The IOL Power Calculation
The IOL Power Calculation
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Foreword
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.
vi Gede PardiantoPreface
(Ed.)
THE INTRAOCULAR LENS POWER CALCULATION
Gedefrom
Note Pardianto
Minister(Ed.)
of Health vii
THE INTRAOCULAR LENS POWER CALCULATION
Gede Pardianto
Medan, Indonesia
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
List of Tables
Gede
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of Tables (Ed.) xi
THE INTRAOCULAR LENS POWER CALCULATION
List of Abbreviations
xii Gede
ListPardianto (Ed.)
of Abbreviations
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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
Gede
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of Abbreviations xv
THE INTRAOCULAR LENS POWER CALCULATION
List of Contributors
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
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
Gede
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of Contributors xvii
THE INTRAOCULAR LENS POWER CALCULATION
Pardianto G, editor. The Intraocular Lens Power Calculation. Medan: Anak Sudarti Foundation. 2022.
bit.ly/maestrolectures
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
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
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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
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
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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
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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
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6 Gede
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36. Norrby S. Sources of error in intraocular lens power tjosr.tjosr_44_17.
calculation. J Cataract Refract Surg. 2008;34(3):368- 45. Hirnschall N, Varsits R, Doeller B, Findl O. Enhanced
376. doi:10.1016/j.jcrs.2007.10.031. Penetration for Axial Length Measurement of Eyes
37. Hirnschall N, Amir-Asgari S, Maedel S, Findl O. with Dense Cataracts Using Swept Source Optical
Predicting the Postoperative Intraocular Lens Position Coherence Tomography: A Consecutive Observational
Using Continuous Intraoperative Optical Coherence Study. Ophthalmol Ther. 2018;7(1):119-124. doi:10.
Tomography Measurements. Investig Opthalmology 1007/s40123-018-0122-1.
Vis Sci. 2013;54(8):5196. doi:10.1167/iovs.13-11991. 46. Sui C, Wo S, Cai P, Gao N, Xu D, Han Y, Du C. Design
38. Hirnschall N, Norrby S, Weber M, Maedel S, Amir- and implementation of optical system for Placido-
Asgari S, Findl O. Using continuous intraoperative disc topography. J Md Opt. 2017;64(21):2413-2419.
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
Oliver Findl
Financial Disclosure:
Gede Pardianto
Nenning (Ed.)
M, Findl O. 9
THE INTRAOCULAR LENS POWER CALCULATION
Chapter 2
What was Known About Biometry
and IOL Power Calculation?
Gede Pardianto
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
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
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
should be no more than 0.30 mm to gain intraocular lens power formula. J Cataract Refract
high outcome accuracy in multifocal IOL Surg. 2000;26(8):1233-1237. doi: 10.1016/
implantation.72 s0886-3350(00)00376-x. PMID: 11008054.
4. Lawless M, Jiang JY, Hodge C, Sutton G, Roberts
Considering a new biometer TV, Barrett G. Total keratometry in intraocular
lens Power Calculations in eyes with previous
Eventually, the surgeon needs to replace
laser refractive surgery. Clin Exp Ophthalmol.
an older biometer with a new one. Here are
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
a. Need of higher acquisition rate, especially OV, Arce CG, Schor P, Campos M. A Direct Method
in denser cataract. to Measure the Power of the Central Cornea
b. Need of lesser dependence on A-Scan After MyopicLaser In Situ Keratomileusis. Arch
immersion Biometry. Ophthalmol. 2004;122(2):159–166. doi: 10.1001/
c. The biometer is 10-years-old or older. archopht.122.2.159. PMID: 14769590.
