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Acta Ophthalmologica Scandinavica 2007

Review Article

Calculation of intraocular lens


power: a review
Thomas Olsen
University Eye Clinic, Aarhus Hospital, Aarhus, Denmark

ABSTRACT. comparable results (Haigis 2001;


This review describes the principles and practices involved in the calculation of Vogel et al. 2001; Kiss et al. 2002;
intraocular lens (IOL) power. The theories behind formulas for calculating Packer et al. 2002; Findl et al. 2003).
IOL power are described, using regression and optical methods employing Finally, the development of aspheric
‘thin lens’ and ‘thick lens’ models, as well as exact ray-tracing methods. (Holladay et al. 2002; Packer et al.
Numerical examples are included to illustrate the points made. The paper 2004) and multifocal IOLs of various
emphasizes the importance of establishing an accurate estimation of corneal designs (Olsen & Corydon 1990; Javitt
et al. 2000; Bellucci 2005; Dick 2005;
power as well as an accurate technique for the measurement of axial length
Chiam et al. 2006) brings within reach
and accurate methods of predicting postoperative anterior chamber depth
the ultimate goal of spectacle freedom
(ACD). It is concluded that current improvements in diagnostic and surgical after lens surgery, provided we have
technology, combined with the latest generation IOL power formulas, make accurate methods of controlling the
the calculation and selection of appropriate IOL power among the most effect- optics of the pseudophakic eye.
ive tools in refractive surgery today.

Key words: accuracy – biometry – cataract – IOL power calculation – lens surgery – optics –
prediction error – ray tracing – refraction
History
The optics of the eye represents one
of the oldest fields in ophthalmology;
Acta Ophthalmol. Scand. 2007: 85: 472–485
ª 2007 The Author
readers of this journal will be well
Journal compilation ª 2007 Acta Ophthalmol Scand aware of important contributions
made a century ago by Scandinavians
doi: 10.1111/j.1600-0420.2007.00879.x such as Alvar Gullstrand (Nobel
Laureate, Sweden) (Gullstrand 1909)
Firstly, the use of small, sutureless and Marius Tscherning (Denmark)
Introduction incisions has greatly reduced surgically (Norn & Jensen 2004). The original
It is often said that cataract surgery is induced astigmatism (Kershner 1991; scientific works by these giants are
refractive surgery, even when no intra- Olsen et al. 1996; Olson & Crandall still highly recommended reading for
ocular lens (IOL) is implanted. How- 1998), making the spherical compo- anyone who wants to understand the
ever, whereas in the old days the nent of the refraction critical to spec- principles of ocular optics.
cataract was removed first and tacle dependency after surgery. The history of IOL power calcula-
the spectacle prescription given last, Secondly, the introduction of optical tion began in 1949 when Harold Rid-
the situation today is reversed: we pre- biometry by partial coherence inter- ley implanted the first IOL in a blind
scribe an IOL to obtain a certain ferometry (PCI) (Drexler et al. 1998) eye. The surgery was reported to be
refractive effect and this may represent for the measurement of axial length as successful (the patient still could not
the indication for lens surgery. The performed with the Zeiss IOLMasterª see) but the refractive error was found
difference between the past and the (Carl Zeiss Meditec, Jena, Germany) to be ) 20 D! The error was soon iden-
present lies in the development of has introduced new standards for the tified by Ridley as involving the opti-
modern diagnostic and surgical tech- measurement of axial length. Not only cal design of the lens. Ridley had tried
niques that control refractive outcome is this optical biometry highly repro- to copy the curvatures of the natural
with ever-increasing accuracy. ducible and therefore potentially more lens as described by Gullstrand, but
There are several reasons why accurate, but, as it is observer-inde- failed to recognize the effect of the
methods of calculating IOL power pendent, it allows surgeons in differ- higher index of refraction of the IOL
have come into focus in recent years. ent parts of the world to obtain material (Perspex) (Apple 2006).

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Acta Ophthalmologica Scandinavica 2007

My own experience with IOL optics curvature in metres. There is a signage subtracting the two vergences V2 and
began as a resident in the early 1980s convention dictating that anterior con- V1 to give:
when implantation of standard-power vex surfaces are given a plus sign and n2 1
IOLs was still popular. When our posterior convex surfaces a minus sign. P0 ¼  1 d ð6Þ
ðAx  dÞ ðK  n Þ
senior professor was asked why no Vergence is another important con- 1

