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Review Article

power: a review

Thomas Olsen

University Eye Clinic, Aarhus Hospital, Aarhus, Denmark

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).

472

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,

473

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.

474

Acta Ophthalmologica Scandinavica 2007

[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.

475

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.

476

Acta Ophthalmologica Scandinavica 2007

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.

477

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).

(spectacle plane)

The refractive effect of the IOL

depends on the optic conﬁguration IOL ¼ intraocular lens.

479

Acta Ophthalmologica Scandinavica 2007

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

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

errors, including labelling errors, coefﬁcients of the regression equation

should also be considered. The author are likely to change. The regression Apple DJ (2006): Sir Harold Ridley and his

has obtained good results by measur- formula will not work in extremes and Fight for Sight. Thorofare, NJ: Slack Inc.

Aramberri J (2003): Intraocular lens power

ing actual ACD in the pseudophakic hence inaccurate predictions are likely

calculation after corneal refractive surgery:

eye and comparing this with the pre- to occur in unusually long or short double-K method. J Cataract Refract Surg

dicted value. The measurement of act- eyes, in steep or ﬂat corneas and in 29: 2063–2068.

ual postoperative ACD together with combinations thereof. Bellucci R (2005): Multifocal intraocular

a repeat K-reading and (optical) Although paraxial ray tracing still lenses. Curr Opin Ophthalmol 16: 33–37.

biometry makes it possible based on has an important role to play in the Bennett A & Rabbetts R (2000): Clinical

the observed refraction to back-calcu- description of IOL optics, wavefront Visual Optics. Oxford: Butterworth-Heine-

mann.

late IOL power in situ within an accu- technology and exact ray tracing (Pre-

Binkhorst RD (1975): The optical design of

racy of ± 1 D. This allows for the ussner et al. 2002) may in the future intraocular lens implants. Ophthalmic Surg

diagnosis of a case of IOL mislabel- represent better ways of describing the 6: 17–31.

ling with reasonable accuracy. The optics of the pseudophakic eye, especi- Binkhorst RD (1979): Intraocular lens power

mislabelling of IOLs has been a prob- ally in cases of non-spherical post- calculation. Int Ophthalmol Clin 19: 237–

lem in some cases in the past (Olsen LASIK corneas, but also when deal- 252.

& Olesen 1993), but it seems to have ing with aspheric IOLs. However, if Chiam PJ, Chan JH, Aggarwal RK & Kasaby

been seldom reported in recent litera- we, as surgeons, are to treat the pseu- S (2006): ReSTOR intraocular lens implan-

tation in cataract surgery: quality of vision.

ture. The higher accuracy of optical dophakic eye as a truly optical system,

J Cataract Refract Surg 32: 1459–1463.

biometry has greatly improved mea- we need more information regarding Colenbrander MC (1973): Calculation of the

suring conditions for diagnosing mis- the physical properties of the IOL to power of an iris-clip lens for distant vision.

labelled IOLs. be implanted. The time when an Br J Ophthalmol 57: 735–740.

A-constant and power to the nearest Dick HB (2005): Accommodative intraocular

0.5 D could be regarded as sufﬁcient lenses: current status. Curr Opin Ophthal-

information on an implant to be mol 16: 8–26.

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new method of calculating intraocular lens Correcting the corneal power measurements Received on September 22nd, 2006.

power after photorefractive keratectomy. for intraocular lens power calculations after Accepted on December 2nd, 2006.

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