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
eyes. J Cataract Refract Surg. 2008;34(5):802-808.
calculation purpose), reducing time
doi: 10.1016/j.jcrs.2008.01.015. PMID: 18471636.
consumption, and making workflow more
7. Borasio E, Stevens J, Smith GT. Estimation of true
efficient.
corneal power after keratorefractive surgery in
e. Need of new formulas for premium IOL eyes requiring cataract surgery: BESSt formula. J
implantation to achieve more valid and Cataract Refract Surg. 2006; 32(12):2004–2014.
accurate measurements, avoiding SIA, and PIMD: 17137976.
giving more adequate measurement for 8. Olsen T. On the calculation of power from curvature
many special cases including post refractive of the cornea. Br J Ophthalmol. 1986;70(2):152-
surgery. 154. doi: 10.1136/bjo.70.2.152.
f. Need of a new “gold standard” in Biometry 9. Savini G Hoffer KJ, Lomoriello DS, Ducoli P. Simulated
for research and scientific reasons. Keratometry Versus Total Corneal Power by Ray
g. Need of easier and friendlier tools to Tracing: A Comparison in Prediction Accuracy of
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31. Shammas HJ, Shammas MC. No-history method Outcomes. Clin Ophthalmol. 2020;14:4209-4220.
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34. Cass K, Thompson CM, Tromans C, Wood IC. Eur J Ophthalmol. 2014;24(4):509-515. doi: 10.5301/
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36. Trivedi RH, Wilson ME. Axial length measurements by target the ideal correction for their patients.
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37. Pardianto G, Moeloek N, Reveny J, et al. Retinal Cataract Refract Surg Today. 2006;11:92-94.
thickness changes after phacoemulsification. Clin 46. Yang J, Wang X, Zhang H, Pang Y, Wei RH. Clinical
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39. Cummings AB, Naughton S, Coen AM, Brennan 48. Calvo-Sanz JA, Bonnin-Arias C, Arias-Puente A.
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49. Gordon RA, Donzis PB: Refractive development of 58. Wang L, Spektor T, de Souza RG, Koch DD. Evaluation
the human eye. Arch Ophthalmol. 1985;103:785– of total keratometry and its accuracy for intraocular
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PMID: 4004614. surgery. J Cataract Refract Surg. 2019;45(10):1416-
50. Norrby S. Sources of error in intraocular lens Power 1421. doi: 10.1016/j.jcrs.2019.05.020. Epub 2019
Calculation. J Cataract Refract Surg. 2008; 34: 368–376. Aug 6. PMID: 31399324.
doi: 10.1016/j.jcrs.2007.10.031. PMID: 18299059. 59. Sramka M, Slovak M, Tuckova J, Stodulka P. Improving
51. Vanderveen DK, Trivedi RH, Nizam A, Lynn MJ, clinical refractive results of cataract surgery
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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.
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Calculation formulas. Sci Rep. 2020;8:9829. doi: Kohnen T. Prediction accuracy of IOL calculation
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54. Xia T, Martinez CE, Tsai LM. Update on Intraocular for a diffractive extended depth-of-focus IOL
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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
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66. Zaldivar R, Schultz M, Davidori J. Intraocular lens situ keratomileusis. Eye. 2021;6(11). doi: 10.1097/j.
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the power of anterior chamber implants. Br J 9. doi: 10.1016/j.ophtha.2009.12.031. Epub 2010
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Author:
Gede Pardianto
Gede Pardianto
Pardianto G. (Ed.) 23
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.
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.
• SRK/T formula: this is one of the classical 2. Hoffer KJ. The Hoffer Q formula: a comparison
thin-lens theoretical formulas.4 It was of theoretic and regression formulas. J
developed by Manus C. Kraff, John A. Cataract Refract Surg. 1993;19:700-712; errata,
Retzlaff and Donald R. Sanders, the authors 1994;20:677;2007;33:2-3.
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once the Holladay 1 formula had been part system for refining intraocular lens power
published and they realized that vergence calculations. J Cataract Refract Surg. 1988;14:17-24.
Gede G.