effort was made to select an individual cept. It is described as the reciprocal Equation 6 is a thin lens formula,
power for the patient, he would of the ‘reduced’ distance to the focal identical in format to the early
answer, ‘In my department we restore point, defined as: so-called ‘theoretical’ IOL power cal-
the patient’s basic refraction,’ claiming n culation formulas (Colenbrander 1973;
that Gullstrand had found the natural V¼ ð2Þ
d Fyodorov et al. 1975; Binkhorst 1975,
lens to have a constant power of 1979). Although the format looks
where V ¼ vergence of paraxial rays in
19 D! rather simple, it involves several
dioptres, d ¼ distance in metres from
Although it is true that ametropia unknowns that should be dealt with if
vergence plane to focal point and n ¼
is strongly correlated with the length the formula is to be applied in clinical
refractive index of the material.
of the eye, it has been known for practice. Some of these unknowns
When a refractive system (i.e. a
some time that biological lens power include the refractive index, how to
lens) of power F is added to a bundle
has a significant statistical distribution accurately calculate the corneal power,
of rays of vergence V1, the vergence
of its own (Sorsby 1956; Stenström how to predict the effective lens plane,
V2 of the rays leaving the lens can be
1946; Olsen et al. 2007). Furthermore, the correction of principal planes of a
calculated by addition:
clinical studies have shown that a ‘thick lens’ model, the accuracy of
fixed IOL power would leave 5% of axial length measurements, and the
patients with refractive errors that dif- V2 ¼ V1 þ F ð3Þ
significance of higher-order aberra-
fered from their basic refraction by tions, etc.
> 5 D (Olsen 1988a). Not only would In general, optical formulas used
such patients be highly dependent on ‘Thin lens’ IOL power calculation for power calculation can be ranked
spectacles after surgery, but, clearly, formula into orders of increasing complexity:
anisometropia of this magnitude Assuming the corneal power (K), the
might cause significant aniseikonia (1) thins lens formulas using sim-
axial length (Ax), the effective lens
and have profound influence on bin- plified thin lens models for the cornea
plane (d) and the refractive index (n)
ocular vision. and the lens;
of the eye are known, what power of
Although much of the following (2) thick lens formulas that regard
IOL is needed for emmetropia?
will deal with methods of controlling the cornea and lens as having finite
the dioptric outcome of lens surgery, Answer thicknesses with separate curvatures
we must not forget that a complete When incoming (parallel) rays leave on their surfaces (paraxial ray trac-
optical description involves not only the cornea, the focal distance is given ing), and
refraction in terms of the sphere and by 1 ⁄ K. When the ray bundle enters the (3) exact ray tracing (wavefront
cylinder of the spectacles, but also the effective lens plane, the focal distance techniques), including higher orders of
magnification of the eye)spectacle sys- is reduced by the distance d ⁄ n1 where d aberrations of the cornea and lens.
tem, possible aberrations, depth of is the effective anterior chamber depth
focus, the question of accommoda- (ACD) in metres and n1 is the refractive
tion, contrast sensitivity, pupil index in the anterior segment. The ver-
dependency, colour perception and gence V1 at the front surface of the lens The statistical
other optical properties of the pseudo- plane can therefore be calculated as the
phakic eye. reciprocal of the new focal distance
(regression) approach
according to equation 2: In the first years of IOL power calcula-
tion, the accuracy of early theoretical
1
V1 ¼ ð4Þ formulas was unconvincing; better
Some basic optical ðK1  nd1 Þ results were reported with a statistical
formulas In order to be focused on the retina, regression approach, first represented
rays leaving the lens plane must have by the Sanders)Retzlaff)Kraff
Assuming paraxial imagery, the
a vergence V2 defined by the distance (SRK I, SRK II) formulas (Sanders &
refractive effect of any spherical sur-
from the lens plane to the retina, Kraff 1980; Sanders et al. 1988). (Note
face can be calculated as described in
that is: that the latest version, the SRK ⁄ T
the following formula (Bennett &
n2 formula [Sanders et al. 1990] is not a
Rabbetts 2006):
V2 ¼ ð5Þ regression formula but, rather, a modi-
n2  n1 ðAx  dÞ
F¼ ð1Þ fied Binkhorst formula with modified
r where Ax is the axial length of the eye ACD-prediction algorithms.)
where F ¼ refractive power of surface in metres, d is the effective ACD in The advantage of any empirical
in dioptres (D), n1 ¼ index of refrac- metres and n2 is the refractive index in approach is that the formula is based
tion of the material before the surface, the posterior segment. on actual measurements, which, to
n2 ¼ index of refraction of the material According to equation 3, the power some extent, eliminates the need to
after the surface, and r ¼ radius of P0 of the IOL can now be found by make assumptions on, for example,

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Acta Ophthalmologica Scandinavica 2007

how to calculate corneal power, how cases were extracted from electronic Table 1 shows clinical data for these
to adjust for principal planes, how to case records at the University Eye Cli- subjects.
correct axial length for retinal thick- nic, Aarhus, Denmark. These referred The IOL power that would have
ness, and how to make any clinical to patients who fulfilled the following produced emmetropia was calculated
measurements work in the physical criteria: from:
sense. The working principle of a P0 ¼ Pi þ 1:5  Rx ð8Þ
(1) they were consecutive patients
regression formula is that it generates
aged 40–100 years, who had been where Pi ¼ actual power of implant
a mean value and incorporates a cor-
admitted for senile cataract; and Rx ¼ actual postoperative refrac-
rection (through regression coeffi-
(2) they had not previously under- tion. A multiple regression analysis
cients) to deviations from mean
gone anterior or posterior segment using the method of least square gave
values. Properly derived, the arithmet-
surgery; the following regression equation
ical mean errors of a regression equa-
(3) they had undergone preopera- (r ¼ 0.96, p < 0.0001):
tion should sum to zero in a
tive keratometry performed with the
representative patient sample. P0 ¼ 151:3  1:2  K  3:3  Ax ð9Þ
same autokeratometer (Nidek
The original SRK I formula consis-
ARK 700; Nidek Ltd, Gamagori, Again, P0 ¼ power for emmetropia,
ted of a simple linear regression equa-
Japan), the results of which showed K ¼ K-reading in dioptres (using
tion (Sanders & Kraff 1980):
no astigmatism > 4 D; common keratometer index 1.3375)
P0 ¼ A  0:9  K  2:5  Ax ð7Þ (4) their axial lengths had been and Ax ¼ axial length using optical
where P0 ¼ power of implant for measured with the Zeiss IOLMasterª; biometry (Zeiss IOLMasterª). Note
emmetropia, K ¼ dioptric keratometry (5) the same type of IOL implant that the present regression equation
reading (using index 1.3375), Ax ¼ (Alcon Acrysof SA60AT; Alcon (equation 9) is quite different from the
axial length of the eye as measured by Laboratories, Fort Worth, TX, USA) old SRK formula (equation 7) derived
ultrasound and A ¼ the A-constant had been used in all of them; over 20 years earlier.
according to the type of IOL and the (6) the IOL had been placed in- When this newly derived regression
mean values of the K-readings and the-bag, and equation (equation 9) was used in
axial length readings. (7) final manifest refraction was retrospect to ‘predict’ the observed
The disadvantage of any empirical recorded at least 2 weeks after surgery actual refraction, the mean numerical
approach is that the formula in prin- with a visual acuity ‡ 20 ⁄ 40. error was observed to be
ciple only works for the dataset
from which it is derived. For exam- Table 1. Clinical data for 1000 consecutive cataract surgeries with recorded final refraction.
ple, if the axial length is measured Axial length was measured with the Zeiss IOLMasterª. The K-reading was calculated from the
by a different technique in another corneal radius using an assumed index of 1.3375.
clinical setting, the A-constant (and Axial length Corneal K-reading IOL power Postop Rx
maybe the regression coefficients) (mm) radius (mm) (D) (D) (D)
will change accordingly. This would
be true when changing biometric Mean (± SD) 23.30 (± 1.14) 7.74 (± 0.27) 43.66 (± 1.54) 22.33 (± 3.45) ) 0.56 (± 0.73)
Range 20.56–30.41 6.88–8.73 38.66–49.06 7.00–33.00 ) 4.00 to + 1.75
technique from ultrasound to optical
coherence interferometry (PCI) (Zeiss IOL ¼ intraocular lens; D ¼ dioptre; Postop Rx ¼ recorded final refraction; SD ¼ standard
IOLMasterª), which tends to pro- deviation.
duce longer readings than ultra-
sound. However, the formula might
also be sensitive to differences in
surgical technique, such as whether
the IOL is placed inside or outside
the capsular bag, a difference that
alters the average position and
refractive effect of the IOL.
Thus, in order to overcome prob-
lems with differences in measuring or
surgical technique, it is recommended
that the formula is personalized and
that the A-constant in a representative
number of cases is backsolved in
order to make it accurate in the aver-
age case (see below).

