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22]

Review Article

Update on Optical Biometry and Intraocular Lens Power

Calculation
Nazneen Nazm, Arup Chakrabarti1
Department of Ophthalmology, ESI‑PGIMSR, ESI Medical College and Hospital, Kolkata, West Bengal, 1Chakrabarti Eye Care Centre, Thiruvananthapuram, Kerala, India

Abstract
Intraocular lens (IOL) power calculation is the single most important determinant of functionally improved result of a technically precise
cataract surgery. We have discussed recent advances in the field of optical biometry and IOL power calculation formulae as a means to achieve
better postoperative visual outcome. The use of automated optical biometry device, the current ‘gold standard’ of IOL power calculation, dates
back to 1999. We have highlighted the evolution of newer optical biometry devices and the technology they are based on, and their advantages
and limitations. We have done technical comparison of contemporary biometers and have included contextual current review of literature. We
have described newer generation IOL power formulae, IOL power calculation in high to extreme myopia, toric calculators and intraoperative
aberrometry, and concluded our discussion with a note on future prospects of IOL power calculation.

Keywords: Barrett universal II formula, Hill‑radial basis activation function formula, intraoperative wavefront aberrometry, optical
biometry, Wang‑Koch’s nomogram

Introduction for intraocular implantation, therefore, form the backbone of

Cataract surgery is the most common surgical procedure
performed worldwide. The goal of cataract surgery is not
just the removal of cataract, but to provide the patient
sharp, clear vision without glasses. Despite the growing
popularity of laser‑assisted in situ keratomileusis (LASIK)
and the growing interest in phakic intraocular lenses (IOLs)
and other refractive procedures, cataract surgery provides
a wider range of refractive error correction than any other
surgical procedure, hence emerged the concept of “refractive
cataract surgery.” For performing refractive cataract
surgery, a cataract surgeon now has, in his armamentarium,
a host of technological innovations such as femtosecond
laser‑assisted cataract surgery and the Zepto capsulotomy
device to name a few. To match patient’s expectations of
crisp and spectacle‑free vision, premium IOLs, namely
multifocal IOLs, accommodating IOLs and toric IOLs
are available. These technological advancements can help
achieve better outcomes after cataract surgery. However,
the improved outcomes are dependent on precise and
accurate biometry. Newer biometry instruments that perform
ocular measurements with micron precision and newer IOL
calculation formulae to provide precise IOL power required
refractive cataract surgery.
Optical Biometry
To provide the best possible refractive outcome is the goal of
the surgeon, whether the eye of the patient is normal or short
or long or postrefractive surgery. Accurate measurement of all
ocular parameters to obtain information about the complete
geometry of the eye is required to arrive at the correct IOL
prediction for each patient.
Optical biometry is a highly accurate noninvasive automated
method for measuring the anatomical details of the eye.
Accurate anatomical measurements are critical for precise
IOL power calculation. For many years, the gold standard of
axial length (AL) measurement was ultrasound (US) biometry.
The introduction of optical biometry in the late 1990s
revolutionized the precision of IOL power calculation. In
Address for correspondence: Dr. Arup Chakrabarti,
Cataract and Glaucoma Services, Chakrabarti Eye Care Centre, Kochulloor,
Thiruvananthapuram, Kerala, India.
E‑mail: arupeye@gmail.com

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DOI: How to cite this article: Nazm N, Chakrabarti A. Update on optical

10.4103/tjosr.tjosr_44_17 biometry and intraocular lens power calculation. TNOA J Ophthalmic Sci
Res 2017;55:196-210.

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Nazm and Chakrabarti: Update on optical biometry and IOL power calculation

1999, the first automated optical biometry device became
available for clinical use – IOLMaster 500 (Carl Zeiss Meditec,
Jena, Germany).[1] Because of its ease of use, accuracy, and
reproducibility, optical biometry is considered the current
gold standard of IOL power calculation in clinical practice
and is an indispensable tool for preoperative evaluation of
cataract patients.[2] The newer optical biometry devices provide
several biometric measurements, namely AL, keratometry (K),
anterior chamber depth (ACD), lens thickness (LT), central
corneal thickness (CCT), pupil size (PS), and white‑to‑white
distance (WTW).[3]
The crucial advantages of optical biometry are:
1. More accurate measurement of AL
a. Optical biometry measures to the center of macula, that
is, along the visual axis. It thus calculates refractive or
optical AL unlike US biometry which measures along
anatomic/geometric axis and thus calculates anatomic
AL. The visual and geometric axes do not coincide.
For IOL power calculation, it is the optical AL which
is important and not the anatomic AL
b. Optical biometry measures AL from corneal epithelium
to the Bruch’s membrane, rather than till internal
limiting membrane (ILM) measured by US biometer.
Since the US biometer measures only till ILM and
since average thickness of retina is 200 µ (distance
between ILM and photoreceptor layer), the earlier
methods of IOL power calculation used to add 200 µ
to the measured AL to make up for this difference.
However, retinal thickness may vary from 160 to
400 µ. Optical biometer measures the true AL from the
anterior corneal vertex to the photoreceptors in the back
of retina, and therefore, no such addition/assumption
for retinal thickness needs to be made[1,4]
c. It uses a partially coherent light source of shorter
wavelength than sound wave. Use of shorter
wavelength yields more precise AL measurement.
The accuracy of AL measurement with US is
approximately 0.10–0.12 mm compared to 0.012 mm
for optical AL[5]
d. It is a noncontact method. Corneal indentation does
not occur. A rigid US biometry tip can cause corneal
indentation between 0.1 and 0.3 mm, resulting in error
from 0.3 to 1.0 diopters/diopters (D) in IOL power
calculation.[6]
2. Accurate biometry can be performed in pseudophakic
and aphakic eyes and eyes with phakic IOLs. Also
AL, measurement is less affected by the type of IOL
material[7‑10]
3. More accurate measurements can be achieved in myopic
eyes with staphyloma, in children and silicone‑oil filled
eyes (no need for velocity conversion equation)[11‑14]
The currently available optical biometers are based on
one of the following technologies:  (1) partial coherence
interferometry  (PCI)  (2) optical low‑coherence
reflectometry (OLCR), or (3) swept‑source optical coherence
tomography  (SS‑OCT). Table 1 lists important optical
biometers and the technology they use.
IOLMaster 500
The IOL Master 500 ( Carl Zeiss Meditec AG, Jena,
Germany) [Figure 1] is an all‑in‑one biometer which measures
AL, K, and other ocular parameters as well as performs IOL
power calculations. It is based on the concept of PCI and
operates as a modified Michelson Interferometer.[15,18,19] PCI
biometry was first developed by Austrian physicist Fercher
and Roth[20] who performed the first in vivo AL measurement
in 1986. The principle involves a dual beam of infrared (IR)
light  (780  nm) emitted by a semiconductor laser diode.
A signal is produced as a result of interference between
the light reflected from the tear film and that reflected by
the retinal pigment epithelium. The photodetector receives
the interference signal to calculate the optical distance (OD)
between the corneal surface and retina.[21] This OD is used to
derive the other geometrical intraocular distances.
The employment of optical AL instead of anatomic AL has
significantly improved the refractive results of cataract surgery.
The IOLMaster 500 has been shown to consistently measure
AL accurately to within ±0.02 mm.[22] This translates into a
5–10‑fold precision in AL measurement. With >100 million
power calculations performed worldwide, the IOLMaster
500 is the current gold standard biometer.[23,24]

