
s0886-3350(13)80140-x. PMID: 7674170. Refract Surg. 2005 Aug;31(8):1530-6. doi: 10.1016/j.
56. Aramberri J. Intraocular lens Power Calculation jcrs.2005.01.035. PMID: 16129287.
after corneal refractive surgery: Double K method. J 64. Prager TC, Hardten DR, Fogal BJ. Enhancing intraocular
Cataract Refract Surg 2003; 29(11): 2063-2068. doi: lens outcome precision: an evaluation of axial length
10.1016/s0886-3350(03)00957-x. PMID: 14670413. determinations, keratometry, and IOL formulas.
57. Yagi-Yaguchi Y, Negishi K, Saiki M, Torii H, Tsubota K. Ophthalmol Clin North Am. 2006;19(4):435-48. doi:
Comparison of the Accuracy of Newer Intraocular Lens 10.1016/j.ohc.2006.07.009. PMID: 17067899.
Power Calculation Methods in Eyes That Underwent
65. Knox Cartwright NE, Johnston RL, Jaycock PD, Tole
Previous Phototherapeutic Keratectomy. J Refract
DM, Sparrow JM. The Cataract National Dataset
Surg. 2019;35(5):310-316. doi: 10.3928/1081597X-
electronic multicentre audit of 55,567 operations:
20190410-01. PMID: 31059580.

22 Gede
Chapter 2: What was Known About Biometry and IOL Pardianto
Power (Ed.)
Calculation?
THE INTRAOCULAR LENS POWER CALCULATION

when should IOLMaster biometric measurements be 70. Fang X, Ben S, Dong Y, Chen X, Xue W, Wang Y. Outcomes
rechecked? Eye. 2010;24(5):894-900. doi: 10.1038/ of the Haigis-L formula for calculating intraocular lens
eye.2009.196. Epub 2009 Aug 14. PMID: 19680278. power in extreme long axis eyes after myopic laser in
66. Zaldivar R, Schultz M, Davidori J. Intraocular lens situ keratomileusis. Eye. 2021;6(11). doi: 10.1097/j.
calculation in patients with extreme myopia. jcrs.0000000000000238. PMID: 32379087.
J Cataract Refract Surg. 2000;26:668-674. doi: 71. Nihalani BR, VanderVeen DK. Comparison of
10.1016/s0886-3350(00)00367-9. PMID: 10831895. intraocular lens power calculation formulae in
67. Villada JR, Raj PS, Akingbehin T. Calculation of pediatric eyes. Ophthalmology. 2010;117(8):1493-
the power of anterior chamber implants. Br J 9. doi: 10.1016/j.ophtha.2009.12.031. Epub 2010
Ophthalmol. 1992;76(5):303-6. doi: 10.1136/ May 13. PMID: 20466430.
bjo.76.5.303. PMID: 1390516; PMCID: PMC504263. 72. Hill WE. Nailing the Power Calculation for Multifocal
68. Lahood B. The Lens Constant. Cataract Refract Surg IOLs. Cataract Refract Surg Today. 2014;10:54-55.
Today. 2021;6:64-66. 73. Hill WE. Something borrowed, something new:
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PMCID: PMC6230294. (Asia-Pacific). 2021;17(4):9-11.

Author:
Gede Pardianto

Financial Disclosure: None

How to cite this chapter:


Pardianto G. What was known about biometry and IOL Power Calculation? In: Pardianto G, editor. The
Intraocular Lens Power Calculation. Medan: Anak Sudarti Foundation. 2022; 11-23.

Gede Pardianto
Pardianto G. (Ed.) 23
THE INTRAOCULAR LENS POWER CALCULATION

24 Gede Pardianto (Ed.)


THE INTRAOCULAR LENS POWER CALCULATION

Chapter 3
Intraocular Lens Power
Calculation Formulas
Giacomo Savini

In the last decade an increasing number of formulas have been introduced in order to improve the
accuracy of intraocular lens (IOL) power calculation. Until around 2015, most ophthalmologists
around the world still relied on the formulas developed in the late Eighties and early Nineties,
the so-called “third generation” formulas, such as the Haigis,1 Hoffer Q,2 Holladay 1,3 Holladay
2 (unpublished) and SRK/T formulas.4 All these formulas should be more properly classified
as “vergence formulas”.5 They are based on the thin-lens model, where both the cornea and
the IOL are considered infinitely thin diopters and the predicted position of the IOL, known as
effective lens position (ELP), does not correspond to the physical distance between the IOL and
the cornea,6 but as the distance between the principal planes of the cornea and the IOL. These
formulas share the structure originally and separately described by Fyodorov and Gernet and
differ mainly in the method adopted to predict the IOL position.7,8 Minor differences can also
be found in the way they calculate the corneal power from corneal curvature and handle the
retinal thickness.
Thereafter, a series of studies demonstrated the newer formulas can provide more accurate
results.9-11 This chapter aims to describe the older and newer formulas. They can be classified
into 4 main categories:5
1) Vergence thin-lens formulas: these are based on Gaussian optics and refer to seminal
articles by Fyodorov and Gernet.7,8 They consider all diopters (cornea and IOL) as infinitely
thin and contain two main equations: one to predict the IOL position and one to calculate the
vergence of the light rays from the cornea to the IOL and from the IOL to the retina. The main
difference lies in the method used to predict the IOL position, whereas minor differences
are related to the method to calculate the corneal power and consider the retinal thickness.
Examples include the Haigis, Hoffer Q, Holladay 1, Holladay 2, K6, Panacea, SRK/T, T2 and
VRF formulas.
2) Vergence thick-lens formulas: these are similar to the previous group of formulas, but
do not consider all diopters as infinitely thin. Examples are Castrop, EVO 2.0 and Næser 2
formulas.

Gede Pardianto (Ed.) 25


THE INTRAOCULAR LENS POWER CALCULATION

3) Ray-tracing formulas: these are based on is available for free at https://calc.apacrs.


a totally different approach, which traces org/barrett_universal2105/ (accessed on
the rays through each diopter using Snell’s September 3rd, 2021) and uses axial length
law and the refractive index of the cornea, (AL), keratometry (K), anterior chamber
the aqueous, the IOL and the vitreous. They depth (ACD, measured from epithelium to
can be further classified as paraxial ray- lens) to predict the IOL position; LT and
tracing formulas (e.g. Barrett Universal CD can be entered optionally. In several
II and Olsen) and exact ray-tracing (e.g. studies it was ranked among the most
Okulix). accurate formulas.
4) Artificial intelligence (AI) formulas: • Castrop IOL formula: this is a new thin-
many formulas include elements of AI. lens formula based on the above-mentioned
Although a clear distinction is difficult, vergence approach by Fyodorov and Gernet.
because in most cases these formulas are Its main features are 1) the adoption of a
unpublished and it is impossible to obtain thick-lens model for corneal power, which is
detailed information, they can be further not calculated with the usual keratometric
classified on formulas entirely based on AI, index, but is obtained entering the anterior
such as the RBF 2.0, and formulas that use and posterior corneal radii and corneal
AI to estimate some parameters, such as thickness into the Gaussian optics formula;
the position of the IOL. The latter include 2) the prediction of the physical position
the Hoffer QST and PEARL-DGS. Kane of the IOL according to a multiple linear
and Ladas formulas may also be grouped regression including AL, CCT, aqueous
into AI formulas, but the role of AI here is depth (AQD) and LT; 3) the adjustment of
unknown. AL according to the method published by
Cooke et al. (Cooke Modified Axial Length,
IOL calculation formulas CMAL).14 The details of the formula have
• Barrett Universal II (BUII) formula: this been fully published.15
formula is the evolution of the Barrett • Emmetropia Verifying Optical (EVO)
Universal I, which was published in 1987 formula: this is an unpublished thick-lens
as a thick-lens paraxial formula.12,13 The formula developed in Singapore by Tun
BUII is essentially based on the same Kuan Yeo, MD. Version 2.0 is available at
concept, although several modifications www.evoiolcalculator.com (accessed on
have been introduced over the years. These September 3rd, 2021) and uses AL, K, and
included using data to predict the radius ACD as the predictors (LT and central
of the globe as alluded to in the original corneal thickness (CCT) are optional). An
article rather than an empirical method. increasing number of studies reported its
Later on, lens thickness (LT) and corneal high accuracy.
diameter (CD) were added. The formula, • Haigis formula: this a classical thin-lens
whose name changed into BUII in 2013, is vergence formula,1 whose main difference
unpublished, so that little is known about lies in the fcat that the ELP is predicted from
its structure. Although Koch et al. listed the ACD and AL, rather than on the K and AL
it among vergence formulas,5 the BUII (for this reason, in post-LASIK eyes it does not
is based on paraxial ray tracing (Graham suffer from the ELP error and does not need
Barrett, personal communication, 2019). It any Double-K adjustment). Moreover, it has 3

26 Chapter 3: Intraocular Lens PowerGede Pardianto


Calculation (Ed.)
Formulas
THE INTRAOCULAR LENS POWER CALCULATION

constants (a0, a1 and a2), which are obtained allows the user to download specified Excel
from multiple linear regression among spreadsheets to populate with their data,
the optimized ELP, the ACD and the AL. upload it to the site and receive multiple
Optimization of all 3 constants is mandatory simultaneous calculation or Hoffer QST
to take full advantage of this formula. lens constant (pACD) optimization.19
• Hoffer Q formula: this is the most • Holladay 1 formula: Published in 1988,3
important formula developed by Dr. Hoffer this formula was the first thin-lens vergence
and represents the evolution of the original formula to use the corneal height formula
Hoffer formula developed in the Seventies.2 of Fyodorov to estimate the postoperative
Like other vergence formulas, it predicts ACD, based on K and AL. In addition, it
the ELP from the preoperative K and AL. introduced a specific constant, the Surgeon
However, the peculiarity of the Hoffer Q Factor (SF), which estimates the distance
formula is that it uses the tangent of the between the iris plane and the IOL. Taken
corneal power to predict the IOL position, together, the estimated postoperative ACD
rather than the corneal height formula of and the SF provide the ELP. Over the years,
Fyodorov.7 For more than 20 years it has several papers have demonstrated its
been the benchmark for comparison when accuracy, mainly in medium and medium-
calculating the IOL power in eyes shorter long eyes. For eyes longer than 25 mm,
than 22 mm.1,16,17 Holladay introduced a polynomial AL
• Hoffer QST formula: this is the last adjustment in 2019.20
evolution of the Hoffer Q formula and • Holladay 2 formula: In 1996, Holladay
addresses two of its limitations: the lack came out with the unpublished Holladay
of the preoperative ACD as a predictor 2 formula, which uses seven biometric
of the ELP and the fair performance in variables and was designed to get the best
long eyes. The former problem, which accuracy in all ranges of AL. There are few
was responsible for the myopic surprises published studies reporting the results with
in eyes with shallow ACD,10,18 has been the Holladay 2; however, Hoffer showed
solved with machine learning, a kind of in 2000 that the Holladay 2 was equally as
artificial intelligence that provides us with accurate as the Hoffer Q in eyes shorter
a non-linear regression model. A new than 22 mm, and that it was less accurate
ELP prediction, based on K, AL, ACD, than the Holladay 1 in eyes between 22 and
corneal radius and gender, was developed, 26 mm.16 In 2019, an updated version that
so that the “ULIB pACD Constant” of the includes AL adjustment for eyes longer
original Hoffer Q formula can still be than 25 was released.20
used. The latter problem was solved with a • Kane formula: this is another unpublished
customized non-linear AL adjustment. The formula, which was developed by Jack
Hoffer QST formula calculator is available X Kane, MD. According to its author, it is
for free at www.HofferQST.com or www. based on theoretical optics and contains
EyeLab.com (accessed on September 3rd, some elements of artificial intelligence,
2021) and includes the Naeser/Savini but its structure is largely unknown. The
Toric calculator with a complete printout formula is available at www.iolformula.com
for the chart or electronic medical record. (accessed on September 11th, 2021) and uses
There is a “Research” section at the top that AL, K, ACD, and gender to predict the IOL

Gede G.
Savini Pardianto (Ed.) 27
THE INTRAOCULAR LENS POWER CALCULATION

position, with LT and CCT being optional is based on exact ray-tracing calculations
factors. An increasing number of studies and can be installed on several corneal
have reported excellent outcomes with this topographers or tomographers. As a unique
formula. A specific version for keratoconus feature, Okulix contains the physical data
eyes is also available. (vertex radii, central thickness, refractive
• K6 formula: this is a thin-lens formula index) of most IOL models available on
developed by David Cooke, MD, and the market. It calculates the IOL power
available at https://cookeformula.com which gives the best focus, i.e. the smallest
(accessed on September 18th, 2021). The ELP simulated image of a Landolt C on the
is predicted with thick-lens calculations, fovea, and takes pupil diameter and corneal
the AL is modified to simulate sum-of- asphericity into account. The IOL position
segment AL (Cooke Modified Axial Length, is mainly predicted from the AL.24
CMAL),14 and six parameters (Ks, ACD, LT, • Olsen C formula: the Olsen formula has
AL, CD, and CCT) are required to calculate undergone several refinements over the last
the IOL power. three decades. It was originally described
• Ladas Super Formula: this method was in 1987,25 and was then updated in
originally developed as a combination subsequent years,26,27 until the last version,
of the Hoffer Q, Holladay 1, Holladay which is based on paraxial ray-tracing and
2 (with Wang-Koch adjustment for AL the C constant concept,28 which predicts
adjustment) and SRK/T formulas.21 Based the IOL position only from the preoperative
on a three-dimensional model, it aimed to measurements of ACD and LT. The formula
choose the best formula for each eye. In can be downloaded at www.phacooptics.net
2019, the formula was updated using the (accessed on September 18th 2021). Actually,
postoperative data of more than 4,000 eyes PhacoOptics software offers two options to
and is now based on artificial intelligence estimate the position of the IOL: by default,
(Ladas Super Formula AI), available at four predictors are used for this purpose
www.iolcalc.com (accessed on September (AL, K, ACD and LT), as in the earlier
versions of this formula; however, AL and
11th, 2021).
K can be omitted from the prediction, so
• Næser 2 formula: this is a thick-lens
that the C constant approach is adopted.
formula developed by Kristian Næser, MD.
For this reason, two versions of the Olsen
The original Næser 1 formula was based
formula are described in the literature: the
on the manufacturer’s cutting-card for the
former is the 4-factor version, also known
front and back curvatures of the IOL.22 The
as Olsenstandalone, the latter, based on the C
Næser 2 formula uses calculated data for
constant, is the 2-factor version and is the
the IOL architecture. AL measurements are
one installed on optical biometers. Like all
optimized so that the refractive outcomes
methods based on a thick-lens approach
are equally good in short, medium and long
(e.g. Næser 2 and Okulix), this is the one
eyes. According to the author, the refractive
of the few formulas which predicts an IOL
outcomes are as accurate as those obtained position that corresponds to the physically
with the BUII formula.23 measured distance between the cornea and
• Okulix formula: this software (Panopsis the IOL. Several studies reported the high
GmbH, Mainz, Germany), which has been refractive accuracy of both versions of the
developed by Prof. Paul Rolf Preussner, PhD, Olsen formula.

28 Chapter 3: Intraocular Lens PowerGede Pardianto


Calculation (Ed.)
Formulas
THE INTRAOCULAR LENS POWER CALCULATION

• Panacea formula: this (unpublished) formulas, based on paraxial physiological


formula was developed by David Flickier, optics, were more accurate than regression-
MD, of Costa Rica, and is available at derived formulas, especially in short and
www.panaceaiolandtoriccalculator.com long eyes. It uses K and AL to predict the
(accessed on September 18th 2021). It is the IOL position and the famous A-constant
only thin-lens formula enabling surgeons to optimize the results. For thirty years it
to enter the corneal asphericity (Q-value) has been the benchmark for comparison in
and the ratio between the anterior and eyes longer than 26 mm.
posterior corneal curvature, which should • T2 formula: this a modification of the
improve the refractive accuracy. original SRK/T, described by Richard M
• PEARL-DGS formula: this formula, whose Sheard, MD, et al. in 2010.30 The main
abbreviation stands for Postoperative purpose of the authors was to correct a non-
spherical Equivalent prediction using physiological behavior of the corneal height
ARtificial intelligence and Linear algorithms, prediction (so-called “cusp phenomenon”),
has been developed by a team of French which occurs for particular combinations
ophthalmologists (G. Debellemanière, D. of AL and K that lead the SRK/T to take
Gatinel, and A. Saad), who relied on thick- the square root of a negative number.31 A
lens equations, sum-of-segments AL and new corneal height formula was developed
artificial intelligence.29 Several parameters to eliminate the cusp. The refractive
are used to predict the position of the IOL, outcomes reported by several studies have
such as the corneal anterior radius, AQD, LT,
confirmed the accuracy of this formula.
CCT and corneal diameter. The formula is
• VRF formula: this a theoretical thin-lens
available www.iolsolver.com (accessed on
vergence formula, developed by Oleksiy
September 18th 2021).
Voytsekhivskyy, MD.32 The IOL position
• RBF Calculator (Radial Basis Function): this
is predicted from AL, K, ACD and CD
was the first IOL power calculation method
with a specific equation based on several
based solely on artificial intelligence.
regression models. Compared to standard
It is available at www.rbfcalculator.com
vergence formulas, the results reported by
(accessed on September 18th, 2021) and
the author are good.
is installed on the Lenstar (Haag-Streit,
Switzerland). Version 2.0 is based on more
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Author:

Giacomo Savini

Financial Disclosure:

- He recieved speaker fees from Alcon, CSO, Johnson &


Johnson, Staar, and ZEISS

How to cite this chapter:


Savini G. Intraocular Lens Power Calculations Formulas. In: Pardianto G, editor. The Intraocular Lens
Power Calculation. Medan: Anak Sudarti Foundation. 2022; 25-31.