A numerical example Fig. 1. The correlation between observed and predicted refraction in 1000 consecutive cases
using a regression formula derived from the same dataset (P0 ¼ 151.3–1.2*K ) 3.3*Ax, where
To investigate the accuracy of a statis- P0 ¼ intraocular lens power for emmetropia (D), K ¼ the keratometry reading of corneal
tical regression approach on a modern power (D) and Ax ¼ axial length as measured by optical biometry (in mm). Obs Rx ¼
dataset, the records of 1000 recent observed refraction error; Predicted Rx ¼ predicted refraction error.

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Acta Ophthalmologica Scandinavica 2007

0.00 ± 0.64 D (± standard deviation Measurement of corneal A magnification is calculated from


[SD]), as plotted in Fig. 1. The corres- this image size, which is directly rela-
ponding mean absolute error was power ted to the radius of curvature of the
0.49 ± 0.42 D (± SD). Corneal power accounts for about reflecting corneal surface. To do this,
For comparison, the mean numerical two-thirds of the total dioptric power the cornea is normally assumed to be
prediction error using the latest genera- of the eye and is an important compo- represented by a spherocylinder. Also
tion IOL power calculation formula nent of the ocular refractive system. If to be considered is the fact that the
(Olsen 2007) on the same dataset was the calculation of corneal power is reading is not taken from the most
found to be 0.00 ± 0.58 D (± SD) inaccurate, it will induce error propa- important central area, but usually
with a mean absolute error of 0.47 D. gation and have profound conse- from a 3-mm diameter midperipheral
Using the original SRK I approach quences on the remaining steps in the zone area, depending on the instru-
(equation 7) and an optimized A-con- calculation of IOL power. Unfortu- ment.
stant of 119.05 for the same dataset, nately, calculating corneal power is For the sake of simplicity, most
the mean numerical error was found to not a straightforward process. keratometers regard the cornea as a
be 0.00 ± 0.87 D (± SD) with a mean No keratometer measures corneal ‘thin lens’ with a single refractive sur-
absolute error of 0.66 D (Table 2, power directly. What is actually meas- face, the dioptric power (D) of which
Fig. 2). (Note that the numerical mean ured is the size of the image reflected can be calculated according to equa-
error was zero in all instances due to from the convex mirror constituted by tion 10:
the optimization of the predictions.) the tear film of the corneal surface. n1
D¼ ð10Þ
r
where r ¼ radius of the front surface
in metres. Assuming n ¼ 1.3375, this
Table 2. The accuracy of intraocular lens power calculation in 1000 consecutive cases using equation becomes:
three different IOL power calculation formulas: a modern thick lens optical formula according 337:5
to Olsen; a newly derived regression formula, and the old SRK I formula using optimized IOL D¼ ð11Þ
r
constants. Values are expressed as observed refraction minus expected refraction in dioptres.
where r ¼ front radius, now in mm.
Olsen optical Olsen regression SRK I regression This index has been used as the com-
mon calibration setting of most kera-
Numerical error (mean ± SD) 0.00 ± 0.60* 0.00 ± 0.64 0.00 ± 0.87
Absolute error (mean ± SD)  0.47à ± 0.39 0.49 ± 0.42 0.66 ± 0.56 tometers (mostly in the USA and not
Range (minimum–maximum) ) 2.29 to + 2.30 ) 2.29 to + 2.30 ) 2.29 to + 2.30 always in Europe). Thus for a cornea
with a 7.5-mm radius, the K-reading
* Significantly different from column 2 (p < 0.05) and column 3 (p < 0.001) by F-test. would be 45.00 D. (To check the calib-
  The SD is not statistically meaningful here because the absolute error is not normally distri- ration, observe the keratometer reading
buted.
corresponding to a 10.0-mm radius of
à Significantly different from column 2 (p < 0.01) and column 3 (p < 0.001) by Wilcoxon
non-parametric paired comparison. curvature. If it reads 33.75 D, the calib-
IOL ¼ intraocular lens; SD ¼ standard deviation. ration index is 1.3375.)
However, we have known for some
time, that the thin lens model of the
cornea does not give a physiological
estimate of power, which is desirable
in IOL power calculation (Olsen
1986a). The cornea has two refracting
surfaces and, in order to calculate the
total corneal power, it is necessary to
know the curvature of not only the
front but also the back of the cornea.
Because the latter is not easily meas-
ured by current clinical methods (see
below), most methods have assumed
posterior curvature to represent a
fixed ratio of the front surface. If, for
example, we assume this ratio to be
the same as for the Gullstrand exact
schematic eye (i.e. 6.8 : 7.7), it is poss-
ible to calculate the power at each
surface and calculate the total power
according to the conventional thick
Fig. 2. The distribution of the prediction error in 1000 consecutive cases using three different
lens formula:
intraocular lens (IOL) power calculation formulas: a modern thick lens optical formula accord- T
D12 ¼ D1 þ D2   D1  D2 ð12Þ
ing to Olsen; a newly derived regression formula, and the old SRK I formula using optimized n
IOL constants.

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Acta Ophthalmologica Scandinavica 2007