Table 1: Optical biometers and the technology used

Technology PCI based OLCR based SS‑OCT based
Examples of IOLMaster 500 (Carl Zeiss), Lenstar LS900 (Haag‑Streit), IOLMaster 700 (Carl Zeiss),
device AL‑Scan (Nidek) Aladdin (Topcon), Galilei G6 (Zeimer) Argos (Movu)
Light source MMLD of 780 nm[15] SLD of 820 nm Rapid‑cycle tunable wavelength laser
source
Principle Laser interferometry: Dual‑beam setup, Laser interferometry; standard Michelson SS‑OCT technology. Length
reflection from cornea and reflection from interferometer setup, patented rotating glass measurement is based on swept‑source
retina assessed in parallel[15] cube system is used to change optical path frequency‑domain OCT enabling a 44 mm
length in reference arm[16] scan depth with 22 µ resolution in tissue[17]
Use Measures AL Permits full A‑scan of entire eye, Enables OCT imaging and visualization
measurement of retinal thickness possible across the entire length of the eye[17]
PCI: Partial coherence interferometry, OLCR: Optical low‑coherence reflectometry, OCT: Optical coherence tomography, SS‑OCT: Swept source‑OCT,
AL: Axial length, MMLD: Multimode laser diode, SLD: Superluminescent diode, IOL: Intraocular lens

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Nazm and Chakrabarti: Update on optical biometry and IOL power calculation
Figure 1: IOLMaster 500 (Carl Zeiss Meditec) is the “Gold standard”
optical biometer
One limitation of IOLMaster was its inability to measure AL
reliably in the presence of opaque media such as corneal opacity
and dense cataract.[25,26] This, however, has been addressed to a
large extent by a software upgrade (version 5, IOLMaster 500).
This software allows averaging of consecutive optical scans,
resulting in a composite scan and thus better ability to perform
biometry through dense cataracts.
Vogel et  al. studied the intraobserver and interobserver
reliability and reproducibility of AL, ACD, and corneal
radius measurements using the IOLMaster based on PCI.[27]
They found reliability of 99.9%, 97.8%, and 99.8%/99.5%
for measurement of AL, ACD, and corneal radius  (r1/r2),
respectively (r1 = flattest radius of corneal curvature; r2 = steep
radius; 90° apart from r1).
IOLMaster 700
IOLMASTER 700 [Figure 2] was the first optical biometer to
incorporate SS‑OCT technology.[16,17,28‑31] Its advantages over
the earlier devices are as follows:
1. It provides full‑length OCT image of the eye. The device
performs 2000 scans/s. It can identify unusual ocular
geometry (e.g., crystalline lens tilt/decentration)
2. It is more accurate. Measurements can be verified visually
resulting in fewer “refractive surprises”
3. The OCT image provides a fixation check. The biometer’s
fixation check feature alerts the user to a suboptimal scan
if the image captured does not show the foveal pit. The
fixation check also helps identify macular pathologies such as
macular holes and age‑related macular degeneration, though
the findings need to be verified with a dedicated retina OCT
4. Unique telecentric K and distance‑independent K: The
unique software of IOLMaster 700 allows highly accurate
distance‑independent corneal surface measurements,
independent of PS and even in restless patients
5. Better cataract penetration rates: the IOLMaster 700 can
perform biometry even through dense cataracts
6. Software includes “Haigis Suite”  (which includes Haigis,
Haigis‑T for torics, and Haigis‑L for postrefractive surgery eyes)
and other IOL power calculation formulae (SRK/T formula:
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Figure 2: IOLMaster 700 (Carl Zeiss Meditec AG, Jena, Germany)
Sanders-Retzlaff-Kraff formula; T for theoretical, Hoffer
Q, Holladay 1 and 2, and Barrett Universal II)
7. This device is especially suited for Toric IOLs. IOLMaster
700 contains inbuilt toric calculator  (Barrett Toric
calculator and Haigis‑T for toric IOLs), and there is no
need to use a separate online toric calculator.
Srivannaboon et  al. evaluated the repeatability and
reproducibility of IOLMaster 700 with the IOLMaster 500 in
100 eyes of 100 cataract patients. K, AL, ACD, WTW, and IOL
power (calculated by the SRK/T and the Haigis formulas) were
measured for each device. The repeatability and reproducibility
of measurements from the two biometers were high for all
parameters. However, the swept‑source biometer had better
lens penetration than the standard biometer.[32]
Akman et al. also found excellent agreement between the two
instruments. However, the IOLMaster 700 was more efficient
in acquiring biometric measurements in eyes with posterior
subcapsular or nuclear cataracts.[17]
Lenstar LS 900
LENSTAR LS 900  [Figure 3] uses the principle of OLCR.
Apart from the parameters measured by IOLMaster, the
Lenstar also measures LT. Use of LT, in conjunction
with the latest state‑of‑the‑art IOL calculation formulas
(Barrett, Olsen, Holladay 2), translates into more accurate
biometry. The latest version of Lenstar LS900 is equipped with
the Hill‑radial basis activation function (Hill‑RBF), Barrett
Universal II, Barrett True‑K, and Barrett Toric calculator. Some
of its other features are
1. Automated positioning system allows for dynamic eye
tracking of patient.
2. Dual‑zone K (at 1.65 and 2.3 mm) and T‑cone topography
(allows true Placido topography of the central cornea)
3. Contains EyeSuite IOL which is a comprehensive set of
premium IOL calculation formulae for cataract surgery
patients and patients postkeratorefractive surgery. Table 2
compares the technical specifications of IOLMaster 500
and Lenstar LS 900.
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Nazm and Chakrabarti: Update on optical biometry and IOL power calculation