Gede G.
Savini Pardianto (Ed.) 31
THE INTRAOCULAR LENS POWER CALCULATION

32 Gede Pardianto
Chapter 3: Intraocular Lens Power Calculation (Ed.)
Formulas
THE INTRAOCULAR LENS POWER CALCULATION

Chapter 4
IOL Power Calculation in Standard
Eyes and for Immediately Sequential
Bilateral Cataract Surgery
Steve A. Arshinoff, Rishi Gupta

Introduction
Cataract and refractive lens surgeries have become progressively precise procedures over
the past six decades. The surgeon must place the IOL with the appropriate refractive power
in as accurate a predicted effective lens position (ELP) as possible, which requires precisely
repeatable surgical technique, reducing surgically induced astigmatism as much as possible
while simultaneously giving the eye the desired focal length. To assist in determining the
predicted IOL power, numerous generations of equations have been developed since the late
1940s, with each subsequent generation aiming to improve upon the preceding ones. These
equations have added progressively numerous variables, beginning with axial length and corneal
optical power assessments, using ever more accurate measuring devices. Increased precision
has required the use of more expensive technology. The goal of this chapter is to review our
march to more accurate but more expensive results, trying to give the surgeon an idea of what
degree of accuracy can be achieved at what cost. This becomes particularly important when
immediately sequential bilateral cataract surgery (ISBCS) is planned, as there is no chance to
return to reassess the calculation’s accuracy between first and second eyes.
Traditionally, throughout the 20th century, when cataract surgery was planned for both
eyes it was performed in one eye at a time; a procedure generally now referred to as delayed
sequential bilateral cataract surgery (DSBCS). Physicians believed that they might use the
postoperative refractive results of the first eye to modify the calculations for the second eye,
as long as the two eyes were optically equivalent and not anisometropic. Over the past few
decades, numerous research articles have shown that progressively better measuring devices
and biometric equations have resulted in second eye potential improvements becoming generally
negligible and clinically insignificant.1,2 This, along with great strides in reducing the risk of post-
operative endophthalmitis to levels less than about 1:5,000, when intracameral antibiotics are
used, suggest that ISBCS is now a viable option in most countries globally. Historically, ISBCS

Gede Pardianto (Ed.) 33


THE INTRAOCULAR LENS POWER CALCULATION

was common throughout history up until Theoretical formulae consider


increased understanding of microbiology physiologic optics and are potentially more
and infection without available infection accurate than regression formulae for unusual
prophylactic methods caused ophthalmologists eyes because they can be used beyond the limits
and indeed all surgeons to move away from of a given clinical database, for example, in
all bilateral procedures at the same sitting in eyes with unusually long or short axial lengths.
the early 20th century. However, ISBCS allows The first theoretical formulae were developed
more rapid rehabilitation of the patient and by Fyodorov and Kolinko, Thijssen, Van Der
fewer patient visits, which saves not only time Heijde and Binkhorst in the 1970s. These
for the physicians, patients and their families formulae incorporate a predicted pseudophakic
but also decreases healthcare costs and risk of ACD to minimize refractive prediction errors.
spread of contagious diseases like COVID-19 An advantage to the surgeon of the early
and is more convenient for everyone involved. regression and theoretical formulas is that
As a result of the COVID-19 pandemic, better they used only measurements of keratometry
surgical techniques, smaller incisions, more and axial length, requiring already available
rapid healing and reduced infection risk, there keratometers and one of the then recently
has been an increasing shift back towards developed ultrasound devices which were
ISBCS. This chapter will discuss the IOL lens portable and relatively inexpensive, and
calculation methods, instruments required to therefore became rapidly available globally.
measure the variables for these calculations,
and the associated increasing costs of more Second Generation
modern calculation methods, as well as all the One of the limitations of the first-
general requirements for the performance of generation formulae is that they typically
ISBCS. relied on a fixed constant for the anterior
chamber depth, dependent on the
Biometric Equations intraocular lens type (i.e., anterior or
posterior chamber). This led to occasional
First Generation
large errors in the outcomes for the patients,
Intraocular lens (IOL) power calculations referred to as “refractive surprises”, due to
originated in the late 1940s when Harold Ridley individual variation in anterior chamber
implanted the first intraocular lens. Since then, depth (ACD). Some of the second-generation
numerous IOL power calculation formulas have formulae improved on this error by including
been devised. There are two different types of modifications to the anterior chamber depth
equations, theoretical and statistical regression. constant by representing it as a function
The early regression formulae used A-constant, of the axial length. The second-generation
the A-constant, as part of the calculations. Sanders, formulae, however, such as the SRK II and
Retzlaff and Kraff (SRK) created the SRK formula, Hoffer, were regression-based formulae and
in which P = A – 2.5L – 0.9K, where P = the are no longer used. They correlated the
intraocular lens power to achieve emmetropia, expected postoperative ACD to the AL. SRK-
A represents the A-constant, L is the axial length II was a modification of the original SRK
of the eye and K = the average anterior corneal equation which provided greater accuracy in
curvature (keratometry). The SRK formula was an eyes with AL of >26 mm and <22 mm. It
improvement on the preceding first generation was later discovered that anterior chamber
theoretic formulas for average eyes. depth did not always correlate well with axial

34 Gede Pardianto
Chapter 4: IOL Power Calculation in Standard Eyes and for Immediately (Ed.)
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THE INTRAOCULAR LENS POWER CALCULATION

length as some highly myopic eyes had small Fourth Generation


anterior chambers and some hyperopic eyes The dawn of the 21st century saw the
had deep anterior chambers. arrival of partial coherence interferometry
Second generation formulas also required with the Zeiss IOL Master in March 2000 being
only keratometry and axial length measurement, the first. This device heralded a quantum
and therefore provided generally increased improvement in biometric accuracy along
accuracy compared to first generation without with a huge increase in equipment cost to
increased cost. attain this accuracy. New equations were
designed to take advantage of the enhanced
Third Generation
accuracy of measurement.
The third generation of theoretical
In 2009, Haag-Streit marketed the
formulas were created in the 1990s and are still
Lenstar as a competitor to the Zeiss IOL Master.
some of the most commonly used formulas.
These two devices were rapidly recognized
The most popular are Holladay 1, SRK/T and
to be superior in accuracy to all methods of
Hoffer Q. These third-generation formulae used
ultrasonic biometry.
biometric data to estimate the effective lens
The previous generation of equations
position within the eye. They are primarily
relied on corneal keratometry and axial
based upon the principles of thin-lens optics.
length for calculating the intraocular lens
All three formulae require the knowledge of the
power and were limited by solely relying
axial length (AL) and corneal power to estimate
on two parameters for estimating the
the effective lens position (ELP). One of the
effective lens position, thereby introducing
major problems historically in determining the
potential errors in atypical eyes as explained
post-operative refractive error is inaccuracy of
above. The latest formulae, belonging to the
ELP prediction of all formulas.
fourth generation, include additional patient
SRK-T: the SRK/T formula is one of the
variables and modifications to better estimate
third-generation formulae, created in 1990
refractive power. One of these, the Haigis
by Sanders, Retzlaff and Kraff. The SRK/T
formula, utilizes three independent constants,
formula combines the advantages of the linear
known as a0, a1 and a2 to mathematically
regression model with the theoretical model,
modify the intraocular lens power prediction
leading to improved accuracy. This formula
curve, leading to increased accuracy of ELP
uses the A-constant to calculate the ACD using
determination. As a result, the Haigis formula
the retinal thickness and corneal refractive
has reduced predictive errors across a wide
index. SRK/T does not take into account the
range of axial lengths and anterior chamber
effective lens position.
depths. Some of the other formulae included
Hoffer Q: This formula predicts the in this generation are the T2 formula (updated
pseudophakic anterior chamber depth and SRK/T formula), Olsen, Kane, Holladay 2, and
the intraocular lens power. It predicts the the Barrett suite of formulae.
pIOL based on a personalized ACD, corneal
Some of the fourth-generation formulae,
curvature and axial length.
such as the T2 modification of SRK/T, Olsen,
Third generation equations continued and Holladay 2 are not widely available onboard
to rely upon the same simple keratometry in existing biometer software. Many find it
and axial length determination and so remain preferable and more efficient to use onboard
financially easily accessible. formulas.

Gede Pardianto
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The Hill-RBF Formulas each surgeon’s postoperative patients’ stable


The Hill-RBF formulas were designed refraction values to calculate a surgeon
to use data derived from cases which had factor for each physician. As a result, this
performed biometry, initially using the Haag- formula adapts to individual general surgical
Streit Lenstar, and then reported biometric technique. This equation is optimal for eyes
results to a central database. Data was with an axial length of 24.6 - 26.00 mm. (See
collected from around the world into a massive also Chapter 3)
database, and proposed cases were evaluated
Hoffer Q
using artificial intelligence to project which
During preoperative measurements, the
IOL power would yield the best results based
Hoffer Q formula requires axial length and
upon the historic database. Clearly, the larger
corneal curvature to calculate a personalized
this database becomes the greater its accuracy
anterior chamber depth (pACD). The pACD
will become. (See also Chapter 3)

Table 1. Variables required by commonly used equations

Equation Generation Type Variable

Fyodorov-Kolinko 1 Theoretical Axial length, Average K


Colenbrander 1 Theoretical Axial length, Average K
Thijssen 1 Theoretical Axial length, Average K
Van der Heijde 1 Theoretical Axial length, Average K
Binkhorst 1 Theoretical Axial length, Average K
Sanders-Retzlaff-Kraff (SRK) 1 Regression Axial length, Average K
SRK-II 2 Regression Axial length, Average K
Hoffer 2 Regression Axial length, Average K
Holladay 1 3 Regression Axial length, Average K
Hoffer Q 3 Regression Axial length, Average K
SRK/T 3 Regression + Axial length, Average K
Theoretical
Haigis 4 All of these equations rely upon increased data
T2 Modification of SRK/T 4 compared to the preceding generations, and
Holladay 2 4 therefore require the IOL Master or Lenstar to
Olsen C 4 acquire the data
Kane 4
Barrett suite of formulas 4
Hill-RBF formulas AI A unique formula requiring accurate input and
using Artificial Intelligence.

required for this formula is unique to each eye


Variables Required for Current Commonly
created as follows:
Used Equations
a. Calculating an ACD based on the axial
Holladay 1 length and corneal curvature.
The Holladay 1 formula uses b. Modifying the ACD for outliers in axial
preoperative corneal and axial length (AL) length (ie. extremely long or short eyes).
measurements, as well as a database of c. A-constant is added to the ACD.

36 Gede Pardianto
Chapter 4: IOL Power Calculation in Standard Eyes and for Immediately (Ed.)
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THE INTRAOCULAR LENS POWER CALCULATION

The parameters required to use this implant position prediction. An aspect unique
formula are the AL and the corneal power. to this method is the C-constant, which is used
Hoffer Q is a recommended formula for eyes to predict the implant location. This constant
that are < 22 mm. (See also Chapter 3) yields an approximation of the empty capsular
bag which will encapsulate the replacement
SRK/T IOL. The only requirements to perform
The SRK/T formula is one of the examples this calculation are corneal power, anterior
that falls under the SRK umbrella. It is a chamber depth and the lens thickness. (See
theoretical formula that uses existing A-constants also Chapter 3)
and optimization methods. The requirements for Barrett II
this formula are the axial length and the corneal
This formula is a thick lens formula.
power. This formula is best for eyes >26 mm. (See
It implements a “lens factor” to determine
also Chapter 3)
the anterior chamber depth. This lens
Haigis factor is dependent on the axial length and
keratometry. One key factor in this formula
This formula uses three variables that
is that the location of the principal plane of
allows for its use in a wide range of eyes.
refraction of the IOL is used as a relevant
The three variables are a0 (moves the power
variable in the formula. The basic parameters
prediction curve up or down), a1 (correlated to
required for this formula are axial length
anterior chamber depth), and a2 (correlated to
and corneal power. Anterior chamber depth,
axial length). The parameters required for this
lens thickness and white-to-white corneal
formula are the axial length, corneal power
diameter are optional additional factors. (See
and anterior chamber depth, making it more also Chapter 3)
useful for a wide range of axial length eyes.
This formula method is referred to as a double Hill-RBF
analysis. (See also Chapter 3) The Hill-RBF Method 3.0 is a unique
formula which uses an artificial intelligence
Holladay 2
system based on previous IOL power
The Holladay 2 builds upon the same calculations from cataract surgeons around the
concepts as Holladay 1, but it uses up to world. The dataset upon which this formula
seven variables to predict the surgeon factor. was based is proven to provide increasingly
The mandatory variables are axial length, reliable outcomes for a wide range of eye axial
corneal power, and anterior chamber depth. lengths. The parameters required to perform
The optional variables are lens thickness, age this calculation in addition to the traditional
of patient, white-to-white diameter and pre- requirements (corneal power and axial
operative refraction data. The details of this length) are lens thickness, white-to-white
formula have not been released to the public. corneal diameter, central corneal thickness
This formula is also recommended for eyes and patient gender. (See also Chapter 3)
that range from short to long.
Modern Instruments Available
Olsen C
The Olsen formula uses a new technique Zeiss IOLMaster 500
known as Ray Tracing. This formula also adds The Zeiss IOLMaster 500, introduced
lens thickness measurements to improve in 2000, is the gold standard in biometry

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THE INTRAOCULAR LENS POWER CALCULATION

Table 2. Recommendation of formulae to use with varying ocular parameters3

Length of Short Normal Long


Eye
Older Holladay 1 W-K adjustment* Normal anterior
generation Hoffer Q Not applicable for long eyes segment anatomy
formulas SRK/T W-K adjustment*
Haigis**
Holladay 2 W-K adjustment* All anterior
Newer Olsen segment types
generation Barrett II
formulas
*Scientifically the W-K adjustment is controversial since it depends on the IOL design whether the
adjustment is required or not
**for short eyes a0, a1 and a2 must be optimized, for normal eyes only a0 must be optimized and for long
eyes, specific constants for meniscus lenses are required, with very long AL, special constants are needed
for IOLs that change from symmetrical to asymmetrical geometry at certain power thresholds. This can
lead to significant principal plane shifts and as a result to different ELP positions

with over 100 million IOL power calculations a. Central Topography: provide information
performed. The measurements provided are on asymmetries on central corneal shape.
axial length, corneal radii, anterior chamber b.
Markerless toric IOL implantation:
depth and white-to-white. The on-board IOL intraoperative matching is performed with
equations available include SRK II, SRK/T, the use of OPMI LUMERA or ARETVO 800
Holladay 1 & 2, Hoffer Q, and Haigis. ZEISS surgical microscopes to eliminate
Some of the additional features of the the need for preoperative corneal marking
IOLMaster 500 are listed below: and additional measurements for toric IOL
a. Distance independent keratometry. alignment.
b.
Markerless toric IOL workflow: the c. Total Keratometry: measure the posterior
IOLMaster 500 works synergistically with corneal surface using SWEPT Source
the CALLISTO eye from ZEISS, allowing for OCT.
elimination of the manual marking steps. Haag-Streit Lenstar 900
Zeiss IOLMaster 700 The LS900, introduced in 2009,
The IOLMaster 700, an upgrade from provides the thickness of the crystalline
the IOLMaster 500, introduced in 2015, relies lens and is integrated with the Hill-RBF,
on Swept Source OCT technology. It measures Barrett and Olsen formulae. This technology
axial length, corneal radii, anterior chamber uses optical low coherence reflectometry
depth, lens thickness, central corneal thickness (OLCR) and captures axial dimensions of
and white-to-white. The IOLMaster 700 also all the optical structures. It can calculate
has numerous IOL calculation formulas the corneal curvature as well as white-
integrated within the software, including all to-white measurements. Furthermore, it
the Barrett and Haigis formulas, Hoffer Q, measures axial values of the entire eye,
Holladay 1 & 2 and SRK/T. provides dual zone autokeratometry, along
with topography. The Hill-RBF method is
Some of the additional features of the
integrated exclusively with the Lenstar 900.
IOLMaster 700 are listed below:

38 Gede Pardianto
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Haag-Streit Eyestar 900 Complications within the first eye


This instrument, introduced in 2019 as must be addressed before proceeding to the
an upgrade to the Lenstar, imaging eyes using second eye. Should a severe complication
swept-source OCT. It provides a summary occur, such as a dropped lens, the second
of axial, keratometric, topographic imaging, eye may need to be rescheduled for another
pachymetry maps and swept-source OCT day. ISBCS patients’ eyes should not be
B-scans. Some of the variables provided are patched. Post-operative topical drops should
axial length, central corneal thickness (CCT), be commenced one hour post-operatively as
anterior chamber depth (ACD), lens thickness they are maximally effective immediately
and white-to-white. The software takes 16 post-operatively and tapered after initial
cross-sections of the anterior chamber for high doses (6 x/day) for about 4 days. Ocular
visual anatomy assessment. medications for other ocular conditions,
such as glaucoma, should be administered
Biometric and Procedural Differences
uninterrupted.
between DSBCS and ISBCS
Some may consider endophthalmitis to
In order to effectively perform
be one of the primary reasons to avoid ISBCS.
immediate sequential bilateral cataract
This can, however, be mitigated through the
surgery, various steps are recommended.
following techniques:
As indicated in any ocular procedure,
concomitant relevant diseases need to be a. Nothing should be in physical contact from
well managed, such as glaucoma or retinal the first to second eyes.
conditions. For expected unusual or complex b. The two eyes should have two separate
cases, the past experience and competence instrument trays with no crossover of
of the surgeon is important when considering instruments, drugs or devices between the
ISBCS. Furthermore, patient consent should two trays.
be obtained, with the patient free to choose c. The use of different OVDs, manufacturers
ISBCS or DSBCS. Surgeons should use precise and surgical supplies between the right and
modern biometry and methods of astigmatism left eyes is encouraged.
reduction for ISBCS, as the opportunity d. Before progressing to the second eye, the
to make adjustments between eyes is
surgical team involved in the procedures
unavailable. Strict sterility and complete
must use acceptable sterile routines of at
separation of the two ocular procedures is
least re-gloving and reprepping the second
paramount.
eye before proceeding.
At surgery, on a board within the
Lastly, surgeons performing ISBCS
operating room, the surgical parameters must
should refresh their own knowledge by
be clearly indicated (ie. which IOL is selected,
reviewing their own cases on a regular
astigmatism, angle, etc.) for both eyes prior to
basis. They should be familiar with up-to-
beginning surgery. The personnel in the OR
date international literature as well. This
should be familiar with biometric methods
would provide them with the continuously
and able to review the data before passing
improving standards for surgery, along with
each IOL to the surgeon. Nursing staff should
novel methods to avoid intraoperative and
be specifically trained and experienced with
postoperative complications.
ISBCS.

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Table 3. Devices that can be used to measure This chapter has been a general review of
Biometric Parameters biometric techniques and their generations of
improvement over time, with respect to choosing
1.Axial length - IOL Master appropriate biometric methods for ISBCS.
- Lenstar References have been included only dealing
- Ultrasound (Immersion) with biometry and ISBCS. For a detailed review,
2. Corneal K’s - IOL Master and a starting point for deeper investigation into
- Lenstar the long history and the intricacies of biometric
- Manual Keratometry methods, the reader is referred to the site of
- Corneal Topography/ American Academy of Ophthalmology (AAO)
Tomography EyeWiki.4,5

References
Summary 1. Olsen T. Use of fellow eye data in the calculation
There has been progressive and of intraocular lens power for the second eye.
incredible improvements in biometric Ophthalmology. 2011;118(9):1710-1715. doi:
accuracy over the past 50 years. This has, 10.1016/j.ophtha.2011.04.030. Epub 2011 Jul 2.
however, been accompanied by increases in PMID: 21723613.
the cost of devices to attain such accuracy. 2. Ahmed II, Hill WE, Arshinoff SA. Bilateral Same
As Warren Hill states, we should be like Day Cataract Surgery: An Idea Whose Time Has
carpenters and measure everything twice Come #COVID-19. Editorial. Ophthalmology. 2020.
before we cut once. That alone greatly On line ahead of print 2020 09 01. DOI:10.1016/j.
decreases our chance of refractive surprise. ophtha.2020.08.028.
Different devices of varying cost are available 3. Modified from IOL calculation formulas explained. ZEISS
to achieve this, as shown in Table 3. Every Medical Technology. Available on: https://www.zeiss.com/
surgeon must look at the available devices, meditec/int/c/-optical-biometry-/iol-power-calculation-
their cost and how much each can add to the formulas-explained.html.
accuracy of surgical accuracy. They must
4. American Academy of Ophthalmology (AAO) EyeWiki.
use this to develop consistent biometric
Available on: https://eyewiki.org/w/index.php?title=_Sp
methodology within their budget and reassess
ecial:Search&search=Biometry&fulltext=1&searchToken
their patients post-operatively to assure
=91t6tbox6k8rj3son28edrtjv.
accuracy of their methods. Surgeons must also
be sure of the consistency of their surgery. 5. Simultaneous bilateral cataract surgery. American Academy
Once both of these steps have been taken, of Ophthalmology (AAO) EyeWiki. Available on: https://
ISBCS can be performed with assurance that eyewiki.org/Simultaneous_Bilateral_Cataract_
it will yield the refractive results as planned. Surgery.