where D12 ¼ total dioptric power of 0.84. These new results may call for a (1) corneal anterior asphericity (ka)
the thick lens, D1 ¼ dioptric power of modification of the corneal power as a function of age:
the front surface, D2 ¼ dioptric power model. However, before we simply ka ¼ 0:76 þ 0:003  age
of the back surface, T ¼ thickness of replace the old Gullstrand ratio with
the lens (in metres) and n ¼ refractive the newer values, it may be necessary and
index. to consider the aberrations of the cor- (2) corneal posterior asphericity
Hence, for a ‘standard’ cornea with nea, firstly, the spherical aberration. (kp) as a function of age:
a 7.7-mm front surface and 0.5-mm kp ¼ 0:76 þ 0:325  ka  0:0072  age
thickness, the calculation is straight-
Spherical aberration of the cornea Using this model, the conic coeffi-
forward (assuming the refractive indi-
ces of air, cornea and aqueous to be The effect of a (positive) spherical cients of the front and back surfaces
1.0, 1.376 and 1.336, respectively): aberration is to increase the effective of the cornea can be estimated to be
power of the cornea. For example, if ) 0.06 and ) 0.37 on average in a 60-
ð1:376  1Þ  1000 we assume the old Gullstrand ratio of year-old subject. Using exact ray trac-
D1 ¼ ¼ 48:83 D 6.8 : 7.7 represents the back sur- ing, the total effective power of the
7:7
face : front surface of the cornea, and cornea can thus be calculated as a
ð13Þ
subject this spherical model to an function of pupil size, as shown in
exact ray tracing technique (wavefront Fig. 4. Note that effective corneal
ð1:336  1:376Þ  1000 analysis), the Gullstrand cornea will power increases with pupil size as a
D2 ¼ ¼ 5:88 D show a spherical aberration of almost result of the spherical aberration.
7:7  ð6:8=7:7Þ
0.5 D for a 4-mm pupil (Fig. 3). To illustrate and compare different
ð14Þ The biological cornea also shows cornea models, corneal power was cal-
and hence spherical aberration. However, as the culated using:
cornea flattens somewhat towards the
0:5 (1) the keratometry reading (refractive
D12 ¼ 48:83  5:88  periphery the shape is more like a
1:376  1000 index of 1.3375);
prolate and the amount of asphericity
 48:83  ð5:88Þ ¼ 43:05 D ð15Þ (2) paraxial ray tracing according
therefore has to be quantified. The
to the Gullstrand schematic eye, and
advent of various topography meth-
(3) exact ray tracing on the Dub-
Note that the back surface of the ods has resulted in a considerable
belman aspheric cornea, assuming a
cornea has a negative power of about amount of data in the literature on
4-mm pupil and a 60-year-old subject.
) 6 D. Also note that the total power the front corneal surface but this is
is about 0.8 D lower than the value insufficient because the posterior sur- Figure 5 shows the results.
obtained with the common keratome- face may also contribute significantly As expected, the results show that
ter index calibration of 1.3375. If we to total optical power. the standard keratometer reads the
apply a refractive index to the front Recent studies, particularly by corneal power about 0.75 D higher
surface that would produce the same Dubbelman et al. (2002, 2006), using than the Gullstrand value. The surpri-
result as the thick lens calculation, the Scheimpflug photography, have provi- sing result is, however, that the effect-
index can be calculated by reversing ded data for normal values of the ive power of the Dubbelman aspheric
equation 10 as: front and back surfaces of the cornea cornea is very close to that of the par-
and their dependency on age. Dubbel- axial Gullstrand spheric model. For a
43:05  7:7 man et al. (2002, 2006) used regres- 7.8-mm cornea, the Dubbelman value
n¼ þ 1 ¼ 1:3315 ð16Þ
1000 sion analysis to derive the following is 0.13 D higher than the Gullstrand
formulas to express: value! This result can be attributed to
This value was used by Olsen
(1987a, 1987b, 1988b) and later by
Haigis (2004). For several years it has
been the lowest value used for the fic-
titious refractive index of the cornea
among current IOL power calculation
formulas.
There is recent evidence, however,
that the old Gullstrand ratio of
6.8 : 7.7 (¼ 0.8831) for the ratio
between the back and front curvatures
of the central cornea may be too high.
As Dunne et al. (1992) show, using
keratometry readings derived from
Purkinje I + II images, a better value
may be 0.823. Recent work by
Dubbelman et al. (2002, 2006) using
Scheimpflug photography show the Fig. 3. Spherical aberration of the Gullstrand cornea (front radius 7.7 mm) expressed as the
Gullstrand ratio to range from 0.82 to difference between the effective and paraxial power as a function of pupil size.

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Acta Ophthalmologica Scandinavica 2007

readings. However, even the best


topographer may not give reliable
readings in the very central area; most
topographers (and all keratometers)
tend to give readings that are too
steep for the effective central zone of
the cornea. This may result in a hyper-
opic error after IOL implantation.
Several methods have been pro-
posed to overcome this problem.
These comprise the clinical history
method, refraction-derived correction
according to Shammas et al. (2003),
the correcting factor according to
Rosa et al. (2002), the variable
Fig. 4. Dubbelman corneal power as a function of front radius and pupil size. refractive index according to Ferrara
et al. (2004), a formula and nomo-
grams according to Feiz et al. (2001,
2005), the corneal thick-lens formula
according to Speicher (2001) and the
regression formulas developed by
Latkany et al. (2005). The different
formulas have been reviewed by
Savini et al. (2006).
The clinical history method, gener-
ally considered to represent the gold
standard, is based on the logical
assumption that a surgically induced
change in refraction should be
explained by the change in effective
corneal power (assuming that no len-
Fig. 5. Corneal power as a function of front central radius for three different corneal models: ticular myopia has developed). To cal-
common keratometry calibration using index 1.3375; Gullstrand paraxial model assuming the culate post-surgical corneal power, the
ratio between the back and front curvature is 6.8 : 7.7, and exact ray tracing on the Dubbelman observed increase in refraction (vert-
aspheric corneal model, assuming the ratio between the back and front curvature is 6.53 : 7.79 exed to the corneal plane) is subtrac-
and a 4-mm pupil.
ted from the preoperative corneal
power. This method therefore requires
the spherical aberration of the cornea, changes in the corneal optic configur- preoperative K-readings.
which increases the effective power of ation relating to the anterior and pos- Another method is the hard contact
the cornea over the paraxial value. terior curvatures of the cornea. lens technique (Holladay 1989;
Difficulties in the calculation of corneal cf. Haigis 2003), which determines the
power can therefore be divided into: difference between refraction with and
Corneal power after refractive surgery without a plano hard contact lens of
(1) topographical problems com-
A growing population of patients who zero power and subtracts this differ-
mon to all post-refractive cases, and
have undergone corneal refractive sur- ence from the base curve of the con-
(2) problems relating to the corneal
gery presents a considerable problem tact lens. However, although it is
model, which is abnormal in the
for the calculation of IOL power. This theoretically sound, the variability of
case of a post-PRK or post-LASIK
is due to changes in normal corneal this method is difficult to control in
cornea.
anatomy, which makes the calculation clinical practice (Joslin et al. 2005; Sa-
of corneal power very difficult. For Although the conventional keratome- vini et al. 2006).
example, if a cornea has undergone ter measures the central 3-mm zone of According to the refraction-derived
radial keratotomy (RK), its topo- the cornea, assuming the cornea to be method of Shammas et al. (2003), the
graphic profile will have been altered a spherocylinder, this assumption is keratometric value (using the 1.3375
by the procedure, with flattening in certainly not appropriate when the index) can be calculated as Kc ¼
the central region and steepening in corneal surface has been changed as a Kpost () 0.23*CR), where Kc ¼ correc-
the periphery. These topographic result of refractive surgery. After myo- ted keratometry, Kpost ¼ postoperative
changes will also be seen in a post- pic keratorefractive surgery, the flat- keratometry and CR ¼ amount of
photorefractive keratotomy (PRK) or test area of the cornea is the central myopia corrected at the corneal plane.
post-laser in situ keratomileusis area, which is not covered by the A variant of this formula is the clinic-
(LASIK) cornea, but, by contrast with keratometer. A better reading may be ally derived correction Kc ¼
the post-RK case, a post-PRK obtained by corneal topography, 1.14*Kpost ) 6.8, which does not take
or post-LASIK case will also show which usually gives more central preoperative refraction into account.