Eyestar 900
The new device based on SS‑OCT was launched in October
2017. The device contains EyeSuite software and provides
elevation‑based topography maps of both front and back of
cornea and provides biometry data of the entire eye from cornea
to retina. In addition, it provides two‑dimensional (2D) and
three‑dimensional (3D) images of anterior segment as well as
crystalline lens. Data acquisition process is smooth and fast,
ensuring patient comfort. The device contains the latest IOL
power calculation formulae such as Hill‑RBF and Barrett
Universal 2.
Various authors have reported excellent agreement
between AL measurements by IOLMaster and the
Lenstar.[16,33‑36] Epitropoulos compared AL acquisition and
other parameters by IOLMaster 500 (version 7.1 software)
with those from Lenstar LS 900 in 105 cataractous eyes
of 63 patients. [37] AL was acquired by the composite
mean value of five measurements  (composite‑5 IM) and
20 measurements  (composite‑20 IM) of IOL Master
500 version 7.1 software and the standard mean of the first five
measurements on standard‑5 LS Lenstar LS900. He observed
that the IOL Master 500 was more reliable and repeatable with
better penetration than the Lenstar in measuring AL in patients
with dense cataracts. In comparison, the Lenstar produced
higher ACD values and flatter K though these differences
were not clinically significant in terms of refractive outcome.
Kołodziejczyk et al. compared the biometric measurements
and IOL power calculation obtained by Lenstar LS900
and IOLMaster 500 V.5 on 204 eyes of 106 patients.[38]
They concluded that Lenstar allows accurate and repetitive
measurement and IOL power calculations comparable with
those obtained using IOLMaster 500 V.5. However, the Lenstar,
in addition, allowed pachymetry, macular thickness, LT, and
pupil measurement [Figure 4].
Hoffer et al. compared AL, ACD, and K values obtained by
the two instruments in 50 eyes with clear lens and 50 eyes with
cataract and reported good correlation between these values
in both the groups.[16]
OA‑2000 (Tomey)
The OA‑2000 by Tomey  (GmbH, Nurnberg, Germany)
was launched in 2014. It combines optical biometry,
corneal topography, and K. Fourier‑domain OCT provides
high‑speed tissue penetration and allows measurement of

Figure 4: A Lenstar LS 900 EyeSuite A Scan printout (here retinal

thickness or RT is automatically set at 200 μ).(1, signal strength scale;
2, front surface of cornea; 3, rear surface of cornea; 4, front of lens; 5,
Figure 3: Lenstar LS900 (Haag Streit Diagnostics, Koeniz, Switzerland) rear lens; 6, inner retinal limiting membrane; 7, retinal pigment epithelium)

Table 2: Comparison of technical specifications of IOLMaster 500 and Lenstar LS 900

IOLMaster 500 Lenstar LS900
Technology PCI OLCR
Source Semiconductor diode laser (780 nm) Superluminescent diode laser (820 nm)
Keratometry Measured at 6 points Measured at 32 points
AC depth Not measured directly; even the latest version of Directly measures ACD
IOLMaster measures it using slit imagery
Definition of ACD Front of cornea to front of lens Measures ACD as well as “aqueous depth,” that is, back of
cornea to front of lens
AL measurement range 14-40 mm 14-32 mm
Retinal thickness Not measured Measured
Ability to perform biometry Better Poorer
through dense cataract
AC: Anterior chamber, ACD: Anterior chamber depth, AL: Axial length, PCI: Partial coherence interferometry, IOL: Intraocular lens, OLCR: Optical
low‑coherence reflectometry

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Nazm and Chakrabarti: Update on optical biometry and IOL power calculation

various parameters even through dense cataracts. In case

of mature cataract, measurements can be performed with
OA‑4000 handheld US biometer, which communicates
with OA2000 through Bluetooth. IOL power calculations
are subsequently performed on OA2000. This biometer is
based on Fourier‑domain technology and Placido disc‑based
topography. The machine provides CCD, ACD, AL and K,
and corneal topography simultaneously at 2, 2.5, and 3‑mm
diameter optical zone. The latter helps to create a topography
map of cornea to help detect irregular astigmatism and also
for comparison of pre‑ and post‑surgery shape of cornea. It is
also useful for analysis of eye after LASIK and other refractive
procedures and for implantation of toric IOLs (to identify the
axis of orientation of toric IOL).

Argos Advanced Optical Biometer (Movu) Figure 5: The Argos (Movu) biometer (The Argos, Santa Clara, CA)
The Argos [Figure 5] uses a 1060‑nm and 20‑nm bandwidth
SS‑OCT technology to collect 2D OCT data of the eye. The
fast image reconstruction algorithm of the instrument is used
to provide real‑time 2D imaging of the eye. The 1050 nm light
cause less scatter than shorter wavelengths leading to more
photons being available to make measurements and hence better
penetration through dense cataract. Equipped with Video K with
IR light‑emitting diode ring illumination, Argos measures AL,
CCT, ACD, LT, PS, aqueous depth, WTW, K, and astigmatism.
The biggest advantage of Argos is its ability to image through Figure 6: Argos biometric measurement though a dense cataract Axial
very dense cataracts through an “Enhanced Retinal Visualization” length was successfully measured by Argos
mode [Figure 6] that increases imaging sensitivity of the retinal
area by 100 times (without increasing laser power).
The Argos uses a propriety swept laser source specifically
designed for deep imaging (>50 mm) at fast 3000 lines/s A‑line
rate. The Argos also features an “Analysis mode” which allows
the surgeons to verify the results obtained.
Shammas et al. reported good repeatability and reproducibility
and comparability of measurements obtained by Argos
biometer, IOLMaster 500, and Lenstar LS900.[31] The study
was performed on 107 eyes. AL was correctly measured in
96% of cases with the Argos compared with 79% for Lenstar
and 77% for IOL Master 500.