Savini Pardianto (Ed.) 29
THE INTRAOCULAR LENS POWER CALCULATION
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J Cataract Refract Surg. 2014;40:764-773. 32. Voytsekhivskyy O. Development and clinical
29. Debellemanière G, Dubois M, Gauvin M, Wallerstein A, accuracy of a new intraocular lens power
Brenner LF, Rampat R, Saad A, Gatinel D. The PEARL- formula (VRF) compared to other formulas. Am J
DGS Formula: The Development of an Open-source Ophthalmol. 2018;185:56-67.
Author:
Giacomo Savini
Financial Disclosure:
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THE INTRAOCULAR LENS POWER CALCULATION
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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
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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
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:
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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
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Authors:
Steve A. Arsinoff
Rishi Gupta
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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.
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
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.
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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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THE INTRAOCULAR LENS POWER CALCULATION
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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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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THE INTRAOCULAR LENS POWER CALCULATION
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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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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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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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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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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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.
hyperopic shift, potentially due to haptic doctor-hill.com/physicians/haigis.htm).
elongation or loss of normal haptic curvature 9. Wan KH, Lam TCH, Yu MCY, Chan TCY. Accuracy and
within the sclerotomies.149 Precision of Intraocular Lens Calculation Using the
New Hill-RBF Version 2.0 in Eyes With High Axial
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90. Stewart CM, McAlister JC. Comparison of grafted Lam PT, Lam DS. Descemet stripping endothelial
and non-grafted patients with corneal astigmatism keratoplasty: effect of the surgical procedure on
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lens implant. Clin Exp Ophthalmol. 2010;38(8):747- 996. doi: 10.1016/j.ajo.2008.01.017. Epub 2008
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528.DOI:10.1001/archopht.1996.01100130517002. 102. Holz HA, Meyer JJ, Espandar L, Tabin GC, Mifflin
93. Taylor DM. Keratoplasty and intraocular lenses. MD, Moshirfar M. Corneal profile analysis after
Ophthalmic Surg. 1976;7(1):31-42. (https://www. Descemet stripping endothelial keratoplasty and
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Descemet's stripping and automated endothelial DY, Auteri NJ, Nordlund ML, Holland EJ. Comparison
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Keratoplasty. Cornea. 2018;37(10):1226-1231.
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10.1016/j.ophtha.2009.06.021. R, Yeh RY, Melles GR. Near complete visual
recovery and refractive stability in modern corneal
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transplantation: Descemet membrane endothelial
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Epub 2012 Oct 26. PMID: 23108011.
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109. Chaurasia S, Ramappa M, Sangwan V. Cataract
C, Frank LE, van Dijk K, Melles GR. Refractive
surgery after Descemet stripping endothelial
change and stability after Descemet membrane
keratoplasty. Indian J Ophthalmol. 2012;60(6):572-
endothelial keratoplasty. Effect of corneal
574. DOI: 10.4103/0301-4738.103803.
dehydration-induced hyperopic shift on intraocular
110. Neff KD, Biber JM, Holland EJ. Comparison of central lens power calculation. J Cataract Refract
corneal graft thickness to visual acuity outcomes in Surg. 2011;37(8):1455-1464. doi: 10.1016/j.
endothelial keratoplasty. Cornea. 2011;30(4):388- jcrs.2011.02.033. PMID: 21782088.
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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.
endothelial keratoplasty with the microkeratome Cornea. 2016;35(8):1073-1077. DOI: 10.1097/
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112. Dickman MM, Kruit PJ, Remeijer L, van Rooij J, Van der of intraocular lens constant improves refractive
Lelij A, Wijdh RH, van den Biggelaar FJ, Berendschot outcomes in combined endothelial keratoplasty and
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cataract surgery. Ophthalmology. 2013;120(2):234- 127. Murray DC, Potamitis T, Good P, Kirkby GR, Benson
239. doi: 10.1016/j.ophtha.2012.08.003. Epub 2012 MT. Biometry of the silicone oil-filled eye. Eye
Oct 27. PMID: 23107582; PMCID: PMC3816366. (Lond) 1999;13 ( Pt 3a):319-324. DOI: 10.1038/