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Acta Ophthalmologica Scandinavica 2007

The method described by Rosa Table 3. Deviation from the mean values of Some eyes do not have perfectly par-
et al. (2002) utilizes axial length in a different variables and corresponding refrac- allel structures, however, and readings
regression formula to account for the tion errors. can be difficult to obtain in eyes with
induced refractive change. This for- Variable Error Rx error dense cataracts and eyes with poster-
mula depends on the association of ior staphyloma. Care should be taken
axial length with myopia, which is Corneal radius 1.0 mm 5.7 D not to indent the cornea if contact
known to represent the strongest cor- Axial length 1.0 mm 2.7 D measurements are used. For this rea-
Postoperative ACD 1.0 mm 1.5 D
relation in the normal population. son immersion readings are generally
IOL power 1.0 D 0.67 D
According to Rosa et al. (2002), the considered more accurate than contact
corneal radius as measured by topog- Rx error ¼ refraction error; ACD ¼ anterior measurements.
raphy should be corrected by a factor chamber depth; IOL ¼ intraocular lens. The introduction of optical biome-
varying between 1.01 and 1.22 accord- try using partial coherence interferom-
ing to the axial length of the eye. The measurement errors and their influ- etry (Drexler et al. 1998)
corneal power is then obtained using ence on refractive error are shown in (commercially available as the Zeiss
the formula (1.3375–1) ⁄ rc, where rc ¼ Table 3. The conversion from IOL IOLMasterª) has significantly
the corrected corneal radius. power error to error in the spectacle improved the accuracy with which
Other formulas use a variable plane is about 1.5 (cf. equation 8). axial length can be measured. The fact
refractive index (Ferrara et al. 2004), For many years ultrasound was the that the retinal pigment epithelium is
according to which the corrected only technique by which the length of the end-point of an optical measure-
refractive index of the cornea the eye could be measured in clinical ment, whereas the interface between
can be calculated as n ¼ ) 0.0006* practice. What is really measured by the vitreous and the neuroretina is the
(Ax*Ax) + 0.0213*Ax + 1.1573, ultrasound is the transit time taken by end-point of an ultrasonic measure-
where Ax ¼ axial length in mm and the ultrasonic beam to travel through ment, makes measurements by PCI
n ¼ corrected refractive index of the the ocular media while it is deflected longer than those taken with ultra-
cornea, that assuming corneal from the internal structures of the eye. sound.
power ¼ (n ) 1) ⁄ r, where r ¼ the The best signal is obtained when the However, just as distance measure-
measured central corneal curvature in ultrasonic beam strikes a surface at ments taken with ultrasound are
metres. This formula also assumes normal incidence that gives rise to a dependent on the assumed ultrasound
that emmetropia is the result of the steep spike on the echogram. With velocity, optical biometry is dependent
refractive procedure and is based on good alignment along the ocular axis, on the assumed group refractive indi-
axial length being a strong predictor it is possible to detect a corneal signal ces of the phakic eye. The indices used
of the preoperative ametropia. (sometimes a double-spike), the front by the Zeiss IOLMasterª were estima-
Many of these methods use the pre- and back surfaces of the lens and the ted by Haigis (2001) and were partly
operative status of the patient to cal- retina at the same time. The ‘retinal’ based on extrapolated data. There is
culate the changes induced in corneal spike is generally assumed to arise at some evidence, however, that index
anatomy. To help in evaluating the the internal limiting membrane of the calibration of the phakic eye may
post-LASIK patient for lens surgery, retina. This may call for correction to need some modification in order to
it would be desirable if all refractive account for retinal thickness when the ensure consistency between preopera-
surgeons kept records of preoperative readings are to be used in an IOL tive and postoperative readings (Olsen
keratometry and refraction values and power formula. & Thorwest 2005) and more studies
gave this information to the patient, It is important to know the velocity may be needed to investigate the index
as is the case with implant surgery. In of ultrasound in order to calculate the calibration of the PCI technique.
addition, it would be helpful if axial distances in question. For the normal It should be acknowledged that
length was measured at the time of phakic eye, velocity is generally readings taken with the commercial
refractive surgery in order to compen- assumed to be 1532 m ⁄ second for the version of the Zeiss IOLMasterª do
sate for the possible development of anterior chamber and the vitreous and not provide a direct measure of the
lenticular myopia, which might ham- 1641 m ⁄ second for the lens (Jansson true optical path length of the eye. In
per the calculation of induced corneal & Kock 1962). In an average eye, this order not to change the system of
change using the history method. is equivalent to 1550 m ⁄ second for the A-constants and other formula
whole eye. However, if we assume a constants that have been used for
constant lens thickness, this average years with ultrasound, readings taken
Measurement of axial velocity is lower in a long eye and with the commercial version of the
higher in a short eye, and should be Zeiss IOLMasterª were calibrated
length corrected to obtain an unbiased pre- (Haigis et al. 2000; Haigis 2001)
Measurement of axial length remains diction in these unusual eyes (Olsen against immersion ultrasound accord-
one of the most crucial steps in IOL et al. 1991). ing to the formula:
power calculation. As a 0.1-mm error The pitfalls of ultrasound measure-
in axial length is equivalent to an ments are numerous: readings should ALðZeissÞ ¼ ðOPL=1:3549  1:3033Þ
error of about 0.27 D in the spectacle be coaxial with the ocular axis. This =0:9571 ð17Þ
plane (assuming normal eye dimen- requires a steep spike from the retina
sions), accuracy within 0.1 mm is as well as good spikes from the anter- where AL(Zeiss) ¼ output reading of
necessary. For comparison, other ior and posterior surfaces of the lens. the Zeiss instrument and OPL ¼ the