Aladdin
Aladdin [Figure 7] combines OLCR biometry with anterior
topography, Zernike corneal wavefront analysis, and
pupillometry in one instrument. Following are its important
advantages:
1. It provides information about corneal asphericity [Figure 8]
by mapping 24 Placido rings (on cornea) and analyzing
1024 data points using its real corneal radii technology. It
provides extensive information on status of anterior surface
of cornea including presence of corneal irregularities,
common signs of keratoconus, and information about
higher‑order aberrations
Dynamic pupillometry allows better assessment of lens
centration, constriction, and dilation of pupil in photopic
Figure 7: The Aladdin optical biometer(Topcon, Tokyo, Japan)
and mesopic conditions to assist in premium IOL selection.
2. Zernike wavefront analysis allows evaluation for
higher‑order aberrations and corneal surface anomalies
like keratoconus
3. It contains inbuilt toric calculators – Barrett IOL Suite
and Abulafia–Koch regression formula
4. The 850‑nm superluminescent diode allows the Aladdin
to penetrate even high‑density cataracts

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Nazm and Chakrabarti: Update on optical biometry and IOL power calculation
5. It generates 3 types of reports
a. IOL Power report
b. Measurement report which gives an overview of
measurements made of both eyes and alerts users to
any unusual findings
c. Aladdin report gives an overview of important
pupillary and topographic features of both eyes which
could influence the choice of premium IOL.
A multicenter clinical trial[39] was conducted in the United States
and China to compare the Aladdin with the IOLMaster 500.
The US group included a sample of consecutive patients
scheduled for cataract surgery. The China group included a
sample of healthy individuals with no cataract. In both the
groups, AL values by the 2 instruments showed excellent
correlation. However, there was a small but statistically
significant difference in K and ACD measurements. The
Aladdin gave a consistently higher value of ACD in both the
groups. Mean K values were found to be flatter with OLCR
device in both the US and China groups. Mandal et al. also
reported a slightly flatter K value with OLCR device.[40] This
study concluded that though there is good correlation between
the main biometric parameters of IOL power calculation,
small differences in K and ACD exist and should not be
overlooked.[40]
AL‑Scan (Nidek)
This easy to use PCI‑based biometer [Figure 9] uses an 830 nm
IR laser diode for AL measurement. It has following features:
1. It contains “3D autotracking” to track patient’s eye
movements along the X, Y, and Z planes. The “autoshot”
feature allows device to capture the scan as soon as it
senses correct alignment
2. Topography and K with double mire rings help evaluate
for aberrations. It measures K at 36 points
3. It employs Scheimpflug imaging to measure CCT and
ACD (a Scheimpflug system images the anterior segment
with a camera perpendicular to a slit beam, thus creating
an optical section of cornea and lens). It also provides data
about pupil position
Figure 8: Corneal topography image by Aladdin optical biometer (Topcon.
The Aladdin provides accurate corneal topography and is especially useful
in selecting patients for toricphakic intraocular lenses
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4. It can perform measurements even through dense cataracts
and also contains an inbuilt US biometer.
Kaswin et  al. compared the performance of AL‑Scan with
IOLMaster 500 in 50 eyes and reported excellent correlation
in the AL and K obtained by the 2 devices when the AL was
in the range of 22–27 mm.[41] Li et al. compared the ocular
measurements obtained by AL‑Scan with Lenstar in 92 eyes
of 92 cataract patients and observed good agreement for AL,
CCT, and ACD measurements. Although slight difference in
WTW values was noted, they were still in reasonably good
agreement. However, PS values were consistently different
and showed the worst agreement.[42]
Galilei G6 Lens Professional
The Galilei G6 [Figure 10] combines OLCR optical biometry,
dual‑Scheimpflug imaging, and Placido‑disc topography. Some
of its features are as follows:
1. It provides high‑definition pachymetry and 3D anterior
chamber analysis
2. It measures total corneal wavefront, curvature, and
K data of anterior as well as posterior cornea, that is,
provides complete data to plan cataract or refractive
surgery
3. Ray‑traced posterior corneal surface data to detect bulging
or asymmetry in late stages
4. The combination of Scheimpflug imaging with optical
biometry makes Galilei G6, especially suitable for
IOL selection in postkeratorefractive surgery eyes and
also (including keratoconus screening) of refractive surgery
candidates. It is also helpful in devising corneal implants
and in planning and follow‑up of keratoplasty patients
5. It includes newer IOL power formulas including Shammas
No‑History, Barrett Universal, and Barrett True‑K Toric
calculator.
The comparability of biometric measurements and IOL
power calculation between IOLMaster 500 and Galilei G6
was studied by Ventura et al. They found similar results
Figure 9: A Nidek AL Scan (AL-Scan, Nidek Co., Aichi, Japan) biometry
and phakic intraocular lens power printout. AL = axial length, ACD =
anterior chamber depth, R1 = flattest radius of corneal curvature; R2 =
steep radius; 90° apart from r1
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Nazm and Chakrabarti: Update on optical biometry and IOL power calculation