40 Gede Pardianto
Chapter 4: IOL Power Calculation in Standard Eyes and for Immediately (Ed.)
Sequential ...
THE INTRAOCULAR LENS POWER CALCULATION

Authors:
Steve A. Arsinoff

Financial Disclosure: None

Rishi Gupta

Financial Disclosure: None

How to cite this chapter:


Arshinoff SA, Gupta R. IOL Power Calculation in Standard Eyes and for Immediately Sequential Bilateral
Cataract Surgery. In: Pardianto G, editor. The Intraocular Lens Power Calculation. Medan: Anak Sudarti
Foundation. 2022; 33-41.

Gede Pardianto
Arshinoff SA, Gupta(Ed.)
R. 41
THE INTRAOCULAR LENS POWER CALCULATION

42 Gede
Chapter 4: IOL Power Calculation in Standard Eyes and for Pardianto (Ed.)
Immediately...
THE INTRAOCULAR LENS POWER CALCULATION

Chapter 5
IOL Power Calculation in Special
Situations
Nisha S. Dhawlikar, Yi Ling Dai, Kate V. Hughes, Naveen K. Rao

Introduction
There are many situations in which the standard techniques for IOL power selection must be
altered to achieve better visual and refractive outcomes. This chapter will address the following
six categories of special situations:
v Axial Length considerations
v Post-refractive surgery
v Corneal pathology
v Correction of residual refractive error
v Retinal pathology
v Non-capsular IOL placement.

Axial Length (AL)


The accuracy of intraocular lens (IOL) power calculation in normal eyes (AL between
22 and 26 mm) has drastically improved within the past 20 years with the advent of third and
fourth generation formulas. However, obtaining accurate IOL power calculation in eyes that are
very short (<22 mm) or very long (>26 mm) has been historically challenging. Obtaining an
accurate AL measurement is critical in determining the IOL power, as a 1 mm change in the AL
can change the IOL power by 2.5 diopter (D) in average eyes. Errors in AL measurements (for
example, due to the presence of staphylomas in myopic eyes) have improved with the use of
optical biometry, which has largely replaced the older A Scans.

Long eyes
Eyes with AL greater than 26 mm are often faced with the issue of unintended post-operative
hyperopia with many IOL calculation formulas. In these eyes, the corneas are often flatter, the
lenses are thinner relative to the length of the eyes, and the anterior chamber depth (ACD)
must be deeper.1 According to Simon et al., only 54% of patients with axial myopia attain target
refractive outcomes when optimization methods are used.2 The simplest correction that many

Gede Pardianto (Ed.) 43


THE INTRAOCULAR LENS POWER CALCULATION

surgeons utilize is to aim for a more myopic linear regression to increase the accuracy.6
goal, however, this is not recommended as This formula has been validated by several
more sophisticated and precise methods are studies involving long eyes. Terzi et al. found
available and outlined below. that the Haigis formula performed best in
myopic eyes compared to other formulas
Wang-Koch adjustment when the lens constants were optimized (not
The landmark paper by Wang and Koch using the manufacturer’s lens constants).7
describes a method for AL adjustment for long Instructions and links to obtaining free lens
eyes when the AL is measured via optical constant optimization can be accessed via
biometry. The amount of error tends to be www.doctor-hill.com.8
greater in highly myopic eyes.3
Hill-radial basis function (Hill-RBF)
Optimized Optical Biometry AL=(0.8289 x
This method incorporates artificial
measured AL) + 4.2663
intelligence and regression analysis of
This modified AL calculation is best postsurgical refractive outcomes to predict
combined with the Holladay 1 formula. Of IOL power. Theoretically, the algorithm may
note, the method should not be applied in be able to recognize undefined factors in IOL
the setting of prior Automated Lamellar power calculation that cannot be captured
Keratoplasty (ALK), Radial keratotomy (RK), with traditional vergence or ray-tracing
Laser in-situ Keratomileusis (LASIK), or equations. However, as the calculator is based
Photorefractive Keratectomy (PRK). on empirical postsurgical data, the accuracy is
limited by the size and characteristics of the
Barrett Universal II Formula database. With the advent of the updated Hill-
The Barrett Universal II formula is one RBF version 2.0 and 3.0, which are derived
of the more popular formulas among surgeons from a larger dataset with expanded biometry
due to its high accuracy. This is reflected in ranges, the precision of IOL prediction in eyes
the findings by Melles et al., which showed with high axial myopia is comparable to that of
that 50% of refractive predictions using the the Barrett Universal II and Haigis formulas.9
Barrett formula were within 0.25 D of the Specific instructions and information can be
true refraction, the highest percentage when found at https://rbfcalculator.com.
compared to other IOL formulas in the study.4
A study by Kane et al. also demonstrated Short eyes
that the Barrett formula had the lowest mean Eyes with AL less than 22 mm have a
absolute prediction error over the entire AL higher probability of having steep corneas
range compared to six other IOL calculation and shallow ACD. In addition, the high optical
formulas.5 The formula is freely accessible on power of the required IOL gives more weight
the website of the Asia Pacific Association of to any error in the predicted IOL position.
Cataract and Refractive Surgeons and no AL
adjustment is needed. Hoffer Q formula
Among the third and fourth generation
Haigis formula formulas, Hoffer Q is widely accepted as the most
As one of the fourth-generation formulas, accurate for short eyes <22 mm.10 The formula
Haigis introduced three independent lens introduces another method of calculating ACD
constants, which can all be optimized via with optimization of the personalized ACD.

44 Gede
Chapter 5: IOL Power Calculation Pardianto
in Special (Ed.)
Situations
THE INTRAOCULAR LENS POWER CALCULATION

Aristodemou et al. found that the Hoffer Q corneal curvature, direct measurements of
formula had the lowest mean absolute error central corneal power (such as keratometry
for extreme short AL (20.00 to 20.99 mm) using or corneal topography) and standard IOL
optimized constants.11 Of note, the Holladay 2 power calculation formulas are inaccurate –
and Haigis formulas have demonstrated good these formulas work under the assumption
outcomes in short eyes as well. that the anterior and posterior segments of
the eye are proportional.14 Correcting for
Others the corneal power must be done regardless
Both the Barrett Universal II and of which IOL power calculation formula is
Hill-RBF formulas have been shown to be used (see subsections below). ELP needs to
comparable to the Hoffer Q formula in eyes be corrected in both post-myopic and post-
with short AL. In the study by Kane et al., hyperopic keratorefractive surgery eyes,
there was no statistically significant difference keeping in mind that these corrections are
in the accuracy between the Hoffer Q, Barrett estimates. A completely accurate method for
Universal II, and five other formulas in patients post-keratorefractive IOL power calculation
with short AL.5 This is similar to the results has yet to be developed.
of Gokce et al., which revealed no significant To correct ELP, third-generation
difference in the absolute refractive prediction 2-variable IOL calculation formulas (such as
error between the Barrett Universal II, Haigis, SRK/T) assume that if the central corneal
Hill-RBF, Hoffer Q, Holladay 1 and 2, and Olsen power is low, the anterior chamber is shallow.
formulas when the mean refractive prediction Consequently, it is incorrectly assumed that
error was adjusted to zero. In the same study, the ELP will be closer to the cornea than
the Hill-RBF formula performed better than normal. This assumption leads to an IOL
the Hoffer Q formula with a significantly recommendation with less power than may
smaller mean absolute error when the mean actually be appropriate, since a more anterior
refractive prediction error was not adjusted to ELP would increase the effective lens power
zero.12 by 1.00 D per 0.50 mm change in position.
This would result in unanticipated post-
Post-Refractive Surgery operative hyperopia.14 To account for this, IOL
power calculation can be completed using the
Post-LASIK and Post-PRK Holladay 2 formula, or “Double K” correction
There are typically two main errors method (proposed by Dr. Aramberri) in
that need to be corrected when calculating conjunction with the SRK/T, Hoffer Q, or
IOL power after prior laser keratorefractive Holladay 1 formulas.15 This method uses the
surgery, such as LASIK and PRK. The first pre-refractive surgery keratometry to calculate
is the corneal power, and the second is the the ELP, while the post-refractive surgery
effective lens position (ELP). PRK employs values are used as a measure of corneal power.
an excimer laser to ablate the anterior corneal In a recent meta-analysis, it was found that the
stroma, creating a new radius of curvature and Holladay 1 formula produced less prediction
decreasing the corneal refractive error. LASIK error than the SRK/T formula when using
uses this same technology, but the procedure the “Double K” method.16 If the Haigis-L
is performed under a lamellar corneal flap formula is used, which generates a corrected
created by a microkeratome or femtosecond corneal radius to be used by the regular Haigis
laser.13 Because of this alteration to the anterior formula to calculate IOL power after myopic

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refractive surgery17, the ELP does not need the Feiz-Mannis Method20, is used to help
to be corrected as this formula does not link provide a better sense of the overall refractive
ELP to central cornea power unlike the third- goal, as it will often produce a myopic over-
generation 2-variable formulas. correction, and is thus the least likely to result
in a hyperopic surprise. It can be used as a
Post-myopic keratorefractive surgery marker for the upper limit of IOL power. The
In myopic eyes, the central cornea IOL power is first calculated using the pre-
tends to be steeper than the peripheral cornea refractive surgery keratometry, without using
(prolate shape). In myopic LASIK or PRK, a special formula correction. The amount of
treatment is focused on flattening the central refractive change after refractive surgery is
cornea and thus lowering its power. As a then divided by 0.7, and this value is subtracted
result, central corneal power is often over- from the prior calculated IOL power to obtain
estimated using standard keratometry in IOL the new estimated IOL power. Another method
calculation, which may lead to a hyperopic to estimate corneal power after refractive
surprise. Because of this, surgeons may want surgery is the Latkany Method.21 This method
to aim for slight myopia (-0.25 D to -0.50 D). is helpful in that it only requires the pre-
Ideally, the cataract surgeon would have refractive surgery refraction (whether from
access to the pre-keratorefractive surgery old records or even an old pair of glasses),
corneal power and amount of refractive and not necessarily details of the procedure
correction. One of the most widely used itself. To use this method, IOL power is first
techniques for corneal power estimation after calculated using the flattest K and the SRK/T
refractive surgery (Ka), the clinical history formula, and then corrected using a regression
method, first described by Dr. Holladay18, adds formula:
the average corneal power before refractive -(0.47 [pre-refractive surgery spherical equivalent]
surgery (Kp) to the spherical equivalent before + 0.85)
refractive surgery (Rp) minus the spherical
equivalent after refractive surgery (Ra), The final IOL power is rounded to the
assuming a vertex distance of 12 mm: nearest 0.05 D to give the final adjusted IOL
power.
Ka = Kp + Rp – Ra
If the pre-refractive corneal power and/
The accuracy of this method is lessened or refractive correction are not known, there
by the amount of time that has passed since are several other techniques to calculate post-
refractive surgery, as changes to the corneal refractive central corneal power. The Modified
surface or increasing cataract size causing a Maloney Method, originally developed by Dr.
shift in refraction may have occurred during Maloney and then modified by Dr. Koch and Dr.
that time. Another technique, the corneal Wang22, does not require any prior refractive
bypass method, described by Dr. Walter19, data, and works by estimating the central
calculates the IOL power without having to corneal power by finding the precise center
calculate the post-refractive surgery corneal of the Axial Map of the Zeiss Humphrey Atlas
power (hence, “bypassing” it). This is achieved topographer. Multiplying this value by 1.114,
by using the post-refractive surgery AL and and then subtracting 6.1 (for the assumed
the pre-refractive surgery corneal power, with posterior corneal power) results in the post-
target refraction set for the pre-refractive refractive surgery corneal power, which
surgery spherical equivalent. Another method, can then be used with either the Holladay 1

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formula or “Double K” correction method as methods using all clinical history data in IOL
previously described. Also described by Dr. power calculation after myopic LASIK/PRK.26
Koch and Dr. Wang, the Topographic Central This finding was supported in a 2016 meta-
Corneal Power Adjustment Method23 takes analysis, which found the Masket method
the 1, 2, 3, and 4 mm power values of the and many no-history data methods to not be
Numerical View of the Zeiss Humphrey Atlas less predictably accurate than the Haigis-L
topographer and averages them to be used as method, as well as the clinical history method,
the central corneal power. This value is then Feiz-Mannis method, and corneal bypass
reduced by 19% for every diopter of myopia method (which all require pre-refractive
that was corrected by refractive surgery, to surgery data) to be associated with less
obtain the post-refractive surgery adjusted accurate predictability.27 The Barrett True-K
corneal power. The Shammas method24, method, based on the Barrett Universal II
based on regression analysis, estimates the formula28, utilizes pre-refractive surgery data
post-refractive surgery corneal power by to calculate a modified keratometry value for
adjusting the measured post-refractive surgery patient who have had myopic or hyperopic
keratometry using the formula: refractive surgery. Additionally, a variation of
the method can determine IOL power without
(1.14 x post-refractive surgery keratometry) –
pre-refractive surgery data (Barrett True-K No
6.8
History method), with refractive information
Another method, the Masket method25, obtained and subsequently interpolated by
works following either myopic or hyperopic computer analysis. Lastly, a helpful resource
keratorefractive surgery. This regression in determining post-refractive surgery IOL
method utilizes the fact that there is a direct calculation is the American Society of Cataract
relationship between the laser vision correction and Refractive Surgery (ASCRS) post-refractive
spherical equivalent (corrected for vertex IOL calculator, which processes all the data
distance) and the over-estimation of central entered by the physician to provide IOL power
cornea power by simulated keratometry. To calculation and an aggregate value.29
obtain the post-keratorefractive surgery IOL A 2016 retrospective case series examined
power adjustment: the accuracy of the Barrett True-K formula
with several alternative methods (using the
(Laser vision correction spherical equivalent x
ASCRS online calculator, including Masket,
-0.326) + 0.101
Wang-Koch-Maloney, Shammas, and Haigis-L)
This number is then added to the IOL to calculate IOL, with a separate analysis of
power, which is calculated using either the the Shammas and Haigis-L compared with
Holladay 1 formula or Hoffer Q formula the Barrett True-K No History method in post-
(depending on AL) without a double K method myopic refractive surgery eyes.30 The authors
correction, to obtain the final adjusted IOL found that the Barrett True-K formula was
power. Interestingly, and important for either at least as accurate as or better than
patients that do not have prior data available, the other methods in predicting IOL power,
a study by Wang et al. found more accurate including the Barrett True-K No History
calculation with smaller IOL prediction errors formula, which had a significantly smaller
and variances with the Masket regression median absolute refraction prediction error
formula and no history methods (Haigis-L, and greater percentage of eyes within ±0.50 D
Wang-Koch-Maloney, Shammas) compared to of the predicted error. In a 2020 meta-analysis,

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the ASCRS average (compared to Haigis-L, applications with intraoperative aberrometry:


Shammas-PL, and Wang-Koch-Maloney) and combining preoperative measurements
Barrett True-K No History formula (compared with intraoperative aphakic refraction (for
to Shammas-PL and Wang-Koch-Maloney) monofocal or toric IOLs), and pseudophakic
yielded significantly higher percentages refraction to evaluate for residual astigmatism,
of refractive prediction error within ±0.5 which can be helpful in refining the axis of toric
D in myopic eyes after refractive surgery, IOLs or deciding on the need for additional
supporting their use in IOL power calculation in astigmatism correction such as incisional
this population.31 In a retrospective case series, surgery.34 This is the only method that uses
four variants of the Barrett True-K formula aphakic refraction, and thus theoretically
were investigated in eyes with prior myopic reduces the inaccuracy of conventional IOL
refractive surgery: with history and measured calculation by decreasing dependence on the
posterior corneal power, with history and variable corneal power measurements.34,35 As
predicted posterior corneal power, no history described by Kane et al. in a 2021 review article,
with measured posterior corneal power, and the main clinical utility of intraoperative
no history with predicted posterior corneal aberrometry depends on how often it advises
power.32 The authors found that the Barrett a different, more accurate IOL power than
True-K formula with history and measured the preoperative IOL power calculation.34 The
posterior corneal power resulted in the lowest authors concluded that in their review of the
median absolute error and highest percentage current literature, intraoperative aberrometry
of eyes with a predictive error within ±0.25 D appears to improves refractive outcomes over
that was significantly significant between the other formulas, especially in eye that have
four options. The Barrett True-K no-history undergone prior refractive surgery; however
formula with predicted posterior corneal these results are comparable with, but not
power yielded the worst refractive outcomes. superior to, the results observed when using
The previously described methods to the Barrett formulas, including Barrett True-K.
calculate post-keratorefractive IOL power, A 2015 retrospective consecutive
in general, relay on certain modifications case series comparing the accuracy of two
of traditional biometry. In an attempt to established methods (the Haigis-L formula,
improve the accuracy and/or confirm IOL where historical data is not needed, and
power calculation in post-keratorefractive the Masket formula, which uses historical
situations, newer innovative strategies have data) with OCT-based and intraoperative
been employed. One example is the use aberrometry to calculate IOL power in both
of optical coherence tomography (OCT) to myopic and hyperopic eyes that underwent
measure central corneal power. Findings keratorefractive surgery found no statistically
suggest that the predictive accuracy of OCT- significant differences among the methods.36
based IOL calculation is better than Haigis-L This supports the use of newer IOL power
and Shammas-PL formulas.33 Another calculation methods of OCT-based and
example is the development of intraoperative intraoperative aberrometry, which may be
aberrometry, such as the Alcon Optiwave particularly helpful in situations when there is
Refractive Analysis (ORA) System, which no pre-refractive surgery data available. Other
utilizes wavefront aberrometry data in real- reports have also demonstrated superior
time to measure and calculate the optimal accuracy of intraoperative aberrometry in
IOL power. There are two main clinical calculating IOL power in eyes with prior

