REFINEMENT OF IOL POWER CALCULATION IOL POWER CALCULATION There are three major components of IOL P calculation Biometry-

y- Measuring AL, corneal power, IOL position Formulas Clinical variables

Biometry-Measurement of AL Certain facts - AL is MC source of error Error of 1 mm causes miscalculation of 2.5 to 3 D Factors affecting measurement of AL1) Technique and machine 2) Setting the ultrasound velocity 3) Retinal thickness Biometry- A scan CHARACTERISTICS OF A GOOD A- SCAN1) A tall echo from the cornea, one peak with a contact probe, and a double peaked echo with an immersion probe. 2) Tall echoes from the anterior and posterior lens capsule. 3) Tall sharply rising echo from retina. 4) Medium tall to tall echo from sclera. 5) Medium to low echoes from orbital fat.

Biometry

Try to get all spikes If not possible concentrate more on posterior spikes 3 different A scan techniquesApplanation A scan Immersion A scan Immersion Vector A / B scan

Applanation A scan:
Disadvantages-

this has the disadvantage of Indentation of cornea which cause error of 0.3 D to 1D

Immersion A scan Advantages

More accurate Removes error due to corneal indentation

Immersion Vector A / B scan Advantages

A scan vector made to pass through center of cornea direct AL from region of fovea High myopia with staphyloma Mature cataract

Partial coherence interferometry (IOL Master) Non contact method Uses partial coherent beam of light
Optical device cannot be used in media opacity in axial region

IOL Master Advantages 5 times more accurate and reproducible Simultaneously measures corneal P, ACD, performs IOL P calculation using modern theoretical formulas saves time

Measurement of AL - Setting the ultrasound velocity Ultrasound velocity through Aqueous and vitreous: 1532 m / s Cornea and lens : 1641 m /s

Ideally diff. ocular compartments at their specific sound velocity

Recommendation Short eyes < 20 mm : 1560 m / s Long eyes > 30 mm : 1550 m /s Measurement of AL - Setting the ultrasound velocity If eye measured with wrong velocity: Velocity (correct) Velocity (measured) CALF (CORRECTED AXIAL LENGTH FACTOR) methodChange velocity to 1532 m/s (aphakic vel.) To this add CALF factor.
x measured AL =True AL

Setting the ultrasound velocity

CALF = TL x ( 1- 1532) VL

TL = 4 + AGE. 100

VL = 1659 [(AGE -10)] 2

TL-axial thickness of lens VL- sound vel through lens

CALF VALUE OF 0.32 CAN BE

APPLIED FOR ALL AGES

Biometry Measurement of AL Retinal Thickness Factor Recommendation RTF considered to account for additional distance from surface of retina to level of photoreceptors Add 0.20 to 0.25 mm to measured AL Measuring Corneal Power These errors are rarely of high magnitude. Considerations for obtaining accurate corneal P1) Instrumentation 2) Contact lens wear 3) Previous refractive surgery 4) Corneal transplant eyes Measuring Corneal Power Instrumentation Manual KeratometerCalculates P by assuming RI of 1.3375 D = RI -1

 Recommendation for manual keratometry = 4 /3 Calibrate on regular schedule Avg. of 3 readings switching to a Javal-Schiotzstyle Keratometer

Measuring Corneal Power

K value calculated is more accurate

Hard Contact Lens-(including gas permeable)Removed at least 2 weeks before measuring K

Measuring Corneal Power Considerations After Photorefractive Surgery1) CLINICAL HISTORY/ CALCULATION METHOD Mean postoperative K =

(Mean preoperative K) (change in refraction at corneal plane) NOTE- postoperative refraction (before myopic shift due to cataract) Convert the pre and postoperative refraction into spherical equivalent at spectacle plane (SEQS ) SEQS = sphere + 0 .5 ( cylinder) Convert SEQS with a given vertex distance (V) in mm into spherical equivalent at corneal plane (SEQC). SEQC = 1000 /[ (1000/ SEQS )- V] Change in refraction at corneal plane = Preoperative SEQC Postoperative SEQC This is subtracted from mean preoperative K to get mean postoperative K value. Biometry-Measuring Corneal Power Considerations After Photorefractive Surgery CONTAC LENS METHOD Spheroequivalent refraction (SER) for eye calculated SER calculated after wearing hard contact lens curve =Effective power of cornea] [of plano power and base

Biometry-Measuring Corneal Power Considerations after Photorefractive Surgery After wearing contact lens -

 If SER remains same K = base curve of contact lens.

cornea by magnitude equal to amount of shift. If hyperopic shift with contact lens base curve of contact lens < than that for cornea by amount of shift. Biometry-Measuring Corneal Power Considerations after Photorefractive Surgery Double K methodIn theoretical formulas, corneal P required for 2 purposes

Predict position of IOL (ACD / ELP) Calculate IOL P Anatomy of ant segment not changed by surgery Kpreop can be used for ELP IOL P calculated with Kpostop

Biometry Considerations after Photorefractive Surgery Other methods Shammas no history method K=1.14 x Kpo-6.8