of IOL power calculation formulae. For many years, most of

the formulae including the Holladay I, SRK/T, and Hoffer Q
required only AL and K reading. Thomas Olsen then came up
with a formula which required four parameters: AL, K, ACD,
and LT. In 1992 Holladay II formula, which required seven
variables for IOL power calculation, was released. Later Barrett
suggested the Barrett Universal II formula which required AL,
K, ACD, LT, and a few optional variables.
The popular newer generation formulae include the Holladay 2,
Barrett Universal II, and the Hill‑RBF. The common factor in
all these formulae (except the Hill‑RBF) is the need to predict
effective lens position or ELP.[52] ELP is defined as distance
Figure 10: The Galilei G6optical biometer (Galilei G6, Ziemer. Port, Switzerland) from the cornea to the principal plane of IOL. Both anatomical
factors (K value, AL, Limbal WTW, Preop ACD, and LT) and
for K, AL, ACD, and IOL power values between the two IOL‑related factors (shape, length, flexibility, anterior angulation
devices.[43] if any, material of the haptic, and shape and material of optic)
affect ELP. The parameters required for the calculation of
Several studies have compared the PCI, OCLR, and SS‑OCT
important IOL power formulae are depicted in Table 5.
biometry devices.[43,44] Most studies have concluded good
correlation between PCI and OCLR and SSOCT biometry
values. Table 3 compares the salient features of available Barrett Universal II (Barrett U2)
optical biometers. The formula is called Universal because it is suitable for all
types of eyes: short, medium, or long and also for different
Intraocular Lens Power Formulae lens styles. This formula is based on a theoretical model of
eye in which ACD is related to AL and K.[53] In this formula,
The first IOL power formula was published by Fyodorov and
ELP is characterized by ACD and LF (lens factor). The LF is
Kolonko in 1967 and was based on schematic eyes.[45] Several
influenced by K, AL, ACD, LT, and WTW in that order. This
IOL power formulae are available at present.[46] Important ones
formula also takes into account the negative value of LF in
are tabulated below [Table 4].
calculating ELP in the presence of negative‑powered type of
Recently, Koch et al. suggested a new classification of IOL IOL. The Barrett U2 formula can be openly accessed on www.
power formula (see below) based on (a) method of calculating apacrs.org. Following are the features of Barrett Universal II
IOL power and (b) the data used for these calculations.[51] formula:
1. Historical/refraction based a. Accurate for all eyes regardless of AL
2. Regression analysis based: SRK, SRK‑II b. Essential variables required for calculation are AL,
3. Vergence formulae (based on Gaussian optics) K, optical ACD, and desired postoperative refraction.
a. Two variable Optional variables required are LT and WTW
i. Holladay 1 c. Lens factor or “A constant” of the selected IOL is required.
ii. SRK‑T If not available, ULIB “A constant” of SRK/T formula
iii. Hoffer Q is recommended  (ULIB is the User Group for Laser
b. Three variable Interference Biometry)
i. Haigis d. AL and K data from optical biometer  (for example,
ii. Ladas Super Formula IOLMaster, Lenstar) is required for calculation.
c. Five variable However, immersion biometry data may also be used.
i. Barrett Universal II Since optically measured AL is different from the US
d. Seven variable measured AL, acoustic A constant will fail to give
i. Holladay 2 optimum results when used with optical biometry.
4. Artificial Intelligence based Therefore, when AL obtained by US biometry is used
a. Hill‑RBF in Barrett formula, an appropriate A‑constant must be
b. Clarke neural network used (This requires pre‑ and post‑operative clinical data
5. Ray tracing and is done on a spreadsheet form in MS Excel format
a. Okulix which can be downloaded from the ULIB website
b. PhacoOptics. ocusoft.de/ulib/)
e. Barrett U2 is able to predict for highly myopic eyes and
The Newer Intraocular Lens Formulae negative powered IOLs without specialized constants or
AL modification.
As our understanding of the eye’s anatomy has increased,
there has been a corresponding increase in the complexity The refractive outcomes using Barrett U2 have been excellent.

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Nazm and Chakrabarti: Update on optical biometry and IOL power calculation

Table 3: Currently available optical biometers, the parameters they measure and their salient features
IOLMaster 500 IOLMaster AL scan Lenstar Aladdin/Aladdin Argos (Movu) Galilei G6
700 LS900 LT
Principle PCI SS‑OCT PCI OLCR OLCR SS‑OCT OLCR
AL + + + + + + +
K + + + + + + +
Topography ‑ ‑ Yes Yes (via Yes ‑ Yes
add‑on
T‑cone Toric
platform)
ACD + + + + (aqueous + + +
depth)
WTW + + + + + + +
LT ‑ + ‑ + ‑/+ + +
CCT ‑ + + + ‑/+ + +
PS ‑ ‑ + + + + ‑
IOL Holladay 1, 2, Hoffer Barett Suite, Holladay, Haigis, Olsen, Holladay 1, Haigis, Haigis, Hoffer Haigis, Holladay
calculation Q, Haigis, SRK Haigis Suite, Hoffer Q, Barrett Toric, postrefractive Q, Holladay 1, 1, Hoffer Q,
formula II, SRK/T, Haigis Haigis‑T, Camellin‑Calossi EyeSuite surgery: Shammas No Shammas no
L (postkeratorefractive Hoffer Q IOL (premium Camellin‑Calossi, history, Barrett history
surgery eyes) IOL Shammas Universal,
calculation no‑history Barrett
formulas) True‑K, Toric
calculator
Compatible ‑ Yes Yes ‑ Yes Yes
with dense
cataract
Additional Gold standard of Can be 3D auto‑tracking Retinal Zernick corneal “Enhanced 3D anterior
attractive optical biometry integrated and autoshot, thickness wavefront analysis, retinal chamber
features well with and in‑built measurement keratoconus visualization” analysis, artificial
as a part of ultrasound screening, can mode intelligence‑based
Zeiss Cataract biometer be upgraded programs for
Suite (contains to perform screening
Callisto eye fluorescein ectasia‑susceptible
and OPMI angiography corneas
Lumera
microscope)
PCI: Partial coherence interferometry, OLCR: Optical low‑coherence reflectometry, OCT: Optical coherence tomography, SS‑OCT: Swept source‑OCT, AL:
Axial length, K: Keratometry, ACD: Anterior chamber depth, LT: Lens thickness, WTW: White‑to‑white corneal diameter, CCT: Central corneal thickness,
PS: Pupil size, 3D: Three‑dimensional, IOL: Intraocular lens, SRK/T: Sanders–Retzlaff–Kraff  (T for theoretical), Characteristic or function present (+),
function not present (-)

Table 4: Important intraocular lens power formulae at a glance

Name of formula Generation of IOL Variables required Comments
power formula
SRK I and Binkhorst I 1st generation K, AL Obsolete, high level of error, should not be used
SRK II and Binkhorst II 2nd generation K, AL Obsolete, high level of error, should not be used
Holladay I 3rd generation K, AL Trend toward better outcomes for eyes between 22.00 mm and
26.00 mm, compared to other 3rd generation[47]
SRK/T 3rd generation K, AL Better outcomes for eyes >26.00 mm, compared to other 3rd generation
formulae[47]
Hoffer Q 3rd generation K, AL Better outcomes for eyes <22.00 mm, compared to other 3rd generation[47]
Holladay 2 4th generation K, AL, ACD, LT, No data has been reported showing an advantage over an appropriately
horizontal WTW, selected 3rd generation formula
age, and preoperative
refraction
Olsen 4th generation K, AL, ACD, LT, and
There is evidence suggestive of improved performance over
horizontal WTW 3rd generation formulae for eyes with AL 20.00-26.00 mm[48,49]
Haigis 5th generation K, AL, ACD Very good outcomes for eyes across the AL range and best reported
outcomes for eyes >28.00 mm.[50] For best results, 3 IOL constants need
to be optimized requiring data from at least 500 eyes
AL: Axial length, K: Keratometry, ACD: Anterior chamber depth, LT: Lens thickness, WTW: White‑to‑white corneal diameter, IOL: Intraocular lens,
SRK/T: Sanders–Retzlaff–Kraff (T for theoretical)