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myopic refractive surgery compared to Corneal Analysis System, which may also
conventional clinical practice methods, require an adjustment based on the refractive
including the surgeon best preoperative correction.40 In a 2017 study, the accuracy
choice, Haigis L, Shammas, and SRK/T in IOL power calculation of seven formulas,
formulas, as well as the ASCRS average.37,38 A including the Barrett True-K and Barrett
2021 retrospective study comparing different True-K No History formulas, were compared
IOL power calculation formulas (including in post-hyperopic refractive surgery eyes.41
Wang-Koch Maloney, Shammas, Haigis-L, and The authors found comparable predictive
Barret True-K) and intraoperative aberrometry accuracy between the formulas without
in post-myopic refractive surgery eyes found significant variation in mean prediction error
that intraoperative aberrometry did not or median absolute refractive prediction
substantially improve IOL power calculation, error between the Barrett True-K and other
as well the best expected results were obtained formulas. A 2021 retrospective study found
with the Haigis-L and Barrett True-K formulas.39 intraoperative aberrometry to be comparable
In addition to significantly higher percentages to Barrett True-K formulas for IOL power
of refractive prediction error within ±0.50 D calculation in normal eyes and post-myopic
with the ASCRS average and Barrett True-K refractive surgery eyes.42 However, in post-
No History formula (as described previously), hyperopic refractive surgery, intraoperative
the 2020 meta-analysis found a similar result aberrometry yielded better results compared
when comparing OCT formula with Haigis-L to Barrett True-K formula. The authors
and Shammas-PL, supporting the use of concluded that intraoperative aberrometry has
OCT in IOL power calculation after myopic overall statistical advantage over the Barrett
refractive surgery.31 True-K No History formula for eyes that have
undergone hyperopic refractive surgery.
Post-hyperopic keratorefractive surgery
In hyperopic eyes, the central cornea Post-RK
tends to be flatter than the peripheral cornea Incisional keratorefractive surgeries
(oblate shape). In hyperopic LASIK or PRK, such as RK were among the first refractive
treatment is focused on the paracentral area, corneal procedures performed. However,
rather than central cornea. This may lead to an with technological advances and improved
underestimation of the corneal power leading techniques, including the development of the
to a myopic surprise, but overall, it is generally excimer laser used in ablative keratorefractive
easier to estimate the central corneal power. surgery (PRK, LASIK, etc.), there has been
Interestingly, in hyperopic keratorefractive a dramatic decrease in the number of RK
surgery, the ratio between the anterior and procedures performed since the early 1990s
posterior corneal radii is increased. and it is no longer routinely performed in the
A common method used to estimate the United States.43 As previously mentioned in
central corneal power is by averaging the 1 the discussion about IOL power calculation
mm, 2 mm, and 3 mm annular power rings of after post-ablative keratorefractive surgery,
the Numerical View of the Zeiss Humphrey the challenge in calculating IOL power post-
Atlas topographer, with an adjustment based incisional keratorefractive surgery such as RK
on the amount of post-surgery refractive lies in determining the central corneal power.
correction.40 Another method is using the RK for myopia flattens both the anterior and
effective refractive power of the EyeSys posterior corneal radii, making the corneal

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power difficult to measure using forms of refractive error, concluding that, while
direct measurement (keratometry and corneal eyes with prior RK are likely to have higher
topography); this will typically over-estimate prediction errors, both the Barrett True-K
central corneal power.44 Similar to post- formula and intraoperative aberrometry are
hyperopic ablative keratorefractive surgery reasonable methods for IOL power calculation.
(hyperopic LASIK or PRK), the ratio between A prospective consecutive case series of eyes
the posterior and anterior central corneal radii with previous RK who underwent IOL power
is increased. In addition to determining corneal calculation using the Barrett True-K formula,
power, it is important to adjust the calculated with residual refractive error predicted using
IOL power to account for the flattened central several other formulas preoperatively and
cornea. The contact lens method, originally intraoperative aberrometry intraoperatively,
presented by Dr. Holladay and described in a found that the refractive prediction accuracy
prospective study by Dr. Zeh and Dr. Koch45, of intraoperative aberrometry was similar to
was once used to estimate the average corneal the Barrett True-K formula, with no significant
power after RK by subtracting the change in difference between these and the other
refraction from before and after the insertion established formulas in post-RK refractive
of a conventional PMMA contact lens from surgery eyes in terms of median and mean
the known base curve. However, subsequent absolute error.48 The Barrett True-K formula
literature reviews now suggest that this produced signficantly more eyes within ±0.50
method may be less accurate than previously D than the SRK/T, Hoffer Q, and Holladay 1
thought.46 Another method, based on the formulas. A 2013 retrospective study of eyes
increased posterior and anterior corneal radii, with previous refractive surgery (myopic and
is using the effective refractive power of the hyperopic LASIK and RK) compared the SRK/T
EyeSys Corneal Analysis System with small formula, average central keratometry, and the
adjustment based on refractive correction40, or ASCRS average to intraoperative aberrometry.49
averaging the 1 mm, 2 mm, 3 mm, and 4 mm While intraoperative aberrometry was most
annular power rings of the Numerical View of often able to predict IOL power within ±0.5
the Zeiss Humphrey Atlas topographer. D of emmetropia, the authors determined that
IOL power calculation can be completed none of these methods were able to achieve this
using the Holladay 2 formula or Dr. Aramberri’s more than 50% of the time, concluding that no
“Double K” correction method in conjunction method was superior. As well, the prediction
with the SRK/T, Hoffer Q, or Holladay for post-RK eyes was worse compared to post-
1 formula, as discussed in the previous LASIK eyes.
section on “Post-LASIK and Post-PRK”,
however several studies have investigated Post-SMILE
newer formulas, such as the Barrett True-K Small incision lenticule extraction
and Barrett True-K No History, as well as (SMILE) is a refractive procedure that uses
intraoperative aberrometry in post-RK eyes. A the femtosecond laser to cut a small corneal
2021 retrospective study compared prediction lens-shaped disc (lenticule) within the cornea,
errors of the Barrett True-K No History which is subsequently extracted in its entirety
formula and intraoperative aberrometry in via a small 2-3 mm incision.50 Currently,
eyes with prior RK.47 The authors found no there is little published data on refractive
statistically significant difference between outcomes of cataract surgery post-SMILE.
these two methods in predicting postoperative Additionally, SMILE produces a significantly

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different corneal shape alteration compared be performed as usual with the pIOL in place.
to LASIK, with a steeper central cornea No special correction is needed for the IOL
but flatter peripheral cornea post-SMILE51, power. Simultaneous pIOL explantation and
which weakens the validity of the IOL power phacoemulsification is acceptable; there is no
calculation used for post-photoablative need to stage the procedures.
procedures. Several studies have found that
ray-tracing52 in addition to other formulas Corneal Pathology
including the Masket formula53 are the most
Keratoconus 
accurate techniques of post-SMILE IOL power
calculation thus far, until more empirical data Keratoconus (KCN) is a bilateral corneal
is available. ectasia with progressive thinning and inferior
corneal steepening. Given its progressive
Post-Phakic IOL nature, patient selection and comprehensive
Phakic IOL (pIOL) implantation is preoperative evaluation of corneal stability
an intraocular surgery used to corrected is of utmost importance before proceeding
high refractive errors while preserving with cataract surgery. IOL power calculation
accommodation, avoiding corneal tissue can be difficult in eyes with KCN given
ablation, and is reversible. There are two main steep keratometric (K) values and unreliable
categories of pIOLs: anterior chamber (AC) biometric measurements.58
and posterior chamber (PC). AC pIOLs can Assumptions made by common IOL
be further subdivided into two types: angle- power formulas do not apply to KCN eyes.
supported and iris-fixated “iris-claw”. Phakic For example, standard lens power calculation
IOLs do not alter the cornea or crystalline lens. assume that the measured keratometry value
Therefore, calculating the power of the phakic is equal to the keratometry at the visual axis
IOL itself is completed using a nomogram and that the effect of any measurement error
provided by the lens manufacturer.54,55 is uniform across all keratometry values. In
Phakic IOLs can accelerate cataract KCN eyes, given the inferior steepening and
formation due to the close positioning between irregular astigmatism, there is decentration
the ICL and the crystalline lens, or secondary of the corneal apex, making estimation of
to surgical technique (inadvertently touching the visual axis challenging. In these eyes,
the crystalline lens during implantation). the measured central keratometry values are
Although intraoperative IOL power calculation not equal to the keratometry values at the
has been reported with autorefraction after decentered apex of the cone. Additionally,
removal of the pIOL, and calculation of an steep keratometric values overestimate
aphakic spherical equivalent refraction, this the corneal power and underestimate the
is not a common method.56 In a prospective IOL target power in KCN eyes, resulting in
case series, Amro et al. found that the selection of a low-power IOL and postoperative
presence of an ICL did not affect IOL power hyperopia. Particularly in advanced KCN,
calculation when using IOLMaster 500 and when the Kmax value is greater than 55 D,
third generation formulas (SRK/T, Holladay 1, there is a higher chance of postoperative
Hoffer Q), and therefore pre- or post-operative hyperopia 59. With longer AL and a steep
data can be used in IOL calculation formulas.57 keratometry measurement, KCN eyes are
When planning cataract surgery in patients expected to have a deeper anterior chamber
with an existing pIOL, optical biometry can with a more posterior ELP.58,60 Thus, regardless

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of the formula used, it can be challenging to considered an improvement over previous


estimate the preoperative biometry in KCN formulas for calculating IOL power especially
eyes for ideal postoperative visual outcomes. in abnormal eyes. More factors are required for
Many studies have been conducted to IOL calculation by these newer formulas, such
evaluate various IOL power calculation and as white-to-white (WTW) diameter, ACD, lens
their outcomes in KCN eyes. Thebpatiphat et thickness and pre-operative refractive data. Some
al. in 2007 conducted a retrospective study on publications have found that Holladay 2 is more
12 KCN eyes and found that SRK II was better in accurate when ELP is variable.63 The SRK/T
estimating the IOL power than SRK and SRK/T formula generally gives more accurate results in
for mild KCN (Kmax <48 D). In moderate KCN myopic eyes compared with SRK II. This may be
(48 < Kmax <52) to severe KCN (<52 D), there useful as myopia is often present in KCN 63.

Table 4. Refractive prediction errors (PE) according to the five formulas in eyes with three
Table
stages 4.
ofRefractive
KCN (in D)prediction
42 errors (PE) according to the five formulas in eyes with three stages of KCN
(in D)42

Table 5. Percentage of eyes with three stages of keratoconus with a refractive PE within ± 0.5, ±0.75,
and ±1 D42

was no difference found between SRK, SRK II, Mild to moderate KCN
and SRK/T formulas.61 Additional research has Watson et al. evaluated 92 KCN eyes and
been conducted in support of SRK II as the most found that in mild KCN and moderate KCN
accurate formula for IOL power calculation in (Kmax 48-55 D), using the actual topographic
various KCN stages, although there was less keratometry readings with the SRK/T formula
reliability in severe KCN.62 led to 60% and 41.9% of patients with
The fourth generation formulas including postoperative refraction within 1 D of target
Holladay 2, Haigis, Olsen, and Barrett are spherical equivalent, respectively.59 This

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study evaluated SRK II, SRK/T, Holladay 1, followed by phacoemulsification using a


and Hoffer Q formulae. Similar results were standard IOL six months later. The study
found in other studies, with no advantage of yielded 5-year follow up data demonstrating
topographic-derived keratometry values over that sequential ICRS and IOL implantation
standard keratometry in mild cases.61 It was provided good visual and refractive outcomes
recommended that in mild to moderate KCN, for treatment of KCN and cataract.67
actual topographic keratometry values should
be used for IOL calculation and that the target Toric IOLs in KCN
refraction should be low myopia, between -1 Given the significant astigmatism
and -2 D. present in KCN eyes, toric IOL placement
can be considered to reduce the astigmatic
Severe KCN burden. Numerous studies have demonstrated
In severe KCN with Kmax >55 D, successful outcomes with toric IOLs in
topographic keratometry values were less KCN patients.69-71 Factors predictive of
predictable than the standard keratometry post-operative success include good pre-
value of 43.25 D often leading to a hyperopic operative spectacle-corrected visual acuity
surprise. Thus, it was recommended that in and topographic stability for at least one year.
severe KCN, the standard keratometry value Factors that predicted failure include rigid gas
of 43.25 D should be used instead of the actual permeable (RGP) or scleral lens dependence,
keratometry value and target refraction should surface irregularity, and central scarring. Toric
aim for low myopia of -1 to -2 D.59,65 IOLs likely will not eliminate the refractive
astigmatism in KCN eyes, however, they can
Corneal collagen cross-linking and significantly debulk it. Toric IOL placement
intrastromal corneal ring segments has been shown useful for mild KCN, with a
Corneal collagen crosslinking (CXL) and Kmax <48 D, whereas outcomes have been
intrastromal corneal ring segments (ICRS) are unpredictable in eyes with moderate or severe
both FDA approved treatments for KCN.60,66,67 KCN.71,72
CXL uses riboflavin and UV-A light to produce If the patient has severe KCN with Kmax
oxygen singlets and radicals and strengthen >55 D, or any progression on topography in
the lamellar fibrils within the corneal stroma, the previous year, it is best to avoid toric IOL
halting the progression of KCN. This helps placement. Placing a monofocal IOL rather
to stabilize corneal keratometry values than toric lens should also be considered
and refraction, allowing for more stable if there is significant irregular astigmatism
keratometry pre-operatively and improved in the central zone of the cornea or if there
visual acuity after cataract surgery. A two-stage is central scarring with the possibility of
approach for treatment of progressive KCN a future keratoplasty.59,73 Given that many
has been studied, involving CXL followed by KCN patients wear RGP or scleral lenses,
phacoemulsification at least six months later, it is advisable to not place a toric IOL if the
with good visual and refractive outcomes.68 patient plans to wear them again post-cataract
If crosslinking is unable to be performed surgery, as the astigmatism of the toric IOL
or does not lead to repeatable biometry will become manifest requiring bitoric RGP
measurements, ICRS should be considered lenses. These are complicated to fit and are
for further stabilization of KCN.60 Alfonso et best avoided.72 KCN eyes tend to have a larger
al. evaluated 70 eyes with ICRS placement capsular bag and a few factors which increase

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the likelihood of postoperative IOL rotation: calculation. In these patients, if the lobes
AL >25 mm, WTW >12.5 mm, and high on topography appear orthogonal within the
myopia. If toric IOL placement is planned in pupillary zone, then it may be reasonable to
these patients, surgeons may consider using a put a toric lens in place. Particularly, if the
capsular tension ring to decrease the chance keratometry is stable and the patient is older,
of post-operative IOL rotation.74,75 placing a toric lens in these patients can help
Intraoperative wavefront aberrometry to reduce the amount of residual astigmatism.
(IWA) is not particularly useful in this setting,
as the wavefront aberrometer is calculating an Anterior basement membrane dystrophy
aphakic spherical equivalent refraction rather Anterior basement membrane
than calculating the keratometry directly. dystrophy (ABMD), also known as map-dot-
Additionally, it is not reliable in very flat or fingerprint dystrophy or epithelial basement
steep corneas with K <30 D and K >60 D, membrane dystrophy (EBMD), is an autosomal
respectively. Alcon’s Optiwave Refractive dominant condition characterized by an
Analysis (ORA) system refines IOL power irregular basement membrane making the
based on a proprietary formula, utilizing corneal epithelium more prone to erosions,
biometry data that the surgeon inputs pre- particularly after ocular trauma or ocular
operatively combined with the aphakic surgery. ABMD is the most common corneal
spherical equivalent refraction. Additionally, dystrophy, affecting 2-3% of the population,
the intraoperative readings on the ORA can and can present with blurry vision and pain
vary widely, especially with the eccentric upon awakening if recurrent erosions are
fixation frequently seen in KCN eyes. Leccisotti present. A thorough history is required during
et al. studied 34 eyes with KCN who underwent the preoperative evaluation to elucidate this
refractive lens exchange with ORA. 26% of diagnosis and fluorescein staining can help
eyes required immediate intraoperative IOL identify subtle cases as patients may be
exchange to correct refractive error of more asymptomatic. If overlooked and untreated,
than 1.5 D and 6% required IOL exchange ABMD can affect the quality of biometric
post-operatively.76 keratometric measurements obtained prior to
surgery and result in incorrect IOL selection
Pellucid marginal degeneration and reduced visual outcomes.77
Pellucid marginal degeneration has a Hyperopic surprise was noted in two
crab-claw type of irregular astigmatism on patients after placement of a multifocal
corneal topography. When looking simply at IOL, thought to be due to underlying EBMD.
the central cornea, pellucid may be confused Goerlitz-Jessen et al. described the change
for against-the-rule astigmatism. In reality, in keratometry values and IOL power pre-
when examining topography maps of the and post-superficial keratectomy in EBMD
entire cornea, pellucid marginal degeneration patients.78 It was noted that after superficial
produces a large amount of irregular keratectomy, mean keratometry values
astigmatism involving asymmetric against- increased and there was a change in IOL
the-rule astigmatism and inferior steepening. power for 21 of 26 patients. Additionally, in
Topographic maps of the cornea measure toric IOL-eligible eyes, the majority of eyes
the central corneal contour and thus may had a mean cylindrical power change of 1.2 D.
be inaccurate when performing IOL power Thus, appropriate diagnosis and management

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of EBMD before cataract surgery is important The majority had cataract removal with
to yield reliable measurements for surgical phacoemulsification and six eyes had
planning. In the setting of significant central extracapsular removal. IOL power calculation
epithelial changes, particularly in patients who were based on corneal keratometry of the
wish to minimize residual refractive error and corneal graft and led to improvement in
maximize best-corrected vision after cataract spherical equivalent with stable cylindrical
surgery, it is advisable to perform superficial refraction as the astigmatism was corneal in
keratectomy before selecting the IOL power. etiology. There was low risk of graft failure
Once the corneal epithelium has healed and following cataract extraction, with 97% of the
keratometry values have stabilized (typically grafts remaining clear at follow up.81
after several weeks to months), topography Penetrating keratoplasty can induce
and optical biometry can be repeated. high degrees of astigmatism, affecting the
visual outcome post-operatively. Corneal
Post-Corneal Transplantation astigmatism following PK can be treated with
incisional corneal treatment such as arcuate
Post-Penetrating Keratoplasty (PK)/Deep
keratotomy, laser keratorefractive surgery,
Anterior Lamellar Keratoplasty (DALK)
and IOL implantation, however post-operative
Cataract formation occurs more rapidly results can vary widely with suboptimal visual
after corneal transplantation due to postoperative outcomes or regression over time.82-84 Studies
steroid use and intraoperative iris manipulation. have reported good visual outcomes with
Rathi et al studied 184 patients who underwent implantation of toric IOLs to correct post-
PK and found that 24% developed a cataract keratoplasty astigmatism and cataract.84-90
within the first few years after surgery, and the Srinivasan et al. analyzed post-PK toric
majority were within the first post-operative IOL placement, secondary piggyback lens
year.79 Thus, cataract surgery is an important placement, and endothelial cell loss following
aspect of achieving good postoperative visual post-PK cataract surgery. Their study found
outcomes after PK. Stabilization of keratometric a mean endothelial cell loss of 9.9% in the 9
readings in transplanted eyes is essential prior eyes studied with no graft failure.85 Cataract
to phacoemulsification, and many factors can surgery with monofocal and toric lenses post-
affect accurate measurements. As corneal suture keratoplasty is effective, with improvement in
removal leads to significant changes in corneal visual outcomes, however one must ensure
curvature, biometry obtained after removal stability of the graft and analyze keratometric
of corneal sutures is more reliable and leads measurements carefully before choosing the
to better accuracy of IOL power calculation.80 IOL model and power.
ACD and AL are also stabilized after penetrating
keratoplasty compared with measurements Simultaneous PK (Triple Procedure)
obtained for a triple procedure (combined PK, Although staged cataract surgery after
cataract extraction, and IOL placement). Thus, penetrating keratoplasty allows for more
deferring biometry measurements and cataract accurate measurements, performing multiple
surgery until after the cornea has stabilized separate surgeries can prolong the process of
allows for improved accuracy of IOL selection. visual rehabilitation. Additionally, staging the
One study by Nagra et al. examined 29 cataract surgery can risk causing endothelial
eyes of 24 patients that underwent cataract damage to the new corneal transplant. In
extraction after penetrating keratoplasty. some situations, it may be necessary to