Maloney Corneal topography method: K= Kt x (376/337.5) - 5.5 Koch modification of Maloney method: K= Kt x (376/337.5) - 6.1 (Kt central K fromcorneal topography) Biometry- Prediction of Post Op IOL Position ACD /ELP/ALP Distance between the posterior corneal surface (some authors use the anterior corneal surface) and the anterior surface of the implanted IOL Methods of measuring ACD: 1) Ultrasonography (applanation & immersion)

2) Partial coherence interferometry 3) Scanning slit topography (Orbscan) 4) Optical methods (less popular)

Biometry- Prediction Of Post Op IOL Position ACD /ELP/ALP Distance between the posterior corneal surface (some authors use the anterior corneal surface) and the anterior surface of the implanted IOL Methods of measuring ACD: 1) Ultrasonography (applanation & immersion) 2) Partial coherence interferometry 3) Scanning slit topography(Orbscan) 4) Optical methods (less popular) FORMULAS 2 major formula categories: Theoretical formulas Ex. Holladay, Hoffer Q, SRK / T

Regression formulas Ex. SRK

The commonly used Formulas

use two predictor of the ELP axial length keratometry

Holladay 1,SRK / T, Hoffer Q Holladay 1-

No ACD input

Calculates predicted distance from cornea to iris plane +distance from iris plane to IOL (Surgeon Factor :Specific for each lens)

3rd generation formulas: Hoffer Q: P is function of

Axial length Avg. K reading Refraction (Rx) { f of AL, K, P, pACD} PACD (constant) {= manufacturers ACD or derived from A constant) 4th generation formula :

Holladay 2 formula: Uses seven variables to predict lens position 1) Axial length 2) Keratometry 3) Horizontal white-to-white corneal diameter 4) ACD 5) Lens thickness 6) Refraction 7) Age of the patient Haigis Formula:

ELP = a0 +[a1 x ACD] +[a2xAL] a0- same as lens constant a1 - tied to ACD a2 - tied to the measured axial length

FORMULAS USAGE Normal AL(22 24.5mm) : any formula Avoid using SRK 1 in AL outside this range

 Short eyes (< 22mm):Hoffer Q Very short eyes (< 19 mm):Holladay 2 Medium long (24.5 to 26mm) :Holladay 1 Very long (> 26mm): SRK / T

Formulas- Personalization Based on surgeons past experience and data Increases accuracy Data collected : Same surgeon, same lens style, same biometry instruments Can be performed using Hoffer programme, Holladay IOL Consultant computer programmes Following parameters noted AL (preop) Corneal power (preop) IOL P Postop refractive error (stable)

Clinical variables Patients needs and desires FINAL SELECTION OF IMPLANT POWER 1) FELLOW EYE REFRACTION:
If refractive P of opposite eye lies between 2 D and + 2 D then emmetropia

should be aimed. Else stepwise reduction (if BE have cataract) can be done
Ex - 4D preoperative refraction can be reduced by aiming for 2D under

correction in 1 eye and emmetropia in other. Clinical variables Patients needs and desires

 Elderly patient reading important err on myopic side (choosing power higher by about 0.5 D)

Active person- near emmetropia is best

Clinical variables-Paediatric IOL power calculation 3 Major approach 1) Adult power / Initial hyperopia amblyopia 2) Initial emmetropia significant late myopia 3) Customized approach (compromise between these 2 extremes
Ideally ,choose P intermediate between the ones calculated by 1st and 2nd

approach Clinical variables Paediatric IOL power calculation Preferably AL and K : during EUA Preferably use Theoretical formulas s / as SRK /T, Hoffer Q, Holladay, Haigis
IOL implantation in < 2 years under correct by 20% Children 2 and 18 years of age-under correct by 10%

If fellow eye is pseudophakic, minimize anisokonia Dense amblyopia leave less hyperopia (or emmetropia) If poor compliance to glasses or CL leave least refractive error Bag vs sulcus IOL P of IOL intended for capsular bag placement should be decreased by 0.75 to 1.0 D when placing in ciliary sulcus Clinical variables Biometry in vitrectomized

 Perform biometry in sitting position

Some newer ultrasound units have adjustable velocities

Formula suggested by Prof. John ShammusTAL= 1133/ 1550 AAL

PREVENTION OF COMMON ERRORS Use immersion A- scan or IOL Master to measure AL Make sure A scan instrument has oscilloscope screen Suspect a staphyloma in eyes >25 mm: use IOL master or immersion vector A/ B scan Use CALF method : measure eye using 1532 m/s and add +0.32 mm to result to correct for any error in sound velocity Regularly calibrate manual keratometer Keep CL out for 2 weeks prior to keratometry Silicone oil eye needs IOL master if possible or ultrasound AL times 0.71 Use Hoffer Q IN <22 mm and in post refractive surgery eye Use Holladay 1 in eyes 24.5 to 26 mm Use SRK / T in eyes longer than 26 mm Avoid using SRK regression (SRK 1& 2) Personalize your ELP factors in the formulas Use the clinical history and contact lens method for post refractive surgery
Consider delaying the IOL implantation until cornea has healed after a PK

rather than performing triple procedure.

Dr. D K Verma, Dy. Commandant (Eye Specialist), Base Hospital, ITBP Force, New Delhi