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Nazm and Chakrabarti: Update on optical biometry and IOL power calculation

Holladay 2 is the only IOL power calculation formula which provides

In 1993, Dr.  Holladay led a worldwide study involving
34 cataract surgeons to determine which of the 7 variables
were relevant as predictors of ELP.[52] Surprisingly, horizontal
WTW measurements emerged as the next most important
variable after AL and K. It was also proved that there is almost
no correlation between AL and size of anterior segment in
80%–90% of the eyes [Table 6]. This led to the concept of
nine types of eyes – not just three (short, medium, or long).
These results led to the formulation of Holladay 2 formula, an
easy‑to‑use program, in which 7 variables (AL, K, ACD, LT,
WTW, age of patient, and previous refraction) are inserted for
calculation of ELP and appropriate IOL power.
This newer formula is a great choice for nearly every eye.[54] It
is a complete software package that not only allows IOL power
calculation in many different types of eyes but also honing of
individual results by personalizing the A‑constant. This formula
is available as part of Holladay IOL Consultant/Surgical
Outcomes Assessment Program (HIC‑SOAP, available at www.
hicsoap.com). It is a paid software.
the user the reliability of result, that is, the software can tell
whether it is likely to be correct or whether it is unsure about
the calculated IOL power. The older version of Hill RBF
online calculator used data from 3400 eyes with a wide range
of preoperative ocular parameters. The RBF calculator has
been updated in 2017 and includes data from 12400 eyes. The
data for normal eyes have been increased by about 7000 eyes.
A total of 1000 exceptionally short eyes and axial myopia with
IOL power up to ‑5D have now been included in the latest
version. In addition, a target other than plano can be set (e.g.,
surgeon can aim for slight myopia and calculate the required
IOL power accordingly).
The Hill‑RBF is the product of the efforts of Dr. Warren Hill
and his team which included engineers from MathWorks,
and 39 investigators from over  17 countries. The Hill‑RBF
is incorporated in Lenstar Eye Suite and is also available
to ophthalmologists globally as an open access web‑based
calculator  (rbfcalculator.com/online). The uniqueness of
Hill‑RBF lies in the fact that greater the number of surgical
outcomes that are fit into the model, greater the accuracy. In

HILL‑Radial Basis Activation Function

(Radial Basis Activation Function Online
Calculator)
The new Hill‑RBF method [Figure 11] is an advanced,
self‑validating method for IOL power selection. It was
launched in 2016. It is purely “data driven,” independent
of ELP and has no data bias. RBF method uses artificial
intelligence‑driven pattern recognition and sophisticated
data interpolation. RBF algorithms are used globally in a
variety of technologies such as facial recognition software Figure 11: The new Hill-RBF method is an advanced, self-validating
and thumbprint security scanners. A special feature is that it method for IOL power selection

Table 5: The parameters required for the calculation of important intraocular lens power formulae
Parameter Haigis Hoffer Q SRK/T Holladay 2 Hill‑RBF Barrett universal II
AL Yes Yes Yes Yes Yes Yes
ACD Yes No No Yes Yes Yes
K Yes Yes Yes Yes Yes Yes
LT No No No Yes Yes Yes
WTW No No No No Yes Yes
Refraction (preoperative) No No No No No Yes
AL: Axial length, K: Keratometry, ACD: Anterior chamber depth, LT: Lens thickness, WTW: White‑to‑white corneal diameter, RBF: Radial basis function,
SRK/T: Sanders–Retzlaff–Kraff (T for theoretical)

Table 6: Nine types of eyes. Intraocular lens calculations are more accurate if nine types of eyes are considered
(not just short/medium/long eyes), with anterior segment size and axial length as independent variables
Anterior Segment Size Short axial length Normal Axial length Long Axial length
Large Megalocornea + axial hyperopia (0%) Megalocornea (2%) Large eye buphthalmos megalocornea + axial
myopia (10%)
Normal Axial hyperopia (80%) Normal (96%) Axial myopia (90%)
Small Small eye nanophthalmia (20%) Microcornea (2%) Microcornea + axial myopia (0%)
Source: Holladay JT82