478
Acta Ophthalmologica Scandinavica 2007

optical path length measured by PCI. (shape factor) of the IOL, its position power to produce the same refractive
This formula makes the reading within the eye, the power of the effect in the spectacle plane.
achieved with the commercial version implant and the amount of spherical
of the Zeiss IOLMasterª equal to that aberration.
obtained by immersion ultrasound in The optic configuration of the IOL Prediction of
the average case. This need not be the determines the effective lens plane, postoperative anterior
case with contact ultrasound, how- which represents the principal plane
ever, as ultrasound measurements may when dealing with paraxial ray trac- chamber depth
be confounded by indentation of the ing. All the dioptric power of a plano- At the time when early theoretical for-
cornea. convex lens is on one surface and thus mulas were being developed, very little
Equation 17 can be rearranged to that surface represents the effective was known about the actual position
give the optical path: lens plane. With a biconvex lens, the of the implant after surgery. For
effective lens plane is ‘inside’ the lens. example, the Binkhorst I formula
OPL ¼ ðALðZeissÞ  0:9571 þ 1:3033Þ
For example, an IOL with a 2 : 1 (Binkhorst 1979) used a fixed ACD
 1:3549 ð18Þ biconvex optic configuration has a value to predict the position of the
radius of curvature on the front sur- implant in each case. It soon became
Assuming a refractive index of face which is twice the radius of cur- obvious, however, that the fixed ACD
1.3574 for the phakic eye (Haigis vature on the back surface. In other model was inappropriate because it
2001), we can obtain the true axial words, the power of the back surface resulted in predictions that were actu-
length according to: is twice the power of the front sur- ally worse than empirically derived
face. formulas. Modern progress in IOL
ALðTrueÞ ¼ ðALðZeissÞ  0:9571 The optic design and hence the power calculation formulas largely
þ 1:3033Þ  1:3549=1:3574 position of the principal plane have reflects advances in methods of pre-
significant influence on the refractive dicting the position of the implant
ð19Þ
effect of the IOL. Table 4 shows the after surgery based on preoperative
The above considerations are valid effect of varying the design on the measures.
for phakic eyes with normal vitreous refractive effect of the IOL in an aver- Today, there is strong evidence that
compartments. In pseudophakic eyes age eye, assuming a constant position postoperative ACD is positively corre-
and ⁄ or silicone-filled eyes the axial of the anterior surface of the IOL. lated with axial length. The fixed-
length should be deduced with regard The changes in refraction will trans- ACD model therefore predicted ACDs
to the altered ultrasonic velocity or late into an equivalent change in the that were too short in long eyes and
refractive index of the eye in question. A-constant of a given lens. For too deep in short eyes. As a conse-
In the case of silicone oil in the pos- example, if the design of one lens quence, a myopic error would be pro-
terior segment, the situation is further changes from a 1 : 2 configuration duced in a short eye and a hyperopic
complicated by the fact that the opti- to a 2 : 1 configuration, the total error in a long eye. To avoid this
cal path length of the posterior seg- refractive effect in the spectacle effect, the prediction of postoperative
ment is altered and the refractive plane is about 0.26 + 0.18 D, thus ¼ ACD should in some way be correc-
effect of the posterior surface of the + 0.44 D, which is equivalent to a ted for axial length. The following
(posterior convex) IOL may be 0.44*1.5 D ¼ 0.66 D change in IOL simple ACD formula was implemen-
reduced (see next section). In such power. This value would be the ted in the Binkhorst II formula:
cases it might be necessary to use a corresponding correction needed for
ACDpost ¼ ACDmean  Ax=23:45 ð20Þ
thick lens formula with a corrected the A-constant.
refractive index for the vitreous cavity In addition to the shift in principal where ACDmean ¼ average ACD (so-
and corrected calculation of the diop- planes, the amount of spherical aber- called ACD constant) of a given IOL
tric power of the posterior surface of ration of the IOL may also have signi- type, and Ax ¼ axial length in mm
the lens. As a rule of thumb, the ficant influence on the refractive effect (Ax < 26 mm).
refractive power of the IOL needs to of the IOL. As IOL power according The Binkhorst II ACD method was
be increased by an amount that com- to the American National Standards an example of a method to avoid
pares with the clinical observation of Institute (ANSI) definition refers to large bias with the axial length. How-
an average + 6-D shift in the refrac- paraxial power, the more aspheric the ever, before we go further and use
tion of the silicone-filled phakic eye. IOL, the higher the labelled IOL more sophisticated methods, it might
Another option would be to use a
planoconvex IOL with all the refrac-
tion on the front surface. Table 4. Refractive effect of a shift in optic configuration. The refractive effect is expressed as
relative to a standard 1 : 1 biconvex 22 D intraocular lens (assuming acrylic material and aver-
age eye dimensions and constant anterior chamber depth of the IOL).

The refractive effect of 22 D IOL 2 : 1 configuration 1 : 1 configuration 1 : 2 configuration

the IOL Refractive effect + 0.26 D 0.00 D ) 0.18 D


(spectacle plane)
The refractive effect of the IOL
depends on the optic configuration IOL ¼ intraocular lens.

479
Acta Ophthalmologica Scandinavica 2007

be worthwhile considering the follow-


ing question: if postoperative ACD
were to be predicted by an accurate
method, would refractive predictions
show no bias according to axial
length?
This question was studied by the
author by measuring the actual post-
operative ACD in a large series (about
1000 cases) and substituting the pre-
dicted postoperative ACD with the
true, postoperative ACD in each case
(Olsen & Corydon 1993). The results
failed to demonstrate any significant
bias according to axial length! A very
important conclusion to be drawn
from this study was that, apart from a
constant used to correct axial length
(called ‘retinal thickness’, which may
in fact correct for other errors), no
fudge factors were necessary to adjust
IOL power calculations. All that was
needed was an accurate prediction of
the physical position of the IOL in Fig. 6. Distances used in the prediction of postoperative anterior chamber depth (ACDpost).
Ax ¼ axial length; ACDpre ¼ preoperative ACD; LT ¼ lens thickness; R ¼ front radius of cor-
each case. This study was encouraging
nea; H ¼ corneal height.
of further research into better means
of predicting ACD.
Today, estimation of an effective Models for anterior chamber depth when discussing ACD in an IOL
postoperative ACD is based on obser- Definitions of ACD vary according to power formula, the distance is nor-
vations of the statistical association context and this should be acknow- mally measured from the anterior sur-
between various preoperative meas- ledged in any discussion of ACD. The face of the cornea and includes the
urements of the eye and effective clinical definition of ACD in the nor- corneal thickness. This is partly justi-
ACD (Table 5, Fig. 6). Thus, estima- mal phakic eye is straightforward, and fied by the position of the second prin-
tion of ACD remains the true empir- refers to the distance from the cornea cipal plane of the cornea, which is
ical content in every IOL calculation to the anterior surface of the lens. close to the anterior surface (actually
formula and different models for Anatomically, ACD is often reckoned about 0.05 mm in front of the cornea).
doing this cause optical IOL power from the posterior surface of the cor- However, the end-point of the ACD
formulas to differ in accuracy. nea, but in an optical context, such as distance is much more complex. Many
formulas do not use the anterior sur-
face of the IOL as the reference point,
Table 5. Variables used by various formulas in the prediction of postoperative anterior cham-
but rather the ‘effective lens plane’
ber depth or effective lens plane.
(ELP), defined as the effective distance
ACD predictor Formula ⁄ author from the anterior surface of the cornea
to the lens plane as if the lens was of
Axial length Binkhorst Binkhorst 1979 infinite thickness (thin lens). The ELP
Hoffer Hoffer 1993
may be back-calculated as the effective
SRK T Sanders et al. 1990
Holladay Holladay et al. 1988 ACD ‘predicting’ the actual postoper-
Haigis Haigis 2004 ative refraction on a given dataset.
Olsen Olsen 1987a, 2006; Hence, the ELP is formula-dependent
Olsen & Gimbel 1993; Olsen et al. 1995 and need not reflect the true ACD in
Corneal height Fyodorov Fyodorov et al. 1975 the anatomical sense. This is the case
SRK T Sanders et al. 1990 for an ACD defined by the manufac-
Holladay I + II Holladay et al. 1988
turer on an IOL container along with
Hoffer Hoffer 1993
Olsen Olsen 1986b, 2006
the A-constant. The ACD in this con-
Preoperative ACD Haigis Haigis 2004 text is most often based on the Bink-
Holladay II, Olsen Olsen 1986b, 2006 horst formula and cannot be taken to
Lens thickness Holladay II, Olsen Olsen et al. 1995, Olsen 2006 reflect the true physical value of the
Others ACD of the pseudophakic eye.
Age Holladay II Unpublished data
Olsen Olsen 2006 Corneal curvature and corneal height
Refraction Holladay II, Olsen Olsen 2006
One of the earliest models for the pre-
ACD ¼ anterior chamber depth. diction of postoperative ACD used the