119. Alnawaiseh M, Zumhagen L, Rosentreter A, eye.1999.82.
Eter N. Intraocular lens power calculation using 128. Montes-Mico R, Pastor-Pascual F, Ruiz-Mesa
standard formulas and ray tracing after DMEK R, Tana-Rivero P. Ocular biometry with swept-
in patients with Fuchs endothelial dystrophy. source optical coherence tomography. J Cataract
BMC Ophthalmol. 2017;17(1):152. DOI: 10.1186/ Refract Surg. 2021;47(6):802-814. DOI: 10.1097/j.
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120. Diener R, Treder M, Lauermann JL, Eter N, 129. Al-Habboubi HF, Al-Zamil W, Al-Habboubi AA,
Alnawaiseh M. Assessing the validity of corneal Khandekar R. Visual Outcomes and Refractive
power estimation using conventional keratometry Status after Combined Silicone Oil Removal/
for intraocular lens power calculation in eyes Cataract Surgery with Intraocular Lens
with Fuch's dystrophy undergoing Descemet Implantation. J Ophthalmic Vis Res. 2018;13(1):17-
membrane endothelial keratoplasty. Graefes Arch 22. DOI: 10.4103/jovr.jovr_252_16.
Clin Exp Ophthalmol. 2021;259(4):1061-1070. DOI: 130. Apple DJ, Isaacs RT, Kent DG, Martinez LM, Kim S,
10.1007/s00417-020-04998-w. Thomas SG, Basti S, Barker D, Peng Q. Silicone oil
121. Holladay JT. Refractive power calculation for adhesion to intraocular lenses: an experimental
intraocular lenses in the phakic eye. Am J study comparing various biomaterials. J Cataract
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9394(14)71745-3. s0886-3350(97)80210-6. PMID: 9209988.
122. Hill W. IOL Power Calculation - Physician 131. Hotta K, Sugitani A. Refractive changes in silicone oil-
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iol-power-calculation/resources-downloads/). 132. Hill W. IOL Power Calculation Silicone Oil. (https://
123. Gayton JL, Sanders V, Van der Karr M, Raanan www.doctor-hill.com/iol-main/silicone.htm).
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90005-2. 2016;165:47-53. DOI: 10.1016/j.ajo.2016.02.023.
124. Rubenstein J. Piggyback IOLs for Residual Refractive 134. Albanese GM, Cerini A, Visioli G, Marenco
Error After Cataract Surgery. CRS Today. (https:// M, Gharbiya M. Long-term ocular biometric
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residual-refractive-error-after-cataract-surgery/). on rhegmatogenous retinal detachment. BMC
125. Kanclerz P, Grzybowski A. Accuracy of Intraocular Ophthalmol 2021;21(1):172. DOI: 10.1186/
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Oil. Semin Ophthalmol. 2019;34(5):392-397. DOI: 135. Lee DH, Han JW, Kim SS, Byeon SH, Koh HJ, Lee SC,
10.1080/08820538.2019.1636097. Kim M. Long-term effect of scleral encircling on
126. Suk KK, Smiddy WE, Shi W. Refractive outcomes axial elongation. Am J Ophthalmol. 2018;189:139–
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intraocular lens calculation formulas. J Cataract J. Scleral-Fixated Intraocular Lenses: Past and
Refract Surg. 2019;45(3):293-297. DOI: 10.1016/j. Present. J Vitreoretin Dis. 2017;1(2):144-152.
jcrs.2018.10.032. 148. Botsford B, Williams A, Conner I, Martel J, Eller A.
137. Wang JK, Chang SW. Refractive results of Scleral Fixation of Intraocular Lenses with Gore-
phacoemulsification in vitrectomized patients. Int Tex Suture: Refractive Outcomes and Comparison
Ophthalmol. 2017;37(3):673-681. DOI: 10.1007/ of Lens Power Formulas. Ophthalmol Retina.
s10792-016-0325-1. 2019;3(6):468-472.