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Nazm and Chakrabarti: Update on optical biometry and IOL power calculation
other words, the more the number of eyes added to database,
the more accurate the calculator becomes.
However, the Hill‑RBF has been optimized for biometry data
from Lenstar LS900 optical biometer and for a particular
IOL  (Alcon SN60WF biconvex IOL). It may be used for
other biconvex IOLs in the range of ‑5 to +30D. Biometry
data from other sources or other IOL models may lead to
suboptimal results.
More information about the calculator can be obtained from
Dr. Hill at hill@doctor‑hill.com and under “Online Tools” at
ascrs.org.
Intraocular Lens Power Calculation in High to
Extreme Myopia
High myopia is one of the most prevalent refractive conditions
globally with a high risk of other associated eye conditions.[55‑57]
Patients of axial myopia (AL >25 mm) are at risk of suboptimal
refractive outcome after cataract surgery.[58] The single most
important consideration in this setting is to avoid unanticipated
postoperative hyperopia. Several authors have reported that
AL measured by the optical biometry is more precise than the
US in an eye with posterior staphyloma.[59,60] Second, the use
of third‑generation formulae may lead to incorrect IOL power
calculation resulting in unsatisfied patient postoperatively.
In their landmark article, Wang et  al. suggested that
modification of AL is required to calculate IOL power with the
SRK‑T, Holladay 1 and 2, Haigis and Hoffer Q formulas in eyes
with AL >25.2 mm.[61] They looked at IOLs (IOL power that
was required to be implanted) in 2 groups – power >5D and
power 5D or less. In both the groups, it was found that adjusting
AL significantly reduced the incidence of postoperative
hyperopia. The idea behind the AL modification is that when
the original AL is fed into the Wang‑Koch’s formula [Table 7],
a value lower than the original AL value is calculated. When
this lower AL value is reinserted into the formulae, an IOL
power of higher dioptric value is obtained. This, in turn,
eliminates the risk of postoperative hyperopia. However, the
Wang‑Koch modification may be less accurate in very low
power/negative lenses.
Ghanem and El‑Sayed found in their study that though SRK/T,
Hoffer Q, Holladay‑2, and Haigis work equally well in eyes
with high myopia in low‑plus powered IOL implantation,
Haigis was better in cases requiring minus power IOL
implantation. Their study was conducted on 127 eyes of
87 patients with cataract and AL >26 mm.[62]
Newer formulae such as Barrett U2 have also been shown to
be accurate in the setting of high myopia.[58,63]
Toric Calculators
The correction of corneal astigmatism with toric IOLs has
become a standard of care to improve refractive outcome
TNOA Journal of Ophthalmic Science and Research  ¦  Volume 55 ¦ Issue 3 ¦ July-September 2017
Table 7: Wang‑Koch’s formula for adjusting axial length
in eyes ≥25.2 mm
Formula Modification
Holladay 1 optimized AL 0.829 × IOLM AL +4.27
Haigis optimized AL 0.929 × IOLM AL +1.56
SRK/T optimized AL 0.854 × IOLM AL +3.72
Hoffer Q optimized AL 0.853 × IOLM AL +3.58
AL: Axial length, IOLM: IOLMaster axial length, SRK/T: Sanders–
Retzlaff–Kraff (T for theoretical), IOL: Intraocular lens
after cataract surgery. Two components contribute to optimum
correction of astigmatism  (1) accurate K and  (2) reliable
method to calculate power of toric IOL. Choosing the correct
toric IOL for a patient is more challenging than choosing a
spherical IOL. Toric calculators are used to select the desired
toric IOL for a given patient. An ideal toric calculator has the
following characteristics:
1. It is comprehensive, that is, it can be used for preoperative
planning, as well as for refractive surprises
2. Software should preferably be a part of the biometric
device
3. It should be applicable to all IOL types
4. There should be dynamic display of variables
(e.g., dynamic adjustment of astigmatic effects of phaco
incision)
5. It should provide an alert for “axis‑flip”
6. It should take into account posterior corneal
astigmatism (PCA).
Few generic toric calculators available online are “Assort
Toric calculator”  (www.assort.com) and “Holladay Toric
calculator” (www.hicsoap.com). The Barrett Toric calculator
contains Barrett Universal 2 formula to predict the required
spherical equivalent IOL power. The formula takes into account
lens position as well as PCA without actually measuring
it. It derives the posterior corneal curvature based on a
theoretical model. The Barrett Toric Calculator is available
on the American Society of Cataract and Refractive Surgery
(www.ascrs.org/barrett‑toric‑calculator) and Asia‑Pacific
Association of Cataract and Refractive Surgeons (www.apacrs.
org) websites.
Several toric IOL calculators are available online
such as Alcon online toric calculator  (https://www.
myalcon‑toriccalc.com), Acrysof toric calculator  (www.
acrysoftoriccalculator.com), AMOeasy toric IOL
calculator (https://www.amoeasy.com > calc), Care Group
toric IOL calculator (www.caregroupindia.com  >  toric),
and Appasamy Associates toric calculator  (https://www.
appasamy.com  >  toric). The new Alcon online toric
calculator incorporates the Barrett Toric algorithm which
takes into account PCA and calculates patient‑specific
ELP. The Barrett toric nomogram and the Baylor toric IOL
nomogram have significantly reduced errors in residual
astigmatism predictions in toric IOL calculations.
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Nazm and Chakrabarti: Update on optical biometry and IOL power calculation

Abulafia et al. evaluated the accuracy of different methods to
measure and predict postoperative astigmatism with toric IOL
implantation. Preoperative corneal astigmatism was measured
with 3 devices (IOLMaster 500, OLCR and Atlas topographer)
and compared with manifest astigmatic refractive outcome
postoperatively. The Barrett toric calculator and the OLCR
device was observed to achieve the most accurate results,
75% and 97.1% of eyes were within ±0.50D and ±0.75D of
the predicted residual astigmatism, respectively.[64]
Several studies have recently compared the newer IOL
power calculation formulae [Table 8]. To summarize, an
analysis of the published literature in the past 50 years
reveals that the Haigis, Hoffer Q, Holladay 2, and Barrett
Universal 2 formulas are the best options for IOL power
prediction in short eyes  (<22  mm), whereas the Barrett
Universal II, Haigis (with optimized constants), and Olsen
formulas provide the most accurate outcomes in long
eyes (>26 mm).[71]

Fullmonte Intraocular Lens 2.0 Intraoperative Wavefront Aberrometry

The FullMonte IOL software system is a new adaptive, optimizing
process based on Markov Chain Monte Carlo process. It is not
a formula, rather a computing process which combines modern
theoretical formulas  (SRK/T, Holladay I, Haigis etc.) with
surgeon’s own postoperative refractive record to provide not a
single value of IOL power for emmetropia but expected refraction
as a graph of probability distributions. The software continuously
optimizes itself, adapting to several factors such as short eye/long
eye, cases of unique anatomy, or postrefractive patients.
One of the latest developments in the field of cataract
surgery is intraoperative wavefront aberrometry. It can
perform aphakic and pseudophakic refractive measurements
in the operating room on the eye being operated, thus
providing real‑time intraoperative refractive information.
This allows surgeon to confirm or revise the IOL power
(calculated through preoperative biometry), optimize the
lens location, and tailor arcuate corneal incisions to the eye’s
astigmatic requirements.[72,73]