480
Acta Ophthalmologica Scandinavica 2007

base of the anterior spherical segment the Olsen formula (Olsen et al. 1992, dependent on axial length. This can
as the reference plane (Fyodorov et al. 1995; Olsen 2006). The importance of be clearly seen in Fig. 7, which was
1975). This plane can be calculated preoperative ACD is ranked second to constructed from an actual dataset
from the corneal curvature and corneal axial length in statistical significance (number of observations: n ¼ 7418)
diameter, the latter by taking an aver- as shown by multiple regression analy- examined to establish the correspond-
age value or by using the white-to- sis (Olsen 2006). ing IOL prediction error (spectacle
white distance of the cornea. The Fy- plane) resulting from a 0.25-mm error
odorov formula was intended for iris- in postoperative ACD versus axial
clip lenses and was adopted by the Lens thickness length. As Fig. 7 shows, the corres-
author for anterior chamber lenses If we accept the importance of preop- ponding prediction error increases
(Olsen 1986b) and later for posterior erative ACD to postoperative ACD, it five-fold from a 0.1-D error in a
chamber lenses (Olsen et al. 1990, seems logical to assume that preopera- 30-mm long eye to a 0.5-D error in
1992). tive lens thickness also has some influ- 20-mm short eye. Accurate prediction
The Fyodorov corneal height for- ence. This is due to the thickening of of ACD therefore remains much more
mula was reintroduced for the calcula- the lens with age and the statistical important in short eyes compared
tion of the so-called ‘surgeon’s factor’, negative correlation between ACD with long eyes.
defined as the difference between the and lens thickness in the normal eye. It should be noted that the means
corneal height and the effective optical Despite this logical assumption and to predict postoperative ACD or ELP
plane of the IOL (Holladay et al. 1988) the fact that most ultrasound equip- to a large extent is based on the statis-
and was adopted at around the same ment is capable of measuring lens tical relationship between several pre-
time as the SRK ⁄ T approach (Sanders thickness, it is surprising how little operatively defined measures and the
et al. 1990). However, recent work by lens thickness has been used in ACD actual position of the implant. This
the author seems to indicate that there prediction algorithms. One exception requires the eye to exhibit a normal
is no significant information in corneal to this rule is the Olsen formula, anatomy. If normality is compro-
height based on corneal diameter, which has used this predictor since mised, as a result of keratorefractive
compared with corneal curvature itself. 1995 (Olsen et al. 1995). More surgery (or the axial length has been
Other predictors, such as axial length, recently, it has also been considered altered as a result of a scleral buckling
preoperative ACD and lens thickness, by other authors (Norrby 2004; Nor- procedure), the statistical model
have been found to be significantly rby et al. 2005). Recent studies on behind the prediction of ACD may no
more important (Olsen 2006). large series have confirmed that lens longer be valid and it may be neces-
thickness is important to accurate sary to ‘normalize’ the anatomy. This
Preoperative ACD ACD prediction, especially in combi- is the rationale behind the ‘double
Today, most newer generation IOL nation with preoperative ACD (Olsen K-method’ reported by Aramberri
power calculation formulas recognize 2006). (2003).
the importance of factors other than Whichever method is used in the Assuming the total prediction error
axial length in predicting ACD. Pre- prediction of postoperative ACD, it in IOL power calculation to be the
operative ACD is one such predictor; should be realized that the error in sum of the error associated with the
it has been used in formulas such as refraction produced by an error in main variables, namely:
the Haigis formula (Haigis 2004) and postoperative ACD is strongly (1) measurement of axial length;
(2) measurement of corneal power,
and
(3) estimation of postoperative
ACD,
it is possible to calculate the relative
magnitude of each of these errors
using ultrasound biometry (Olsen
1992). Assuming current axial length
measurement error using optical
biometry and the latest generation of
ACD prediction algorithm (Olsen
2006), the relative contribution of
these three sources of error was esti-
mated (Fig. 8). Although ACD predic-
tion is probably one of the most
accurate algorithms currently avail-
able, the error contribution from axial
length measurements (36%) was found
Fig. 7. Intraocular lens prediction error (spectacle plane) as a result of a 0.25-mm error in
anterior chamber depth (ACD) prediction versus axial length calculated on an actual large to be less than the error from ACD
dataset (n ¼ 7418). Note that the error increases five-fold from a long eye of 30 mm (about predictions (42%). This result con-
0.1 D refractive error) to a short eye of 20 mm (about 0.5 D refractive error). Bars indicate trasts with previous error estimation,
± 1 standard deviation. showing axial length measurements