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perform a triple procedure, which consists of keratometry readings given the variability of
a penetrating keratoplasty, cataract extraction, postoperative measurements.
and IOL implantation.91,92 Combined surgery Another study utilized donor keratometry
can also reduce the overall cost of surgery readings for IOL power calculation, as their
and risks of separate anesthesia episodes, prospective study noted a correlation between
particularly in patients with multiple postoperative corneal power and donor corneal
comorbidities. power.98 Flowers et al. compared SRKII, SRK/T,
Of course, the triple procedure has its Holladay, and Hoffer Q formulas and found that
own risks. The cataract is typically removed choice of IOL power formula does not affect
“open sky”, after the patient’s cornea has IOL power prediction.99 More recently, Inoue
been removed but before the donor cornea described a case in which the SRK formula
has been sutured in place. This result in an was used in combination with keratometry
increased risk of suprachoroidal hemorrhage, readings of 42 D for a refractive target of -2 D.
which can lead to excess vitreous pressure, A myopic target was selected because aiming
making the IOL implantation more difficult. for emmetropia often led to high hyperopic
Refractive results are highly unpredictable outcomes after suture removal.91
due to the need for the surgeon to estimate the
post-keratoplasty keratometry values in order DSAEK
to calculate the IOL power. Descemet stripping automated
There is no consensus regarding obtaining endothelial keratoplasty, or DSAEK, replaces
accurate IOL power measurements for a triple the central diseased endothelium and
procedure. Taylor first described this procedure Descemet membrane with donor posterior
in 1976 and implanted an +18.0 D lens in all corneal stroma and endothelium. After DSAEK,
eyes.93 Katz compared keratometry readings of a hyperopic shift has been reported, thought to
the operative eye versus the fellow eye versus result from the concave-shaped configuration
simply using a standard corneal power of 42 D. of the endothelial graft, thicker in the periphery
He found that measuring the operative eye led and thinner in the center.100-103 Several studies
to a more accurate intraocular lens calculation.94 have reported this refractive shift, ranging
In contrast, Crawford et al. noted that there from 0.7 to 1.5 D.101,102,104-107 As the physiologic
is no correlation between pre- and post- relationship between the anterior and posterior
operative keratometry given the many variables corneal surfaces are altered after DSAEK, the
surrounding a PK: recipient bed configuration, accuracy of keratometry measurements and
donor button shape, suture pattern, depth of IOL power calculation is reduced, which makes
suture placement, tightness of sutures, ratio choosing an IOL for cataract surgery more
of donor cornea to host corneal diameters, complicated.108 Given the hyperopic shift post-
and variability in the same surgeon.95 If the DSAEK, in eyes with endothelial dysfunction
surgeon knows their own average postoperative that will eventually require DSAEK, many
keratometry readings and A-constant , more surgeons target -1 to -1.5 D when selecting the
predictable post-operative refractive error can IOL. Additionally, keratometry values based on
be obtained.96 Musch and Meyer studied 52 corneal tomography (rather than topography)
patients and used their own formula (IOL power are more reliable given that tomography
= 56.95 – 1.62 x AL), and found that 85% of their measures both the anterior and posterior
triple procedure patients had 20/40 or better surfaces of the cornea. In phakic patients with
visual acuity.97 This formula is independent of visually significant cataract and endothelial

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dysfunction, combined phacoemulsification membrane and endothelium. The graft is much


with DSAEK can be performed. In these thinner because it does not include any donor
combined cases, the refractive aim would stroma, allowing for faster visual rehabilitation
similarly be slight myopia to counteract the and improved corneal transparency compared
expected hyperopic shift from the DSAEK to DSAEK. Accurate IOL calculation are
donor lenticule. particularly important after DMEK, given the
In eyes with an early cataract, in a possibility of near-complete visual recovery.115
younger patient, or in cases when the anterior There is a slight refractive change after DMEK,
chamber is poorly visualized, a surgeon may opt noted to be +0.32 + 1.01 D in a study by Ham
for endothelial keratoplasty alone. However, et al.116 The hyperopic shift is thought to result
endothelial keratoplasty may accelerate the from a reversal of the preceding myopic shift
rate of cataract formation. There may be from stromal swelling in endothelial disease.116
concern about damaging the endothelium This hyperopic refractive surprise has also
of the endothelial keratoplasty graft with been noted in studies looking at eyes after
triple DMEK. Although a DMEK graft does
subsequent cataract surgery. In theory,
not induce as much change as DSAEK with
performing DSAEK first, followed by staged
respect to the refractive power of the posterior
cataract surgery, may allow for more accurate
corneal surface, this can also be a factor which
IOL power calculation. However, the anterior
explains some of the hyperopic shift from a
and posterior corneal curvature relationship is
DMEK graft.117 Most optical biometers do
altered, so IOL calculation may still be amiss. A
not measure the posterior corneal surface
case report from LV Prasad Eye Institute aimed
directly, but rather estimate it by using the
for a target of -0.5 D in a patient undergoing
corneal refractive index and measurements
cataract surgery after DSAEK. At three-month
of the anterior corneal surface.118 The
follow up, the graft was compact with excellent
keratometric power is overestimated by
visual outcome of 20/30.109
the IOL Master in eyes post-DMEK due to
Conventional DSAEK grafts have generally the changes in anterior/posterior corneal
been thicker than 130 microns. More recently, curvature relationship, and thus the refractive
ultrathin and nanothin DSAEK grafts have been target for IOL power selection should be slight
used for endothelial keratoplasty, measuring less myopia.119,120
than 100 microns and 50 microns, respectively.110-114
Scheimpflug-based tomography systems
No studies have been published to date analyzing
measure the curvature of both the anterior and
IOL power calculation or cataract surgery
posterior cornea, allowing for more accurate
outcomes after ultrathin or nanothin DSAEK.
keratometry. A study of 28 eyes performed
However, given that the donor tissue is thinner IOL power calculation with Pentacam imaging
than prior DSAEK tissue, the hyperopic shift post- and compared pre- and post-DMEK surgery
DSAEK is likely less and thus a target refraction measurements. In the central cornea, the
closer to plano (less myopic) may achieve good simK value changed minimally, however the
post-operative outcomes. post-operative total corneal refractive power
(TCRP) decreased significantly compared with
Post-DMEK the pre-operative values. The study concluded
Descemet’s membrane endothelial that DMEK surgery induces a 1D decrease in
keratoplasty (DMEK) replaces damaged host the TCRP and that this should be taken into
endothelial cells by using donor Descemet’s consideration when calculating IOL power.117

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Correction of Residual Refractive Error For example, if the target refraction was plano
After cataract extraction and IOL and the postoperative refraction was -0.5 D, then
placement, residual refractive error may need when estimating the IOL power needed for IOL
to be addressed. Although this can frequently exchange, the surgeon should aim closer to +0.5
be addressed with conservative measures D with a lower power lens.
such as glasses or contact lenses, sometimes Another option for estimating IOL
this may require additional surgery. Options power needed in IOL exchange is to use an
include laser keratorefractive surgery, IOL Excel spreadsheet provided by Dr. Warren
exchange, and piggyback IOL placement. Hill, available on his website.122 Calculation
are based on the refractive vergence formula
IOL exchange described previously. Patient information
required includes ELP, vertex distance, steep
Refractive Vergence Formula
and flat K values, current refraction, and
The Refractive Vergence Formula, as desired spherical equivalent refractive target
described by Holladay in 1993, calculates the post-IOL exchange. The IOL power provided
optical power that must be added to or subtracted in this spreadsheet is the IOL power added to,
from the eye when a significant refractive or subtracted from, the eye based on desired
error is noted.121 This formula is described for post-operative refraction. For example, if the
pseudophakic or aphakic eyes, however, it can original IOL placed resulted in a postoperative
also be applied to the phakic eye. hyperopic refraction of +0.5 D, the IOL power
on the spreadsheet will note a positive value,
indicating by how much the IOL power should
be strengthened to achieve the desired target
postoperative refraction.

Piggyback IOL 
Occasionally following cataract surgery,
To calculate the IOL power required for a when the postoperative refraction is not
target refraction, the effective lens position (ELPo) acceptable to the patient and the surgeon,
is required, as well as the pre-operative (PreRx) a second IOL can be placed in the ciliary
and post-operative (DPostRx) refractions. The sulcus rather than exchanging the IOL. This
net optical power of the cornea (Ko) is calculated second lens is termed a “piggyback” IOL. This
by multiplying the keratometric power of the approach may be preferred over a refractive
cornea by 0.98765431. The vertex distance (V) is lens exchange for a few reasons:121
12.0 mm. The ELP of an anterior chamber IOL, a. Removing the original IOL may rupture
sulcus IOL, and capsular bag IOL is 3.50, 4.80, the capsule and/or loosen zonules,
and 5.55 mm, respectively. making placement of a second IOL more
Many surgeons prefer to utilize the pre- challenging.
operative IOL calculation and compare the target b. Inserting a piggyback lens is easier
IOL power and refractive goal with the final technically than attempting a lens exchange.
refraction. If there is a discrepancy noted between
c. The true cause of refractive error is unknown.
the target and final refraction, the surgeon
can then estimate based on that difference the On the contrary, there are risks associated
change in IOL power needed for IOL exchange. with piggyback IOL placement as well:

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a. Development of uveitis-glaucoma-hyphema setting of proliferative vitreoretinopathy and/


(UGH) syndrome or proliferative diabetic retinopathy.
1. Higher risk in shorter eyes due to sulcus There are two main issues a surgeon
location of piggyback lens. should consider when faced with a silicone oil-
2. Higher risk when correcting for hyperopic filled eye. First, the refractive index of silicone
surprise – the piggyback lens shape oil differs vastly from that of the vitreous and
required is concave (thicker in the as a result, the effective power of the IOL is
periphery than in the center) which could altered. The silicone oil causes a significant
contribute to increased chafing of the iris. hyperopic shift and acts as a negative lens when
b. Formation of interlenticular opacification a biconvex IOL is implanted. Second, silicone
– if the optics of the original and piggyback oil in the vitreous cavity leads to erroneous AL
lenses are made of the same material, there measurements, especially if the silicone oil has
is a tendency for a layer of lens epithelial been emulsified. Due to these issues, only 1/3
cells to grow in between the two IOLs. This is of eyes filled with silicone oil achieve within
primarily a concern when both IOLs are placed +1.0 D of target refraction despite employing
within the capsular bag. Nd:YAG capsulotomy optical biometry and correct calculation
is not effective to remove this membrane formulas, compared to 97.2% of normal eyes.125
and management typically requires surgical Other studies have also reported variable post-
removal of both IOLs. Choosing a piggyback operative refractive results, ranging from 30-
lens with an optic made of a different material 85% within +1.0 D of target refraction.126
can prevent this complication. The most pertinent question for surgical
c. Centration of the piggyback lens within the planning in these situations is how long the
ciliary sulcus is important to achieve good silicone oil will stay in the eye. Short-term
postoperative refractive outcomes. solutions, such as a contact lens or piggyback
IOL placement, can be utilized if the silicone
To calculate the required power of a
oil is temporary.
piggyback lens, the only required data include
the patient’s pseudophakic refractive error
AL measurement
and the A-constant for the piggyback IOL.123
The viscosity of silicone oil is very
In patients with a post-operative hyperopic
different from that of the vitreous. This changes
surprise, multiply the post-operative spherical
the attenuation on returning soundwaves
equivalent by 1.5 to estimate the required
during ultrasound measurement of AL. There
piggyback IOL power. To correct a myopic
are currently two viscosities of silicone oil in
post-operative outcome, multiply by the
use: 1,000 mPa.s silicone oil (Silikon, Alcon
post-operative spherical equivalent by 1.2 to
Laboratories, Ft. Worth, Texas) slows sound
calculate the piggyback IOL power needed.124
waves to 980 m/sec (little more than half the
The refractive vergence formula can also be
speed of normal vitreous) and 5,000 mPa.s.
used to calculate piggyback IOL power.
silicone oil (ADATO SIL-ol 5000, Bausch &
Retina pathology Lomb Surgical, San Dimas, California) slows
sound waves to approximately 1,040 m/sec.
Silicone oil Due to this, ultrasound measurement
Silicone is commonly used to manage of AL has been traditionally inconsistent
complex retinal detachments, often in the and clinically inadequate. Based on a paper

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THE INTRAOCULAR LENS POWER CALCULATION

by Murray et al., true AL can be calculated when compared with other lenses.130 Biconvex
from various measurements of the ACD, lens IOLs should also be avoided as the silicone
thickness, and vitreous cavity depth with oil will alter the refractive power of the IOL’s
adjustments for the sound velocity.127 This posterior surface. As mentioned previously,
tedious process has largely been avoided with the difference in the refractive index of silicone
the advent of optical biometry based on partial oil results in a significant hyperopic shift,
coherence interferometry (PCI), which utilizes especially when a biconvex lens is implanted.
light to measure the various part of the eye. Hotta and Sugitani found a mean hyperopic
Swept source optical coherence shift of +5.69 D ± 1.71 D with silicone oil
tomography (SS-OCT) is one of the newest instillation following placement of a biconvex
optical technologies used to determine IOL.131 There was also a strong correlation
biometric parameters. SS-OCT has the between the posterior radius of the IOL and
advantage of using longer wavelengths than the absolute refractive shift, indicating that
PCI, which results in deeper light penetration the steeper the posterior convex curvature,
and significantly improves the rate of the greater the refractive deviations.
attainable AL measurements.128 Since the posterior surface is flat
If the plan is to either remove the oil against the silicone oil, convex-plano IOLs are
at the time of the cataract surgery, or soon recommended as it decreases the degree of
thereafter, the IOL power should be calculated refractive error when placed in a silicone oil
using the silicone oil setting on the biometer, filled eye. Of note, these lenses are composed
but without making additional adjustments of poly methyl methacrylate (PMMA) and
to the IOL power. AL measurements in these require large scleral incisions as they are
cases can also be obtained intraoperatively non-foldable. Even with the usage of PMMA
following silicone oil removal by the convex-plano lens, additional adjustment
vitreoretinal surgeon. A piggyback IOL can to the IOL power should be performed to
be placed later in the sulcus to overcome the account for the silicone oil. The additional
anticipated hyperopic shift (and should be of power needed for a convex-plano PMMA IOL
a three-piece IOL of a different material) to is usually between +3.0 to +3.5 D when using
avoid the risk of interlenticular opacification. average eye dimensions. The formula below
Al-Habboubi et al., compared the performance can be used to calculate the adjustment and
of third-generation formulas including Hoffer it is also available on www.doctor-hill.com.132
Q, Holladay 1, and SRK/T formulas in silicone
oil-filled eyes based on PCI biometry and Additional IOL power (D) = ((Ns-Nv)/(AL-
found satisfactory prediction accuracy in all ACD)) x 1.000
formulas.129 Ns = refractive index of silicone oil (1.4034)
On the other hand, if the plan is to Nv = refractive index of vitreous (1.336)
keep the silicone oil in the eye for some time
AL = Axial Length in mm
after cataract surgery, the surgeon needs to
appropriately select both the lens material ACD = anterior chamber depth in mm.
and power calculation. Silicone lenses should
be avoided as the silicone oil will adhere to its Scleral buckle
surface and alter the optical quality. This was The scleral buckle (SB) was first
demonstrated by Apple et al., which found introduced in 1937 as a treatment for
100% adherence of silicone oil to silicone IOLs rhegmatogenous retinal detachments and

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greatly alters the anatomy of the eye due to Posterior staphyloma


its circumferential tightening of the globe. Posterior staphyloma is considered as
Significant changes include increased AL, a hallmark of pathologic myopia, as it can
increased ACD, and induced astigmatic errors be found in 70% of eyes with AL >33.5 mm.
and/or myopic shifts.133 These findings are Patients with posterior staphyloma generally
echoed by various studies, including Albanese have poorer vision compared to normal eyes
et al., who found mean increase in AL of 0.83 due to the presence of myopic degeneration
mm, a mean decrease in ACD of 0.09, and in the macula. Problem can arise in AL
mean myopic shift of 1.35 D.134 measurements using ultrasound, as the most
In eyes with a SB, optical biometry posterior portion of the globe (anatomic AL)
is preferred over conventional ultrasound may not correspond with the fovea (refractive
methods in measuring the AL, as ultrasound AL).138
uses the vitreoretinal interface as the posterior The simplest and easiest way to accurately
target, which can be underestimated by the measure the AL is via optical biometry.
interface of the detached retina. In terms of However, in cases of poor vision (where the
the timing of measurement, Lee et al. found patient cannot fixate) or unavailability of optical
that AL measurements stabilized 3 months biometry, immersion vector A/B-scan can
following SB and therefore recommends be used to measure the refractive AL. This
biometry to be performed no earlier than 3 method, when performed correctly, allows
months post SB surgery.135 for accurate measurement of the refractive
Fourth generation formulas, such as the AL by intersecting the vectors of the B-scan
Haigis, Olsen, Holladay 2, and Hoffer 2, are and A-scan at the foveal region. Specific
recommended in patients undergoing cataract instructions on this method are available at
surgery following SB placement. This is due www.doctor-hill.com.139
to the concomitant long-term shallowing of In terms of choosing the appropriate
the AC following SB surgery, which can pose IOL power calculation formulas in the setting
inaccuracies in third-generation formulas that of posterior staphyloma, please refer to the
predict ELP based on AL and keratometry. long AL section under the sub-chapter of Axial
In contrast, fourth-generation formulas that Length above.
employ modern ELP prediction algorithms
based on preoperative ACD will help improve Non-capsular IOL placement
accuracy.133 When capsular or zonular support is
inadequate for placement of an IOL within
Post-vitrectomy the capsular bag, a lens may be inserted
While some find more variable outcomes in a different location to achieve visual
and hyperopic surprise in patients after pars rehabilitation. This usually occurs when
plana vitrectomy compared to normal eyes there is a defect in either the capsule or the
regardless of calculation method136, multiple zonules from prior trauma, disease (such as
studies have found similar refractive outcomes pseudoexfoliation), or surgical complication,
in patients with previous vitrectomy compared which can impact the integrity and stability of
to normal controls.137 Lamson et al. found that capsular bag placement. Late dislocation can
the Holladay 2 formula was most accurate, with also occur months to years after uncomplicated
60.42% of eyes within 0.5 D of refractive target.136 cataract surgery, leading to lens subluxation