Table 8: Comparison of newer intraocular lens power calculation formulae by different authors
Study
Roberts et al.,[65] Clin Exp
Ophthalmol 2017
Kane et al.[66] (RANZO 2016,
free paper)
Kane et al.,[67] JCRS 2017
Zhang et al.,[58] Nature 2016
Abulafia et al.,[68] JCRS 2015
Bai et al.,[69] Zhonghua Yan Ke
Za Zhi 2008
Moschos et al.,[70] IJO
IOL: Intraocular lens, RBF: Radial basis function, SRK/T: Sanders–Retzlaff–Kraff (T for theoretical), AL: Axial length, 6D: Six‑dimensionals, ULIB: User
group for laser interference biometry
Aim Number of IOL formulae Result
eyes compared
Comparison of Hill‑RBF, Barrett 400 Hill RBF, Barrett Hill RBF and Barrett gave
universal II, and current 3rd universal II, 3rd superior results
generation formulae generation formulae
Comparison of 10 methods of IOL 3168 Hill‑RBF calculator, Barrett universal II was
power calculation FullMonte Decision found to be most accurate
Support System, Ladas
“Super Formula”, Barrett
universal II, Holladay 2,
T2, Hoffer Q, Holladay
1, Haigis, SRK
Comparison of 3 methods of IOL 3122 Hill RBF, FullMonte, Barrett universal II was
power selection using 5 formulae Ladas Super Formula found to be most accurate
with Holladay 1, Barrett
universal II
Accuracy of IOL power 171 SRK/T, Haigis, Holladay, Barrett universal II was
calculation formulas for highly Hoffer Q, and Barrett found to be most accurate
myopic eyes (AL >26 mm) universal II
IOL power calculation for eyes 106 eyes: In Holladay 1, SRK/T, SRK/T, Haigis (ULIB),
with AL >26.0 mm: Comparison 76 eyes IOL Hoffer Q, and Haigis, Barrett universal II,
of formulas and methods power was 6D Barrett universal II, Holladay 2, and Olsen best
or more; in Holladay 2, Olsen for ALs over 26.0 mm and
30 eyes IOL IOL powers 6.0 D or higher
power was Holladay 1 (with AL
<6D adjustment), Haigis (with
AL adjustment), and Barrett
universal II best for AL
>26.0 mm
IOL power <6.0 D
Selection of accurate IOL formula 31 eye with Haigis, SRK II, Hoffer IOLMaster: Haigis
in high hyperopia cataract and Q, Holladay, SRK/T A‑scan: Hoffer Q
high hyperopia
69 patients SRK/T, Hoffer Q, Haigis, Haigis or Hoffer Q were
with AL <22 Holladay 1 accurate
mm

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Nazm and Chakrabarti: Update on optical biometry and IOL power calculation

Optiwave Refractive Analysis System With Holos

Verifeye Another intraoperative aberrometer is HolosIntraOp
ORange wavefront aberrometry system  (WaveTec [Figure 13a and b] by Clarity. It utilizes rapidly rotating
microelectromechanical mirror and quad detector to measure
Vision Systems, Inc.) was the first commercially available
magnitude of wavefront displacement. Like the ORA, Holos
intraoperative wavefront aberrometer. It has now been
gathers optical wavefront and refraction data intraoperatively
replaced by the Optiwave Refractive Analysis  (ORA)
to verify the preplanned IOL power and helps choose the
system [Figure 12]. ORA utilizes IR light and Talbot Moire
size and location of incisions to correct astigmatism.[77] Up
interferometry, a system in which two gratings are set at a
to 90 measurements second are taken per second. Like the
specific angle and distance to produce a fringe pattern as
ORA, it is attached to operating microscope for intraoperative
wavefronts are diffracted through the grates.[74] This fringe
refractive measurements.
pattern is then analyzed to provide information on sphere,
cylinder, and axis to guide proper IOL selection  (including
premium IOLs) as well as placement. ORange is attached to a The Future of Intraocular Lens Power
surgical microscope and aphakic, and pseudophakic refractions Calculation
are performed in the operating room. It takes 40 measurements
in less than a minute. The Univers intraocular lens calculator
The UniversIOL was developed by Dr. Samir Sayegh et al.[78] It
It has a special role in toric IOL implantation. The device is a web‑based calculator which combines all the high‑quality
shows promise particularly in postrefractive surgery eyes and third and fourth generation formulae with a toric IOL
eyes at the extremes of AL spectra. By providing real‑time calculator. It does not propose a new formula. The surgeon can
data to surgeons during cataract surgery, the intraoperative use one or a combination of formula for IOL power calculation
aberrometer allows an unprecedented precision. to achieve optimum results. The calculator also tells how much
ORA has revolutionized premium cataract surgery practice, the formula differs from each other so that the surgeon has an
and some surgeons use it in all their toric, multifocal, and idea how close s/he will be to the target. The calculator also
accommodative IOLs in addition to using it as a guide for
intraoperative astigmatic keratotomy. Another situation where
ORA is useful is in postrefractive surgery patients.
However, there are some drawbacks as well. It has a learning
curve. Dr. Mahdavi conducted a survey which revealed
that it took 20% of the 101 respondents >100 cases to feel
comfortable with ORA. It also prolongs the surgical time by
up to 5–6 min.[75]
Woodcock et al. compared intraoperative aberrometry (ORA with
VerifEye) with standard preoperative biometry in patients
with bilateral cataracts undergoing toric IOL implantation.
Intraoperative aberrometry measurement was performed in
a
one eye and standard IOL power calculation with inked axis
marking in the contralateral eye. The use of the former technology
increased the proportion of eyes with postoperative refractive
astigmatism of 0.50 D or less (89.2% vs. 76.6%) and reduced
mean postoperative refractive astigmatism at 1 month.[76]

b
Figure 12: The Optiwave Refractive Analysis system(ORA, Alcon, Fort Figure 13: (a; see above, B; below): Holos intraoperative aberrometer
Worth, TX) by Clarity

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Nazm and Chakrabarti: Update on optical biometry and IOL power calculation
contains all IOLs made so that an appropriate power as well
as IOL can be chosen.
Okulix
Okulix is a newer IOL formula calculation program that is
based on the principle of “ray‑tracing.” It introduces the
concept of “true geometrical position” of IOL and uses
anterior and posterior central curvature radii, asphericity of
IOL surfaces, central IOL thickness, and index of refraction to
describe IOL position.[79] It may find particular use in toric and
phakic IOLs and IOL power calculation in postkeratorefractive
surgery eyes.[80,81]
Conclusion
IOL power calculation in normal and complex eyes has evolved
significantly in the last two decades. With ever‑evolving lens
designs and increasing patient expectations, performing the
best possible measurements is the key for successful surgery
with good refractive results and a satisfied happy patient.
The latest biometry technologies armed with newer IOL
power calculation formulae have become necessary tools for
the refractive cataract surgeon. With current biometers and
newer formulae expecting outcomes in the range of ±0.50D
has become a reality in majority of the patients. However,
attainment of target postoperative refraction is still not a reality
in all cases (such as irregular corneas and postkeratorefractive
surgery eyes) and further research is required in this direction.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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210 TNOA Journal of Ophthalmic Science and Research  ¦  Volume 55 ¦ Issue 3 ¦ July-September 2017