481
Acta Ophthalmologica Scandinavica 2007

‘optimized’. Optimization means that vastly improved conditions for greater


the numerical error of predictions standardization in calculating IOL
counting both negative and positive power. For the first time, we now
deviations will average to zero for the have a highly accurate, observer-inde-
entire dataset. The IOL power calcula- pendent technique by which axial
tion formula works at its best when length can be measured. This allows
this is so, leaving only statistical surgeons around the world to com-
(measurement) errors to influence the pare results and exchange information
result. If a systematic error arises any- regarding the most appropriate
where in the system, the Gaussian dis- A-constant or other IOL constants. It
tribution of the predictions would should be remembered, however, that
gather around a certain offset value. the A-constant by nature depends on
Optimization aims to correct for this the population average. If, for exam-
Fig. 8. Breakdown of total intraocular lens error (Fig. 9). ple, the population in one country has
power prediction error into the three main There are different sources of sys- on average longer eyes than that of
sources of error: axial length measurement by tematic error. Systematic deviations in another region, this would call for an
optical biometry (AX); measurement of cor- measurement error translate directly adjustment of the A-constant,
neal power (K), and estimation of postopera-
into equivalent errors in IOL power although the axial length measure-
tive anterior chamber depth (IOL ACD). The
graph was constructed assuming average eye prediction (cf. Table 3) and should be ments were made with the same
data and the current statistical measurement dealt with accordingly. If, for equipment.
error of each variable. RX ¼ refractive error. instance, ultrasound measurements are Every IOL has its own refractive
compared with those of PCI, it is effect depending on the optic configur-
with ultrasound to be responsible for likely that the readings will be some- ation, the amount of spherical aberra-
> 50% of total error. The reason for what longer with optical biometry. tion and the effective ACD (see
the relatively lower contribution from Thus, if one surgeon achieves perfect section above). The existence of a
the axial length source and the higher results using a particular SRK A-con- ‘personalized’ ACD may have been
contribution from the ACD source is stant with ultrasound, it is likely that viable in the old days, when surgeons
the higher accuracy of the optical bi- he ⁄ she will need to increase the had different ways of opening the cap-
ometry using Zeiss IOLMasterª. A-constant by the equivalent value of sule and therefore different ways of
Therefore, the degree of accuracy the shift in axial length measurement anchoring the IOL in the eye. If, for
with which postoperative ACD can be from ultrasound to optical biometry. example, one surgeon implanted every
predicted is the major limiting factor To some surgeons this may seem sur- IOL within the capsular bag, while
in the accuracy of modern IOL power prising, as the A-constant is often another placed the IOL in the sulcus,
calculation. regarded as an IOL-related constant. they would achieve different refractive
The truth is, however, that the A-con- results. As anterior displacement of
stant is a ‘black box’ that contains the IOL enhances its refractive effect,
Optimization and any offset errors that arise in the the sulcus surgeon would need to use
entire clinical environment, as demon- IOLs with a power 0.5–1.0 D lower
accuracy strated in the numerical example given than those used by the in-the-bag sur-
Most of what has been said in the above. geon in the average case. However,
foregoing sections has been under the The introduction of optical biome- since the introduction of the continu-
assumption that predictions have been try by coherence interferometry has ous curvilinear capsulorhexis tech-
nique (Gimbel & Neuhann 1991),
most surgeons have developed a very
standardized way of implanting the
IOL, thus decreasing the variability of
postoperative ACD. Theoretically,
however, it is still possible that a cap-
sulorhexis with a large diameter may
cause the IOL to be more anteriorly
located than a small capsulorhexis due
to postoperative shrinking of the cap-
sule, which leaves some room for per-
sonalized ACDs.
The amount of spherical aberration
has significant influence on the effec-
tive power of the IOL. Due to the
positive spherical aberration of a con-
ventional, spherical IOL, the effective
power of that IOL is actually higher
Fig. 9. The distribution of prediction error with and without correction for an offset error of than its paraxial (labelled) power and
0.5 D by optimization. higher than that of an aspherical IOL

482
Acta Ophthalmologica Scandinavica 2007

with negative spherical aberration. To empirical methods that have used tures of the front and back surfaces,
obtain the same refractive result with ‘fudged’ formulas to compensate for thickness, index of refraction, and
an aspherical IOL as with a spherical the unknowns in the system. However, conic coefficients, etc. In the accurate
IOL, the surgeon would need to use a the advent of better diagnostic equip- prediction of the optical properties of
higher labelled power. The amount of ment and ever-improving surgical the pseudophakic eye, whether the
‘extra’ power needed equals the techniques has decreased the number optic configuration changes with
amount of corrected spherical aberra- of unknowns, and optical methods power, what the conic coefficients of
tion, which may be estimated from now hold sway in IOL power calcula- the aspheric surfaces are, and whether
the physical constants of the IOL (i.e. tion. the power varies by ± 0.5 D or
the conic coefficients of the surfaces). To conclude the discussion of ± 0.1 D from the labelled value mat-
However, due to the Stiles)Crawford regression versus a theoretical ter greatly.
effect, which tends to correct for the approach, it would be unfair to say The average refractive prediction
spherical aberration of the ocular sys- that the regression approach is inac- accuracy that can be achieved with
tem (Olsen 1993), the effective power curate as its accuracy is comparable modern methodology (using optimized
of an IOL may not be 100% dedu- with that of the theoretical approach conditions and the latest generation
cible from its optical bench power. in a normal dataset. The theoretical ACD prediction algorithms) is
Therefore, only by clinical studies is it approach does, however, give more < 0.5 D (absolute error). The stan-
possible to evaluate the true effective accurate predictions, as can be dem- dard deviation of the numerical error
IOL power and obtain the necessary onstrated in a significant number of is < 0.6 D, which means that about
IOL constants to optimize and fine- observations under optimized condi- 90% of cases fall within ± 1.0 D and
tune IOL power calculations. tions. The disadvantages of the regres- 99.9% within ± 2.0 D of their targets,
In the event of unexpected refrac- sion approach include the need for a again assuming optimized conditions.
tion after surgery, every effort should large series from which to derive the Prediction is more accurate in long
be made to identify the error. A empirical constants and the limitations eyes and less accurate in short eyes.
recommended procedure would be to defined by the ‘normal’ population The calculation and selection of
verify all measurements by remeasur- and the clinical environment. If the appropriate IOL power are among the
ing the corneal curvature and axial clinical environment changes, for most significant tools in refractive sur-
length and comparing the results with example by using a more accurate gery today.
preoperative measurements. In most device for axial length measurement
cases this will reveal the error to be a or by using a more standardized surgi-
measurement error. However, other cal technique, the offset value and References
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0.5 D could be regarded as sufficient lenses: current status. Curr Opin Ophthal-
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(1998): Partial coherence interferometry: a
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theoretical formulas, the majority of would include other useful informa- gery. Am J Ophthalmol 126: 524–534.
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Acta Ophthalmologica Scandinavica 2007

posterior surface of the ageing human cor- Holladay JT, Prager TC, Chandler TY, Mus- Olsen T (1992): Sources of error in intraocu-
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