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and/or dislocation into the vitreous cavity. power causing a greater difference between
Options for non-capsular IOL placement and capsule and sulcus placement. For instance, if
considerations for IOL power calculation in the predicted IOL power is from 18.0 to 25.0 D,
these specific situations are described below. the power should be reduced by at least 1.0 D
for sulcus placement, and if the predicted IOL
Anterior Chamber placement power is greater than 25.0 D, the power should
Anterior chamber IOL (ACIOL) be reduced by 1.5 to 2.0 D.141 This assumes that
placement should only be performed if the the capsular bag ELP is 5.20 mm, as with the
patient has a healthy corneal endothelium Alcon MA60AC lens. The ELP is estimated to
and a normal ACD. Complications can include be 4.70 mm for the ciliary sulcus. Of note, when
endothelial damage (which may progress to choosing a lens for sulcus placement, a three-
pseudophakic bullous keratopathy), chronic piece lens with thinner, longer haptics and a
iris-lens chaffing leading to UGH syndrome, more posteriorly vaulted optic is generally
and cystoid macular edema. Flexible open- preferred over a one-piece lens with thicker,
loop ACIOL implant designs have improved shorter haptics. This is due to a decreased risk
the rates of these complications, but significant of chronic iris rubbing (and therefore UGH
issues remain with malposition and improper syndrome) and lens decentration. Additionally,
sizing of the implant to the white-to-white if the anterior capsule is still intact, performing
corneal diameter. In ACIOL placement, the optic capture within the anterior capsule with
lens is more anterior compared to capsular haptic sulcus placement can provide more
placement which causes an increase in overall stability than passive sulcus fixation without
effective power. Thus, an ACIOL requires optic capture.142 If optic capture is performed,
less power to achieve the refractive goal. To the adjustment to the IOL power is much
calculate the IOL power, the A-constant can smaller, if needed at all, since the estimated
be used (particularly if this decision is made lens position of the optic is essentially equal to
intraoperatively), as the difference between where it would be in the capsule.
A-constant s is equal to the difference in IOL
power. Subtracting the difference between Iris fixation
A-constant s from the capsular IOL power An advantage of iris-sutured posterior
will result in the AC IOL power.140 In terms of chamber IOL placement, especially with in-the-
diameter, the ACIOL should be 1.0 mm greater bag IOL subluxation or dislocation, is that there
than the horizontal white-to-white corneal is no need for IOL exchange. However, due to the
diameter. abundant vascular network of the iris, potential
complications include recurrent bleeding/
Sulcus placement hyphema or UGH syndrome. For iris-sutured
Ciliary sulcus placement, as with AC IOL fixation, there does not need to be an IOL
placement, means the IOL is more anterior power calculation adjustment, as the ELP is
compared to capsular placement, causing an essentially equal to that of capsular placement.
increase in overall effective power and myopic Results of a retrospective, non-randomized,
shift.(See also Chapter 2) Therefore, a decrease non-comparative case series found that only a
in the IOL power is required to compensate for moderate lens power adjustment may be required
this more anterior lens position. The amount when using the Barrett Universal II formula II
of change is based on the base power of the for eyes with long AL (equal to or greater than
IOL at the capsular bag, with a greater base 25.5 mm).143 The authors found that in eyes

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with normal AL, the overall prediction error was flanged intrascleral fixation. The fibrin-glue
moderate, despite the lack of any adjustments. assisted technique utilizes intrascleral pockets
They postulate that suturing the lens to the iris for securing the haptics. This strategy was
leads to a slight posterior displacement of the originally proposed by Dr. Gabor Scharioth
iris diaphragm, which places the IOL near the and refined by Dr. Amar Agarwal.145 Flanged
ELP of a capsular IOL, and thus no IOL power intrascleral fixation was described by Dr. Shin
adjustment is needed. Yamane. This method uses 30-gauge needles
to create scleral tunnels, through which the
Scleral fixation haptics of a 3-piece lens are externalized,
Trans-scleral suture fixation is achieved flanged with low-temperature cautery, and
by directly suturing the IOL haptics through then tucked back into the sclera to securely
the ciliary sulcus or pars plana. Techniques anchor the lens.146 The Zeiss CT Lucia 602 is
include ab externo (sutures passed outside to a 3-piece lens with polyvinylidene fluoride
inside) or ab interno (sutures passed inside to (PVDF) monofilament haptics, rather than
outside) approaches, and with or without the polypropylene haptics. PVDF haptics have
use of scleral pockets (“Hoffman pockets”).144 been found to be stronger with better stability,
If there is capsular bag instability or dialysis, particularly for the Yamane ISHF technique.
scleral fixation may be the better option There is unfortunately no IOL calculation
compared to sulcus placement in the sulcus or formula specifically for scleral-sutured IOLs
iris-fixation, which often rely on the anterior or ISHF, and ELP may vary depending on the
capsule for supplemental support. surgical technique and how far posterior to the
There are several types of IOLs used limbus the haptics are anchored. This leads
for trans-scleral suture fixation, including the to a more variable post-operative refraction
Alcon CZ70BD, the Bausch and Lomb Akreos compared to capsular placement. The more
AO60, or the Bausch and Lomb enVista MX60, anterior the haptics are fixated, the more
which all contain haptic eyelets through anterior the ELP is, and the greater the overall
which sutures can be passed. It is important effective power (and therefore the more
to keep in mind that these techniques are myopic the refractive outcome).147 There has
considered “off-label”. Traditionally, 10-0 been reported success of using an in-the-bag
polypropylene sutures have been used, but target of around -1.0 D, intentionally erring
due to their increased durability and thickness on the side of myopia in order to prevent
9-0 polypropylene and CV-8 (7-0) Gore-Tex an unwanted hyperopic surprise in scleral-
have become more popular. This technique sutured cases. In a retrospective case series
typically requires larger incisions (4.0 mm for examining different IOL power calculation
the Akreos AO60, and 7.0 mm for the Alcon formulas used in 31 scleral-sutured cases, with
CZ70BD), and risks include suture breakage lenses sutured 3.0 mm behind the limbus with
or conjunctival erosion over the suture knot, an in-the-bag IOL power target, the Barrett
which can increase the risk of endophthalmitis. Universal II, SRK/T, Holladay 2, and Hoffer
Intrascleral haptic fixation (ISHF), Q formulas were found to be non-inferior to
which is suture-less and performed through a each other.148
smaller incision compared to scleral-sutured For the Yamane ISHF technique, the
IOL placement, is achieved by burying the haptics are typically placed 2.0 mm posterior
IOL haptics in scleral tunnels or flaps through to the limbus. For the fibrin-glued ISHF
two general techniques: fibrin-glue assisted or technique, the sclerotomies are typically made

Gede Pardianto
Dhawlikar NS, Dai (Ed.)
YL, Hughes KV, Rao NK. 63
THE INTRAOCULAR LENS POWER CALCULATION

1.0 to 1.5 mm posterior to the limbus. IOL Surg. 2016;42(10):1490-1500. doi: 10.1016/j.
power can be determined using the A-constant jcrs.2016.07.021. PMID: 27839605.
and Barrett Universal II Formula. In general, 6. Haigis W. Intraocular lens calculation after
as with scleral-sutured IOLs, surgeons target refractive surgery for myopia: Haigis-L formula. J
these patients to be slightly myopic (-0.5 D Cataract Refract Surg. 2008;34(10):1658-1663. doi:
to -1.00 D) and adjust based on their prior 10.1016/j.jcrs.2008.06.029. PMID: 18812114.
refractive outcomes. It is important to keep in
7. Terzi E, Wang L, Kohnen T. Accuracy of modern
mind that with the Yamane ISHF technique,
intraocular lens power calculation formulas in
while trimming the haptics can often improve
refractive lens exchange for high myopia and high
the lens centration, it will also move the
hyperopia. J Cataract Refract Surg. 2009;35(7):1181-
optic anteriorly, thus creating a more myopic
1189. doi: 10.1016/j.jcrs.2009.02.026. PMID:
result. A modified version of the Yamane ISHF
19545805.
technique, using trocars to form the scleral
tunnels, has been reported to cause a more 8. Hill W. Optical Biometry Lens Constants, The Haigis
posterior IOL position and tendency toward Formula East Valley Ophthalmology. (https://www.
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within the sclerotomies.149 Precision of Intraocular Lens Calculation Using the
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10.1016/j.ophtha.2008.02.010. Trial of Ultrathin Descemet Stripping Automated
104. Koenig SB, Covert DJ, Dupps WJ, Jr., Meisler DM. Endothelial Keratoplasty (DSAEK) versus DSAEK.
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recovery and refractive stability in modern corneal
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dehydration-induced hyperopic shift on intraocular
110. Neff KD, Biber JM, Holland EJ. Comparison of central lens power calculation. J Cataract Refract
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endothelial keratoplasty. Cornea. 2011;30(4):388- jcrs.2011.02.033. PMID: 21782088.
391. DOI: 10.1097/ICO.0b013e3181f236c6.
117. Alnawaiseh M, Rosentreter A, Eter N, Zumhagen L.
111. Busin M, Madi S, Santorum P, Scorcia V, Beltz Changes in Corneal Refractive Power for Patients
J. Ultrathin descemet's stripping automated With Fuchs Endothelial Dystrophy After DMEK.
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double-pass technique: two-year outcomes. ICO.0000000000000842.
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cataract surgery. Ophthalmology. 2013;120(2):234- 127. Murray DC, Potamitis T, Good P, Kirkby GR, Benson
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Alnawaiseh M. Assessing the validity of corneal Khandekar R. Visual Outcomes and Refractive
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with Fuch's dystrophy undergoing Descemet Implantation. J Ophthalmic Vis Res. 2018;13(1):17-
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123. Gayton JL, Sanders V, Van der Karr M, Raanan www.doctor-hill.com/iol-main/silicone.htm).
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Error After Cataract Surgery. CRS Today. (https:// M, Gharbiya M. Long-term ocular biometric
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lenses and long-term stability. Clin Exp Ophthalmol.
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72 Gede
Chapter 5: IOL Power Calculation Pardianto
in Special (Ed.)
Situations
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Authors:
Nisha S. Dhawlikar

Financial Disclosure: None

Yi Ling Dai

Financial Disclosure: None

Kate V. Hughes

Financial Disclosure: None

Naveen K. Rao

Financial Disclosure: None

How to cite this chapter:


Dhawlikar NS, Dai YL, Hughes KV, Rao NK. IOL Power Calculation in Special Situations. In: Pardianto G,
editor. The Intraocular Lens Power Calculation. Medan: Anak Sudarti Foundation. 2022; 43-73.

Gede Pardianto
Dhawlikar NS, Dai (Ed.)
YL, Hughes KV, Rao NK. 73
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74 Gede Pardianto (Ed.)


THE INTRAOCULAR LENS POWER CALCULATION

Chapter 6
Toric IOL Power Calculation and
Managing Residual Astigmatism
Brent Kramer

Introduction
Minimizing a patient’s astigmatism at the time of cataract extraction is a key step to help those
who have set down the path of spectacle independence. A toric intraocular lens (IOL) is an
invaluable tool that can help the nearly 40% of patients who have 1 D of corneal astigmatism.1,2
Since their launch in the 90’s, rotational stability of these lenses has improved3-6 and the breadth
of knowledge regarding surgically induced astigmatism (SIA) and posterior corneal astigmatism
(PCA) has expanded. Despite these advances, 1 D of residual astigmatism post toric IOL
placement can still occur in up to 10% of cases.3,4 Regarding residual astigmatism, it is easily
stated that an ounce of prevention is worth a pound of cure. However, a clear and confident
strategy in managing residual astigmatism can limit patient and surgeon dissatisfaction and
frustration alike. This chapter will discuss strategies to help best utilize toric IOLs and also how
to manage residual astigmatism when it arises.

The pre-op evaluation


Patient selection
Patient selection for toric IOL placement is an understated key to success. A patient should
have some degree of motivation for postoperative spectacle independence but also understand
the goal of astigmatism reduction rather than complete elimination. Toric IOLs are designed for
patients with regular corneal astigmatism and their use in irregular corneal astigmatism may
be contraindicated. It is also important to note that toric IOLs should not be placed in patients
who intend to wear hard contact lenses after their surgery.
Another critical aspect of patient selection is evaluation of the ocular surface. Corneal
fluoresceine staining and tear breakup time are cost effective and quick tests that should
be performed during every cataract evaluation. It is important to take the time to optimize
the surface and repeat calculations if necessary. If ocular surface diseases such as anterior
basement membrane dystrophy (ABMD), Salzman Nodular Degeneration, or pterygium are
present, they must be addressed with superficial keratectomy or excision, and measurements

Gede Pardianto (Ed.) 75


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should be repeated 1-3 months later. If a measurements should be obtained to be certain


patient is unwilling to invest the time, effort, of the patient’s baseline corneal astigmatism.5
and resources to optimize their surface, they If a patient is dependent on contact lenses
may not be a good candidate for a toric IOL. for functional vision, staging the contact lens
holiday and surgeries may be necessary.
Measurement If using intraoperative aberrometry it is
The anterior surface of the cornea can be important the patient remains out of contact
measured directly via many methods: manual lenses through the surgical date.
keratometry, automated keratometry, placido-
disc topography, slit-scanning topography, Calculation (Formulas, SIA, posterior
optical coherence tomography (OCT), corneal astigmatism (PCA))
Scheimpflug imaging, partial coherence While there are many toric calculators
interferometry (PCI), optical low-coherence available, the author prefers the Barrett
reflectometry (OLCR), post-source color Toric Calculator with predicted posterior
light-emitting diode topographers and others. corneal astigmatism (PCA) (freely available
A common means of validating both the at APACRS.org). Regardless of the formula
magnitude and axis of corneal astigmatism is used, PCA cannot be ignored as it typically
to utilize multiple methods from above and contributes 0.2 to 0.3 diopters (D) of against-
ensure similar results. Higher variability is the-rule (ATR) astigmatism to the overall
anticipated and tolerable for lower amounts refraction.6 Disregarding PCA altogether will
of astigmatism, while higher magnitudes of result in under correction of with-the-rule
astigmatism are expected to be more precise (WTR) astigmatism and over correction of ATR
across platforms and modalities. astigmatism. Fortunately, there are multiple
It is the author’s anecdotal preference to methods that can be utilized to account for
compare keratometry values from automatic PCA. The Baylor Toric Nomogram was the first
keratometry, biometry, and tomography, and published algorithm available.7 Most modern
ultimately utilize the K values from a biometry calculators will either predict PCA via an
device for final calculation (either LenStar algorithm or offer an option to account for PCA
LS900 [Haag-Striet, Köniz, Switzerland] or via total or posterior corneal measurements.
IOLMaster700 [Carl Zeiss, Oberkochen, It is important to ensure one does not account
Germany]). Ensuring the patient’s head is for PCA twice by using both methods (e.g. you
straight during the measurement (i.e. not cannot enter total corneal measurements from
tilted to the left or right) is important to ensure a tomographer into the Barrett Toric Calculator;
an accurate axis measurement. you will be accounting for PCA twice. To use
tomography values, you must select “measured
Contact Lens Considerations PCA” and enter the posterior corneal values as a
Due to corneal warpage in long-term separate entry.)
wearers, discontinuation of contact lens use Another consideration in toric IOL
prior to initial evaluation is recommended. power calculation is surgically induced
While Polymethyl methacrylate (PMMA) and astigmatism (SIA).8 To clarify, SIA here refers
rigid gas permeable (RGP) lenses typically to surgically induced corneal astigmatism
cause the most warpage, soft contact lenses created by the incision made during surgery.
have also been shown to have a significant In principle the cornea should flatten along
effect. Ideally, two similar consecutive the axis of the incision, although the axis and

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Chapter 6: Toric IOL Power Calculation and Managing Pardianto
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THE INTRAOCULAR LENS POWER CALCULATION

magnitude of flattening can be highly variable marking and to prevent cyclorotation. One can
between patients. Due to the high variability mark the horizontal and/or vertical meridians
in SIA compared to the low mean of induced and use these as reference points or mark the
astigmatism, the author does not account for intended axis directly by using devices such as
it in their calculations.9 If accounting for SIA, the RoboMarker (Surgilum, Wilmington, North
one should either use a small amount (~0.1 Carolina, USA).
D), or utilize Dr. Warren Hills SIA calculator
(https://sia-calculator.com/) to calculate their Intraoperative considerations
personal SIA. An important step to consider that
A final consideration when making will assist with good post-operative IOL
calculations is the natural drift of corneal positioning is the capsulorhexis. Maintaining
astigmatism to higher ATR astigmatism over an appropriately sized continuous curvilinear
time.6 While minimizing astigmatism is the first capsulorhexis that will provide 360° overlap
priority, if between toric powers, it is typically of the optic edge may improve stability and
preferrable to leave a patient with slightly more centration and also limit IOL tilt. After the
WTR astigmatism opposed to ATR astigmatism. IOL is placed and in good position removing
Overall, there are many ways to OVD from behind the lens is critical to prevent
calculate the toric power and axis. The key is postoperative rotation. The author prefers
to be consistent in one’s methodology, track to place the irrigation and aspiration (I&A)
outcomes, and periodically analyze results to handpiece behind the lens to ensure complete
help minimize future error. removal.

The Surgery Advanced Technologies


Marking Femtosecond Laser Assisted Cataract
There are many methods to mark the axis Surgery (FLACS): If performing femtosecond
of desired toric placement. If marking the eye, it is cataract surgery, the laser may assist
important to do so preoperatively with the patient with marking the axis of lens placement.
sitting up, head straight, and fixating at a distant The LENSAR laser system (LENSAR Inc.,
target with both eyes open to ensure accurate Orlando, Florida, USA) can make marks in the

Figure 4. Toric IOL aligned with the IntelliAxis Refractive Capsulorhexis axis mark which was created
using the LENSAR femtosecond laser by using preoperative data.