138. Navon SE, Edge R. Outcome of cataract surgery 149. Aykut V, Esen F, Sali F, Oguz H. Refractive outcome
associated with posterior staphyloma. J Cataract of trocar-assisted sutureless scleral fixation
Refract Surg 1999;25(1):83-90. DOI: 10.1016/ with 3-piece intraocular lenses. Int Ophthalmol.
s0886-3350(99)80016-9. 2021;41(8):2689-2694.
139. Hill W. IOL Power Calculation Posterior
Staphyloma. (https://www.doctor-hill.com/iol-
main/staphyloma.htm).
140. Devgan U. The Rule of Nines for Sulcus IOL
Power. June 25, 2018 (https://cataractcoach.
com/2018/06/25/how-to-determine-sulcus-iol-
power-and-ac-iol-power/).
141. Dubey R, Birchall W, Grigg J. Improved refractive
outcome for ciliary sulcus-implanted intraocular
lenses. Ophthalmology. 2012;119(2):261-265.
142. Tian T, Chen C, Jin H, Jiao L, Zhang Q, Zhao P.
Capture of intraocular lens optic by residual
capsular opening in secondary implantation: long-
term follow-up. BMC Ophthalmol. 2018;18(1):84.
143. Ansah D, Li X, Gehlbach P, Jun A, Soiberman U.
Prediction error in iris suture fixated intraocular
lenses and long-term stability. Clin Exp Ophthalmol.
2020;48(9):1175-1182.
144. Hoffman R, Fine I, Packer M. Scleral fixation
without conjunctival dissection. J Cataract Refract
Surg. 2006;32(11):1907-1912.
145. Agarwal A, Kumar D, Jacob S, Baid C, Agarwal
A, Srinivasan S. Fibrin glue-assisted sutureless
posterior chamber intraocular lens implantation in
eyes with deficient posterior capsules. J Cataract
Refract Surg. 2008;34(9):1433-1438.
146. Yamane S, Sato S, Maruyama-Inoue M, Kadonosono
K. Flanged Intrascleral Intraocular Lens Fixation
with Double-Needle Technique. Ophthalmology.
2017;124:1136-1142.
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Authors:
Nisha S. Dhawlikar
Yi Ling Dai
Kate V. Hughes
Naveen K. Rao
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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.
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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.
Figure 4. Toric IOL aligned with the IntelliAxis Refractive Capsulorhexis axis mark which was created
using the LENSAR femtosecond laser by using preoperative data.
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THE INTRAOCULAR LENS POWER CALCULATION
Figure 5. Zeiss Callisto display showing precise alignment of a toric IOL. Note that corneal marks are not
necessary and therefore aren’t seen
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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.
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.
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
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Astigmatism
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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)
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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
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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.
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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
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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
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25. Ni Dhubhghaill STM, Van Os L. Innovative Implantation Space. Ophthalmic Res. 2016;56(4):222-226. doi:
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Surgically induced astigmatism after intraocular 34. Hedwig Sillen , Jan Van Looveren, Philip Plaeke, Luc
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Surgery, Springer, 2019; doi.org/10.1007/978-3- 35. Tassignon MJ, Van Os Luc, Essentials of Paediatric
030-03086-5. Cataract Surgery: Chapter 4 Bag in the Lens.
30. Marie-José Tassignon 1, Sorcha Ní Dhubhghaill. Real- Editors Sudarshan Kumar Khokhar, Chirakshi Dhull.
Time Intraoperative Optical Coherence Tomography Springer 2021, Doi: 8-981-16-0212-2 (eBook)
Imaging Confirms Older Concepts About the Berger https://doi.org/10.1007/978-981-16-0212-2.
Author:
Marie-José Tassignon
Financial Disclosure:
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Tassignon MJ. (Ed.) 93
THE INTRAOCULAR LENS POWER CALCULATION
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.
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
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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
Supported by:
Note