Gede Pardianto
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THE INTRAOCULAR LENS POWER CALCULATION

capsulorhexis itself which eliminates possible Managing Postoperative Residual Astigmatism


parallax error (Figure 4). Other laser systems Treatment methods of residual astigma-
can make marks in the cornea at the desired tism are listed in Table 6 and a treatment
axis of placement. algorithm is seen in Figure 6.
Intraoperative Guidance Systems
Among other features, Zeiss Callisto Toric IOL Misalignment
allows the surgeon to bypass preoperative and If the toric IOL is not aligned with
intraoperative marking altogether. Reference the steep meridian of corneal astigmatism,
images are obtained during preoperative its ability to correct corneal astigmatism is
biometry and used to create an alignment diminished by roughly 3.3% for every degree
mark in the ocular of the microscope at the of misalignment. If the IOL is 90˚ away from
desired axis (Figure 5). Each time the eye is the ideal axis the astigmatism is doubled.10
marked there is the possibility of imprecision, Table 7 shows this loss of function and how
and therefore eliminating these steps may lead the absolute loss is greater in IOLs with higher
to a more precise accurate toric IOL alignment. power (Figure 7).

Figure 5. Zeiss Callisto display showing precise alignment of a toric IOL. Note that corneal marks are not
necessary and therefore aren’t seen

Intraoperative aberrometry A misaligned toric IOL can leave a post-


ORA (Alcon, Geneva, Switzerland) implant patient unsatisfied with their uncorrected
uses Talbot-Moiré interferometry to take distance visual acuity because of residual
intraoperative wavefront measurements to astigmatism. When this happens, physicians
measure total aphakic refractive astigmatism. should consider rotating the toric IOL to its ideal
The device uses these measurements in position. In doing so, several questions can help
combination with preoperative data to determine the course of action.
recommend a toric power and axis. It also
provides a display in the oculars that assists with What is the current location of the toric
aligning the lens. Pseudophakic measurements IOL?
can also be taken to ensure minimal residual It is important to check the current
astigmatism. axis of the toric IOL. While the normal

78 Gede
Chapter 6: Toric IOL Power Calculation and Managing Pardianto
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Astigmatism
THE INTRAOCULAR LENS POWER CALCULATION

angular markings on a slit lamp typically dilated, align the slit beam light on the slit
don’t offer the precision necessary to lamp with the patient’s toric IOL markings.
determine the exact IOL location, there Then, using a level app on a smartphone
are a few methods that can be used. that displays degrees of rotation, line the
A simple method identified by Dr. Roger smartphone up with the slit beam lamp to
Steinert utilizes smartphone technology. Once determine the toric IOL location.

Table 6. Treatment Methods of Residual Astigmatism

Figure 6. A treatment algorithm for residual astigmatism after toric IOL placement. (LRI: Limbal Relaxing
Incision)

Gede Pardianto
Kramer B. (Ed.) 79
THE INTRAOCULAR LENS POWER CALCULATION

Another method can be carried out shows the angulation and power of the toric
with wavefront aberrometry and corneal IOL and can be used for calculations. This
topography in a device such as the OPDScan method is particularly helpful if the toric
III (Nidek, Fremont, CA). The internal OPD power of the IOL is unknown.

Table 7. Loss of Refractive Power Upon Toric IOL Rotation

Figure 7. The effects of a misaligned SN6AT9 AcrySof Toric IOL (Alcon, Fort Worth, TX).

80 Gede
Chapter 6: Toric IOL Power Calculation and Managing Pardianto
Residual (Ed.)
Astigmatism
THE INTRAOCULAR LENS POWER CALCULATION

Does the toric IOL need to be rotated? Results Analyzer (http://astigmatismfix.com)


Once the location of the IOL is measured, (Figure 8). By entering the patient’s current
the next step is to identify if: refraction along with the toric IOL location
and power, the website calculates the ideal
a. The toric IOL is not in its intended location
toric IOL position and the expected residual
due to inaccurate placement or post
refraction. The refraction is critical and
procedure rotation, or if.
obtaining a wavefront scan with a device such
b. The intended location or power is not correct as the iDesign (Johnson&Johnson Vision, New
due to inaccurate measurements, inaccurate Brunswick, NJ, USA) to determine the exact
markings, or surprising surgically induced axis of refractive astigmatism may improve
astigmatism or posterior corneal astigmatism. accuracy of the final refraction.
While the primary treatment for residual
astigmatism is to rotate the toric IOL into its Will I have a reasonable chance of clinical
optimal location, the task of calculating the success if I rotate the IOL?
optimal toric IOL location can be difficult. It is typically not worth rotating the
This process is simplified with the Toric IOL unless it will correct at least 0.5 D of

Figure 8. Data entry and results page from the Toric Results Analyzer (freely available at astigmatismfix.com)

Gede Pardianto
Kramer B. (Ed.) 81
THE INTRAOCULAR LENS POWER CALCULATION

astigmatism. Additionally, unless the residual capsular bag with viscoelastic and place new
astigmatism will be below 0.5 D, the patient will viscoelastic posterior to the IOL to loosen it
still likely have unacceptable uncorrected visual from the posterior capsule. If there is difficulty
acuity. If there is significant residual undesired injecting OVD under the anterior capsule edge,
myopia or hyperopia, then rotation of the IOL a 25G Atkinson retrobulbar needle on OVD can
may not solve the patient’s dissatisfaction. be used to lift the anterior capsule off the edge
of the optic; the blunted tip prevents cutting of
What time frame should the toric IOL the anterior capsule. Free the capsule-capsule,
rotation surgical procedure occurs? capsule-IOL, and capsule-haptic adhesions.
The optimal timeframe in which to Ensure the haptics are free prior to rotation to
rotate the toric IOL is between 2 and 12 weeks prevent zonular trauma. Rotate the IOL (usually
post-surgery. This will allow enough time for clockwise) into the correct position, aligning
the refraction to stabilize but still allow for the corneal marks with the IOL alignment
easy rotation since complete fibrotic healing marks. Consider performing intraoperative
has not yet occurred. aberrometry to confirm astigmatism has been
minimized. If the configuration of the capsular
How do I rotate a toric IOL? bag originally allowed rotation insertion
The cornea can be marked with the of a capsular tension ring, especially the
current location of the toric IOL and then the Henderson ring with undulating contour may
ideal location (typically, the amount of rotation be useful to reduce chances of rotation of the
required in the clockwise direction). Note that IOL. Once aligned, remove the viscoelastic
when utilizing this method of marking, there from the eye and behind the IOL. Gently push
is no need to worry about cyclorotation since the IOL posteriorly to create contact between
the IOL itself is the reference point. Reopen the posterior capsule and the IOL. Ensure that
the incisions used during cataract surgery to the IOL is centered and all edges are covered
reduce the introduction of new SIA. Inflate the by the capsulorhexis. (Table 8)

Table 8. Rotating a Toric IOL

82 Gede
Chapter 6: Toric IOL Power Calculation and Managing Pardianto
Residual (Ed.)
Astigmatism
THE INTRAOCULAR LENS POWER CALCULATION

IOL Exchange IOLs. When residual astigmatism does occur,


If rotation of the IOL is not enough managing the problem effectively can help
to reduce the astigmatism to an acceptable patients get back on the path to better vision
level, exchanging the toric IOL for one with and spectacle independence.
a different power may be a viable treatment
option. The Toric Results Analyzer can help References
with this decision. 1. Hoffmann PC, Hutz WW. Analysis of biometry and
prevalence data for corneal astigmatism in 23,239
Corneal surgical correction eyes. J Cataract Refract Surg. 2010;36(9):1479-
1485. doi: 10.1016/j.jcrs.2010.02.025. PMID:
If a patient is unable to tolerate an
20692558.
intraocular procedure, if the capsular bag is
2. Wu Z, Liu C, Chen Z. Prevalence and Age-Related
compromised, or if rotation alone will not
Changes of Corneal Astigmatism in Patients
solve the problem adequately, then corneal
Undergoing Cataract Surgery in Northern
refractive surgery may be preferred. Limbal China. J Ophthalmol. 2020;2020:6385098. doi:
Relaxing Incisions (LRIs) may be a good option 10.1155/2020/6385098. PMID: 33062314; PMCID:
if the spherical equivalent of the residual PMC7542495.
refraction is near the goal. LASIK or PRK are 3. Holland E, Lane S, Horn JD, Ernest P, Arleo R,
good options if there is residual hyperopia/ Miller KM. The AcrySof Toric intraocular lens in
myopia that needs to be addressed in addition subjects with cataracts and corneal astigmatism: a
to the residual astigmatism. randomized, subject-masked, parallel-group, 1-year
study. Ophthalmology. 2010;117(11):2104-2111.
Glasses or Contacts doi: 10.1016/j.ophtha.2010.07.033. Epub 2010 Sep
Patients who’ve elected to receive toric 16. PMID: 20846724.
IOL implants during cataract surgery are 4. Visser N, Bauer NJ, Nuijts RM. Toric intraocular
usually striving for spectacle independence lenses: historical overview, patient selection,
at distance, however glasses or contacts are IOL calculation, surgical techniques, clinical
also an option, and many patients are happy outcomes, and complications. J Cataract Refract
Surg. 2013;39(4):624-637. doi: 10.1016/j.
enough with the improvement in their vision
jcrs.2013.02.020. PMID: 23522584.
from the cataract surgery and some reduction
in the refractive error that this may be a viable 5. Tsai PS, Dowidar A, Naseri A, McLeod SD. Predicting
time to refractive stability after discontinuation of
option.
rigid contact lens wear before refractive surgery. J
Cataract Refract Surg. 2004;30(11):2290-2294. doi:
Conclusion
10.1016/j.jcrs.2004.05.021. PMID: 15519077.
For any procedure, there are potential
6. Koch DD, Ali SF, Weikert MP, Shirayama M, Jenkins
pitfalls, and yet by learning pearls to improve R, Wang L. Contribution of posterior corneal
the chances for success and having tools for astigmatism to total corneal astigmatism. J
damage control when all is not as planned, Cataract Refract Surg. 2012;38(12):2080-2087.
typically the patient and surgeon are happy doi: 10.1016/j.jcrs.2012.08.036. Epub 2012 Oct 12.
with the final outcome. Future designs of PMID: 23069271.
IOLs, range of powers, and even combination 7. Koch DD, Jenkins RB, Weikert MP, Yeu E, Wang
of multifocality and astigmatism will increase L. Correcting astigmatism with toric intraocular
the use of toric IOLs, and also the importance lenses: effect of posterior corneal astigmatism.
of having a plan for success when using these J Cataract Refract Surg. 2013;39(12):1803-1809.

Gede Pardianto
Kramer B. (Ed.) 83
THE INTRAOCULAR LENS POWER CALCULATION

doi: 10.1016/j.jcrs.2013.06.027. Epub 2013 Oct 26. laser-assisted clear corneal incisions. Eur J
PMID: 24169231. Ophthalmol. 2018;28(4):398-405. doi: 10.1177/
8. Hill W. Expected effects of surgically induced 1120672117747017. Epub 2018 Feb 23. PMID:
astigmatism on AcrySof toric intraocular lens 29973075.
results. J Cataract Refract Surg. 2008;34(3):364-367. 10. Felipe A, Artigas JM, Diez-Ajenjo A, Garcia-Domene
doi: 10.1016/j.jcrs.2007.10.024. PMID: 18299058. C, Alcocer P. Residual astigmatism produced by
9. Fernandez J, Rodriguez-Vallejo M, Martinez toric intraocular lens rotation. J Cataract Refract
J, Tauste A, Pinero DP. Prediction of surgically Surg. 2011;37(10):1895-1901. doi: 10.1016/j.
induced astigmatism in manual and femtosecond jcrs.2011.04.036. Epub 2011 Aug 23. PMID: 21865007.

Author:

Brent Kramer

Financial Disclosure: None

How to cite this chapter:


Kramer B. Toric IOL Power Calculation and Managing Residual Astigmatism. In: Pardianto G, editor. The
Intraocular Lens Power Calculation. Medan: Anak Sudarti Foundation. 2022; 75-84.

84 Gede
Chapter 6: Toric IOL Power Calculation and Managing Pardianto
Residual (Ed.)
Astigmatism
THE INTRAOCULAR LENS POWER CALCULATION

Chapter 7
IOL Power Calculation for
the Bag-in-the-Lens (BIL)
Implantation Technique
Marie-José Tassignon

Introduction
The bag-in-the-lens (BIL) was patented in February 2001 (US patent 6,027,531) with the
claim of preventing posterior capsule opacification (PCO) after Intraocular Lens (IOL)
implantation. The implant consists of a central optic, like other lens implant, but a very
different haptic design that not only will eradicate PCO but will ensure lens centration
(Figure 9,10). The BIL implant features a groove defined by both anterior and posterior
flanges of the haptics into which the anterior and posterior capsules are inserted. The
implantation of this lens needs (preferentially) both anterior and posterior capsule
support so both an anterior and posterior rhexis are required. If the anterior and posterior
capsules are properly stretched and positioned in the lens groove, the remaining capsular
epithelial cells will continue their natural behaviour in the restricted volume they are
confined to.
The first implantation with the bag-in-the-lens was performed in 1999. Only one power
(+21 D) was available. I thus had to find the ideal patient for implantation. The formula used
for IOL calculation was the SRK-T and the A-constant was 119. This was just a guess based on
the refractive index of the IOL that was like that of a traditional S shaped IOL manufactured by
the same IOL manufacturer (Morcher, Germany), assuming that the position of the IOL in the
anterior segment would be identical. This was a wrong assumption.
In 2000, my team at Antwerp University was joined by an engineer in physics, Dr. Laure
Gobin, educated at Paris School of Optics and who became my dear and close collaborator for
many years. She took care of the clinical trial related to the bag-in-the-lens (BIL) and advised on
all optical issues to improve the development of the BIL. Our friendship never ended even after
she left the University for the industry.

Gede Pardianto (Ed.) 85


THE INTRAOCULAR LENS POWER CALCULATION

Parameters influencing the final position only be achieved by performing comparative


of the IOL in the eye: Posterior capsule studies. However, it is ethically very difficult
healing process to perform comparative studies in the same
Posterior capsule healing process patient when knowing that the incidence of
encompasses the relationship between the the most frequent complication, posterior
posterior capsule, with the remaining lens capsule opacification, is zero. We thus did
epithelial cells (LECs), and the IOL. This not perform this kind of study, but besides
foreign body is made of a biomaterial that is PCO we carefully evaluated the incidence
considered biocompatible but reacts with the of the two most common postoperative
LECs. The degree of reaction will result in complications after cataract surgery and IOL
different clinical expressions of PCO. implantation: retinal detachment and cystoid
macular edema.13,14 We were able to show that
The most common long-term
the incidence of these complications was not
complication of modern cataract surgery is
higher (even slightly lower) compared to the
PCO, also known as secondary cataract.1-3 This
LIB implantation.
process is due to proliferation and migration
Opening the posterior capsule using a
of residual lens epithelial cells in the
Nd:Yag laser is the most effective treatment
capsular bag,4,5 resulting in opacification and
for PCO.15 While this is associated with a low
contraction leading to loss of visual acuity.6,7
risk of complications16, it is not zero and does
R. Quinlan and his team explained in a
represent a cost in both time and money to the
recent paper8 why PCO can be avoided when health care systems worldwide. Meticulous
using the BIL technique. The clue is the surgical techniques including cleaning the
sequestration of the LECs in the periphery capsular bag, covering the edge of the optic
of the remaining lens capsule as shown with the anterior capsulorhexis, perfect lens
in fig 1-2. These LECs will then have fewer positioning, and posterior capsulorhexis can
opportunities to transform into cells with all reduce the risk of PCO but not eliminate
fibroblastic characteristics. it. Even primary posterior capsulorhexis has
I had the honour to write a comment in been shown by De Groot et al17 to be prone to
Ophthalmology9 based on the predictions of cell migration on the posterior face of the IOL
David Apple about eradication of PCO over or on the anterior face of the anterior hyaloid.
time by adapting the shape, the biomaterial Changes in the implant shape18-21 (e.g. square
and improving the surgical techniques. edges), changes in implant material, use of
David Apple was unfortunately wrong in his antibodies and of special coatings or the use
predictions, the only way to eradicate PCO is to of a capsular tension ring, have all reduced
adapt the implantation technique. The bag-in- proliferation of lens epithelial cells, but have
the-lens implantation technique showed zero not eradicated the occurrence of PCO.
PCO in adults (fig 3) and extremely reduced
PCO in children and babies.10-12 Surgeon controlled BIL centration
When a new IOL with new implantation So far, the BIL is the only IOL that can
technique like the BIL is introduced, its claim PCO eradication and surgeon-controlled
non-inferiority or superiority should be centration, which is a degree of freedom that
studied compared to the traditional IOL has not enough been studied in the literature.
implantation technique called the lens-in- When performing the BIL technique,
the-bag (LIB). Evaluation of superiority can the anterior circular and continuous

86 Gede Pardianto
Chapter 7: IOL Power Calculation for the Bag-in-the-Lens (BIL) Implantation (Ed.)
Technique
THE INTRAOCULAR LENS POWER CALCULATION

capsulorhexis or Anterior Continuous The toric BIL was introduced in 2009.


curvilinear capsulorhexis (ACCC) is calibrated The results of our early implantation series
based on the intraocular positioning of a ring were published in 2011.26 The details for the
calliper (US patent 8,663,235B2-March 2014), calculation and the order form can be found
with internal diameter of 4.5 mm or 5 mm on the website of Morcher, Germany: www.
(or whatever internal diameter needed for a morcher.com under the name Toric BIL order
specific IOL).22 This technique allows a very form.
accurate sizing and centration of the anterior I take this opportunity to thank once
capsulorhexis.23,24 more the engineer Laure Gobin, for having
The centration of the ACCC remains been very instrumental for developing her
debatable and all techniques used present own calculation method applied in the BIL
specific limitations regarding the accuracy technology in collaboration with Morcher,
of centration. I personally prefer operating Germany. This collaboration resulted in a
from the temporal side to be more accurate high degree of satisfaction for the BIL users
in both the vertical and horizontal axis based and their patients.
on active fixation of the patient into the light Rotation stabililty is one of the most
of the microscope. This is possible because important issues after toric IOL implantation
most of the cataract surgeries are performed and this is also valid for the BIL toric IOL.
under topical anaesthesia. I also developed Rotation stability was studied by Rozema JJ
an instrument for limbal centration, which in 2009.27 I recommend the toric BIL users
is very useful especially in case of toric to use the 4.5 mm ring calliper to ensure a
BIL implantation in patients with regular very strong fixation of the IOL. In case of too
astigmatism.25 This instrument is called large ACCC and Primary Posterior Continuous
the eye cage and is manufactured by Eye curvilinear capsulorhexis (PPCCC), rotation
Technology, UK, ref: ECT 100. stability might become compromised.
Centration is of utmost importance and Our next focus relies on the concept
will define together with the tilt, the quality of a continuous extended depth of focus
of the image as perceived by the patient. (CEDOF) BIL profile, which is currently under
If, in addition, the optic of the IOL is more development.
complex, including a tore or multifocality,
these parameters will further be influenced by Size of the cornea/cornea-scleral/scleral
the final position of the IOL in the eye. incision
The measurement of the BIL centration This current monofocal BIL implant
was made possible by using an image IT is a biconvex lens and consists of a central
programme developed by J. Rozema.23 optical zone of 5 mm. Enlarging the optical
The center of the lens is determined by an zone is possible but will increase the IOL
elliptical fit of the edge of the implant. The size and thus the cornea incision through
determination of the pupil and limbic center which it can be inserted into the anterior
is made by the same type of adjustment. chamber of the eye. The current model and
We found a mean center (centroid of optical biomaterial with a 28% of hydration allows
centers) of 0.3040.17 mm @-24.9113°, that is to the BIL to be inserted through a 2.0 cornea
say voluntarily inferonasal for the preservation incision for powers lower than 24 D. For
of the angle kappa. higher powers the incision should be 2.2 up

Gede Pardianto
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THE INTRAOCULAR LENS POWER CALCULATION

to 2.6 for +30 D or plus. Its peripheral haptic On request of Prof C Eckardt from
design comprises two oval elliptical haptics, Frankfurt, Germany, one haptic (to be
one anterior and the other posterior. The implanted anteriorly) has been made 8.5 mm.
anterior flange is oval (face) and is oriented The reason for this larger anterior haptic is to
perpendicular (90°) to the major axis of the prevent iris capture when cataract surgery is
oval of the posterior flange (Figure 9). The combined with vitrectomy (with or without
shape and orientation of the two haptics gas filling).
have been specifically designed to prevent In case of the BIL, tilting of the IOL/
the tilt of the implant once it has been capsule complex is not to be expected except
properly placed (Figure 10A). At its widest, in eyes within the normal biometrical
the diameter of the implant is 7.5 mm, and at parameters. Large capsules, however, are
its smallest it is 6.5 mm. Each haptic blade is more frequent in myopic eyes. We therefore
0.20 mm with a 0.25 mm groove in between insert prior to performing the PPCCC, a
them. This results in a total haptic thickness capsular tension ring of Morcher, Germany
of 0.65 mm. in eyes with axial length of 25 mm or longer.
Because lens tilt remains quite difficult to
evaluate after cataract surgery, we did not yet
study the efficacy of this additional surgical
step. We do have the clinical perception that
postoperative wobbling of the BIL/capsule
complex is reduced in time and frequency
after surgery. In most eyes, wobbling
resolves spontaneously once the periphery
of the capsule bag is filled with lens fibrils
coming from the remaining LECs. In the
traditional IOL implantation, lens wobbling
will be reduced based on the stiffening of the
capsule bag. This is an important difference
based on the capsule healing process as
described earlier.
The cornea incision will influence the
surgically induced astigmatism. This was
studied by our group in 2011.28 Our conclusion
was that using an incision of 2.8 mm (we
now use 2.0 to 2.2 mm in most of the cases),
the induced astigmatism was statistically not
significant.
Figure 9. Diagram of the double rhexis implant, Refractive performance using the
illustrating the central optical part surrounded by its
haptic. The two oval-shaped anterior and posterior SRK-T calculation formula
haptics are oriented perpendicular to each other to In our initial cohort of 295 eyes, 195
ensure optimal IOL stability. The side view of the patients were followed for more than one year
implant shows the characteristic groove in which the two
capsules will be placed. (1. Optics, 2. Groove, 3. Posterior (mean 33.1 ± 14.7 months (12 to 84 months).
Haptic, 4. Anterior Haptic, 5. Mark of Orientation) Postoperative visual acuity was 0.94 ± 0.18

88 Gede Pardianto
Chapter 7: IOL Power Calculation for the Bag-in-the-Lens (BIL) Implantation (Ed.)
Technique
THE INTRAOCULAR LENS POWER CALCULATION

Figure 10. A- "bag-in-the-lens" lens implant positioned in the double rhexis, where the epithelial cells of
the lens are captured in the peripheral portion of the remaining capsule and therefore cannot migrate
to the pupillary axis. B- conventional implantation scheme of the lens in the capsular bag 'in the bag'
showing the epithelial cells of the lens in the equatorial region an d on the posterior capsule.

decimal Snellen. In 91.5% of the patients the since 2016. 30 This interface is unfortunately
uncorrected distance visual acuity was better not possible to measure preoperatively
than 0.8. The postoperative refraction was using OCT imaging, even with the Casia
-0.19 ± 0.84 D (-3.5 to + 5 D) for the sphere and (Tomey-Japan). Once the crystalline lens
-0.58 ± 0.77 D for the cylinder. The spherical is removed, it is possible to evaluate the
equivalent was -0.48 ± 0.82 D for a target anterior interface using the intraoperative
refraction of -0.24 +/- 0.71 D. In function of OCT embedded in the Lumera microscope
time, the A-constant was adjusted from a value (Zeiss, Germany), However, if the aim is to
of 119.0 for the first patients studied to 118.4 evaluate whether the ligament of Wieger
for the next 459 patients studied and currently is still detached or not, this can only be
we use an A-constant of 118.2. The A-constant evaluated after having filled the retro-
will define the antero-posterior position of the capsular space with Ophthalmic viscoelastic
IOL in the anterior chamber of the eye. devices (OVD) after having punctured the
Details about the technical specifications of posterior capsule to initiate a PPCCC. One
the bag-in-the-lens implant have been published can only speak about Berger space in case
in chapter 6 of a book published by Springer in the ligament of Wieger is still attached.
2019.29 If not, it would be more correct to speak
about the retro capsular space. When the
Role of the anterior interface of the eye ligament of Wieger is detached, we speak
on the final position of the IOL about an anterior vitreous detachment
The anterior interface has received (AVD). This term has been used by Emanuel
more attention lately. Our team in Antwerp Rosen in 1966. 31 He described that AVD was
studied this interface in relation to the BIL only possible after severe trauma. This is

Gede Pardianto
Tassignon MJ. (Ed.) 89
THE INTRAOCULAR LENS POWER CALCULATION

currently considered erroneous since AVD parameters of the eyes measured belong to
has been described by Scheie in pigment the standard ocular biometrics. When both
dispersion syndrome and is most probably formulas are not in agreement the biometrics
an age-related condition, just as it is the of the eyes measured do not belong to the
case for posterior vitreous detachment. standard measurements for 1, 2 or more
In a recent publication32, we were able to biometrical parameters measured. What we
evaluate the incidence of anterior vitreous should define is the normative biometrical
detachment evaluated peri-operatively by values for each parameter of the eye in a
means of the Lumera OCT of Zeiss. AVD was population (Caucasian, Asian, and African)
mainly defined by a detached ligament of and defines the outliers. These outliers need
Wieger and was found in 63% after removal more attention to predict the final position
of the crystalline lens content and after of the IOL in the anterior segment. This is a
having separated the anterior hyaloid from study that is currently in development at our
the posterior capsule with an OVD. The role department. I am personally convinced that
of a detached ligament of Wieger on the this approach will improve our predictability
final position of the BIL/capsule complex of the refractive outcome.
is not yet known. Does the anterior hyaloid
We are currently thinking bidimensional
pull the complex posteriorly, causing slight
but thinking volumetric might increase our
postoperative hyperopia or will the complex
prediction in calculating the IOL power.
move slightly anteriorly in presence of an
AVD causing slight postoperative myopia? What we cannot measure so far is the
This is a matter that still needs to be studied. nature of our zonules: are they intact, have
they preserved elasticity, do they transfer the
The anterior interface is an extremely
changes of the ciliary body correctly? Is there
interesting structure, and it was very recently
a transmission of energy from the ciliary body
that our group was able to define a new cause of
or is this transfer hydraulic? So many unknown
congenital cataract based on a dysgenesis of the
answers on questions that it is surprising how
anterior interface (posterior capsule-anterior
good and acceptable our current approach is.
hyaloid or both). 33,34 The role of AVD on loss
of accommodation is not yet known but it is Regarding the babies and the children,
my feeling that AVD contributes to a decreased we did publish a chapter in a book edited by
range of accommodation by ageing. Khokar Sudarshan.35 In this article we stress the
fact that many other factors play a role e.g.: eye
Unmet needs in ocular biometrics of the growth, intraocular pressure, visual training
anterior segment of the eye and what is most probably the most important:
Although this chapter is dedicated data collection. The European Registry on
to the IOL calculation using the BIL, I Childhood Cataract (EuReCCa) was therefore
approached the topic in a very unusual initiated very recently by the European Society
way. I tried to explain why we might have of Cataract and Refractive Surgeons (ESCRS).
postoperative refractive surprises and We do not yet have any results since the registry
inaccuracy. The current formulas used to was lounged only recently in 2021.
calculate our IOL power are not bad at all.
I am routinely using two different formula’s Conclusion
Haigis and SRK-T. My observation is that Our clinical experience with the BIL
when both formulas agree, the biometrical confirmed the capacity of the BIL to eradicate

90 Gede Pardianto
Chapter 7: IOL Power Calculation for the Bag-in-the-Lens (BIL) Implantation (Ed.)
Technique
THE INTRAOCULAR LENS POWER CALCULATION

Figure 11. Assembling of different postoperative images after BIL implantation at different postoperative
times up to 1 year postoperatively. Visual axis remains clear in all eyes provided the BIL is properly implanted.

PCO in adults and to decrease dramatically its the centration and rotation of the BIL and this
incidence in children and babies provided the in both children and adults. It also allowed us
surgery is performed properly. The tight fit to describe pathologies of the anterior interface
of the two capsules on the peripheral groove and its relationship with congenital cataract.
of the IOL blocks the migration of the lens There is still a lot to learn, and this is the positive
epithelial cells and their action is confined message towards the young colleagues.
to the remaining peripheral capsular bag.
We also showed that the BIL implant allows References
a surgeon-controlled centration and that its 1. Nishi O. Incidence of posterior capsule opacification in
rotation in the eye is very limited provided the eyes with and without posterior chamber intraocular
capsulorhexis have the right dimensions. lenses. J Cataract Refract Surg. 1986;12:519–522.
Overall, designing and implementing 2. Apple DJ. Harold Ridley, MA, MD, FRCS; a golden
the BIL IOL has been an iterative process, anniversary celebration and a golden age (editorial).
developed by us in collaboration with the many Arch Ophthalmol. 1999;117:827–828.
authors of the different papers and with Morcher 3. Pandey SK, Apple DJ, Werner L, et  al. Posterior capsule
Olaf, Germany (Chief Executive Officer of the opacification: a review of the aetiopathogenesis,
company). However, outcomes show that it experimental and clinical studies and factors for
was worthwhile, as the lens confers superior prevention. Indian J Ophthalmol. 2005;16:2–7.
results, not only in PCO prevention but also in a 4. Apple DJ, Solomon KD, Tetz MR et al. Posterior capsule
surgeon controlled degree of freedom regarding opacification . Survey of Ophthalmol. 1992;37:73-116.

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5. Rakic JM, Galand A, Vrensen GFJM. Separation of Tassignon. Clinically significant pseudophakic cystoid
fibers from the capsule enhances mitotic activity of macular edema after bag-in-the-lens implantation.
human lens epithelium. Exp Eye Res. 1997;64:67-72. J Cataract Refract Surg. 2020;46(4):606-611. doi:
6. Meacock WR, Spalton DJ, Boyce J, Marshall J. The effect 10.1097/j.jcrs.0000000000000102.
of posterior capsule opacification on visual function. 15. Aslam TM, Devlin H, Dhillon B. Use of Nd :YAG Laser
Invest Ophthalmol Vis Sci. 2003; 44:4665-4669. capsulotomy. Surv Ophthalmol. 2003; 48:594-612
7. Aslam TM, Aspinall P, Dhillon B. Posterior capsule 16. Billotte C, Berdeaux G. Adverse clinical consequences
morphology determinants of visual funtion. Graefes of neodymium: YAG laser treatment of posterior
arch Clin Exp Ophthalmol. 2003; 241:208-211. capsule opacification. J Cataract Refract Surg. 2004;
8. Weiju Wu , Noemi Lois,  Alan R Prescott,  Adrian 30: 2064-2071.
P Brown, Veerle Van Gerwen,  Marie-José 17. De Groot V, Vrensen G, Willekens B, Van Tenten
Tassignon, Shane A Richards , Christopher D Y, Tassignon MJ. In vitro study on the closure of
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Author:

Marie-José Tassignon

Financial Disclosure:

- Intellectual property in the bag-in-the-lens and ring caliper licensed


to Morcher-Germany

How to cite this chapter:


Tassignon MJ. IOL Power Calculation for the Bag-in-the-Lens (BIL) Implantation Technique. In: Pardianto G,
editor. The Intraocular Lens Power Calculation. Medan: Anak Sudarti Foundation. 2022; 85-93.

Gede Pardianto
Tassignon MJ. (Ed.) 93
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94 Gede Pardianto (Ed.)


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Acknowledgements
Our deepest gratitude goes to all of our devoted teachers, inventors, pioneers, and great writers
in the field of Biometry and IOL Power Calculation, who have dedicated their lives to serve
humanity and eradicate blindness through serving the people, finding formulas, teaching,
delivering scientific lectures, as well as writing in books, magazines, and scientific journals
around the globe. Some of them have been long gone, but their genuine work and contributions
will always shape, and light up the world.
Thanks to them, the correct power of IOLs have been implanted through a huge number
of cataract surgeries, which has helped millions of patients around the planet to see better, get
back to work, improve their family’s wealth, all of which makes the world a beautiful place to
live in.

Gede Pardianto (Ed.)


Acknowledgements 95
THE INTRAOCULAR LENS POWER CALCULATION

About the Editor


Dr. Gede Pardianto is a Consultant Ophthalmologist at the Sabang
Merauke Eye Center (SMEC), Medan, Indonesia. Dr. Pardianto graduated
as an MD and Ophthalmologist from Airlangga University, and achieved
his PhD by (Summa) Cum Laude from the Sumatera Utara University.
Dr. Pardianto is an author of 60 national and international papers.
Some of which were published in Q1 journals such us JCRS and Clinical
Ophthalmology, and presented in Paris, Sydney, Vienna, Seoul, New Haven,
Singapore, Amsterdam, Tokyo, Boston, London, Copenhagen, Kathmandu,
Lisbon, Washington DC, Barcelona, Marrakech, and Cape Town in the
meetings of AAO, ASCRS, ESCRS, ESCRS Winter Meeting, EuCornea,
Euretina, WOC, APAO, APACRS, EyeWorld USA Interview, etc. Some were indexed in Scopus, PubMed,
EMBASE, and MEDLINE; and cited as references in more than 100 international journal articles and
papers in various fields, such as Medicine, Dentistry, Veterinary, Zoology, Psychology, Pharmacy and
Engineering, some of which have been published in multiple languages, including English, Spanish,
Portuguese, Chinese, Arabic, Greek, Urdu, Finno-Ugric and Cyrillic; and were published by Elsevier,
Springer, SLACKS, Wolters Kluwer, StatPearls, Dovepress, Hindawi, Willey, etc.
Dr. Pardianto is an editor for 2 international journals and a reviewer for 8 international
journals, as well as an editor of 2 books and an author of 3 books. He has reviewed more than
80 international journal’s manuscripts. In total, he contributed to 214 published international
papers from multiple very top universities in the world.
Dr. Pardianto is the Course Director of 24 Maestro Lecture Series that were filled by world’s
best ophthalmologists, and were attended by a thousand participants from 121 countries of 6
continents. He was awarded 9 medals from the President of the Republic of Indonesia.
Dr Pardianto is married to Dr Diyah Purworini for the last 23 years and they have
1 daughter and 1 son, Fira Fatmasiefa and Bramasto Rahman Prasojo: both are NASA (+ISS)
young researchers, international multiple gold medalists and champions of the world. Diyah
is a children’s development, talent, and education consultant in Indonesia, meanwhile Fira is
now pursuing her dream, winning multiple scholarships, achieving multiple prestigious awards,
working at Lawrence Hall of Science, Space Science Laboratory (SSL) and Lawrence Berkeley
National Laboratory (LBNL), working with Nobel Prize Winner, and studying Astrophysics at the
University of California Berkeley, and Bram is passionately attending the University of California
Davis, majoring in Aeronautical and Astronautical (Aerospace) Engineering. Nothing provides
greater joy for Dr. Pardianto than spending time with his beloved family.

96 Gede Pardianto (Ed.)


About the Editor
THE INTRAOCULAR LENS POWER CALCULATION

Index

A
A-constant 13, 16, 18, 20, 29, 34, 35, 36, 56, 59, 62, 64, 85, 89
Actual Lens Position xii, 13
Amplitude Mode Scan/Display 14
ANSI Z80.30-2010 13
Anterior Chamber Depth xii, 7, 12
applanation technique 14
Aqueous Depth xii, 12
Artificial Intelligence xii, 14
A-Scan x, xii, 3, 4, 14, 19
Average Central Corneal Power xii, 14
Average Corneal Power xii, 11
Axial Length xii, xiii, 8, 12, 26, 28, 43, 60, 61, 66

B
Biometry ix, 1, 2, 4, 6, 7, 8, 9, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 40, 44, 64, 66, 71, 95
Brightness Mode Scan/Display 14
B-Scan x, xii, 4, 5, 14, 61

C
C-constant 14, 37
Central Corneal Power xii, 11, 14, 47
Central Topography 14, 38
Combined Surface 11
Corneal Thickness xii, xiii, 7, 12, 16

E
Effective Lens Position xiii, 12, 20
Equivalent Keratometry Reading 12

I
immersion technique 14
Internal astigmatism 12
Internal Lens Position xiii, 13
Intraoperative Aberrometry 66
Intraoperative optical refractive Biometry 17, 22
ISO Permitted Tolerance 13

Gede
Index Pardianto (Ed.) 97
THE INTRAOCULAR LENS POWER CALCULATION

K
K1 11
K2 11
Keratometry xiii, xiv, xv, 11, 12, 14, 19, 38, 40

L
Lens Constant 18, 23
Lens Factor xiii, 13
Lens Thickness xiv, 13

N
Negative spherical aberration 15
No-History 14

O
Optical Biometry ix, 1, 2, 4, 6, 8, 9, 15, 44, 64
Optical Low Coherence Reflectometry xiv, 3, 15

P
Paraxial Ray 14
Partial Coherence Interferometry xiv, 15, 21
Positive spherical aberration 15
Posterior x, xiv, 12, 61, 72, 86, 87, 88, 91, 92

R
Ray Tracing 19, 20, 37
Refractive Index 12
Residual Astigmatism ix, xi, xiv, 15, 21, 75, 76, 78, 79, 80, 82, 84

S
Simulated Keratometry xiv, 12, 19
Spherical Aberration xiv, 15, 21
Surgeon Factor xiv, 13, 27
Surgery-Induced Astigmatism or Surgically-Induced Astigmatism xiv, 15
Swept-Source Optical Coherence Tomography xv, 15, 21

T
Target Refraction 15
Topography 11, 14, 38, 40
Total Corneal Astigmatism 12
Total Corneal Power xv, 12, 19
Total Keratometry xv, 14, 38

U
Ultrasonographic (USG) Biometry 14
Ultrasound Biometry 14

W
White-to-White 11

98 Gede Pardianto (Ed.)


Index
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Supported by:

Gede Pardianto (Ed.) 99


THE INTRAOCULAR LENS POWER CALCULATION

Note

100 Gede Pardianto (Ed.)


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Gede Pardianto (Ed.) 101

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