Acta Ophthalmologica Scandinavica 2007

Review Article

Calculation of intraocular lens

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

ABSTRACT. comparable results (Haigis 2001;

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

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

472

My own experience with IOL optics
began as a resident in the early 1980s
when implantation of standard-power
IOLs was still popular. When our
senior professor was asked why no
effort was made to select an individual
power for the patient, he would
answer, ‘In my department we restore
the patient’s basic refraction,’ claiming
that Gullstrand had found the natural
lens to have a constant power of
19 D!
Although it is true that ametropia
is strongly correlated with the length
of the eye, it has been known for
some time that biological lens power
has a significant statistical distribution
of its own (Sorsby 1956; Stenström
1946; Olsen et al. 2007). Furthermore,
clinical studies have shown that a
fixed IOL power would leave 5% of
patients with refractive errors that dif-
fered from their basic refraction by
> 5 D (Olsen 1988a). Not only would
such patients be highly dependent on
spectacles after surgery, but, clearly,
anisometropia of this magnitude
might cause significant aniseikonia
and have profound influence on bin-
ocular vision.
Although much of the following
will deal with methods of controlling
the dioptric outcome of lens surgery,
we must not forget that a complete
optical description involves not only
refraction in terms of the sphere and
cylinder of the spectacles, but also the
magnification of the eye)spectacle sys-
tem, possible aberrations, depth of
focus, the question of accommoda-
tion, contrast sensitivity, pupil
dependency, colour perception and
other optical properties of the pseudo-
phakic eye.
Some basic optical
formulas
Assuming paraxial imagery, the
refractive effect of any spherical sur-
face can be calculated as described in
the following formula (Bennett &
Rabbetts 2006):
n2  n1
F¼ ð1Þ
r where Ax is the axial length of the eye
where F ¼ refractive power of surface
in dioptres (D), n1 ¼ index of refrac-
tion of the material before the surface,
n2 ¼ index of refraction of the material
after the surface, and r ¼ radius of
Acta Ophthalmologica Scandinavica 2007
curvature in metres. There is a signage
convention dictating that anterior con-
vex surfaces are given a plus sign and
posterior convex surfaces a minus sign.
Vergence is another important con-
cept. It is described as the reciprocal
of the ‘reduced’ distance to the focal
point, defined as:
n culation formulas (Colenbrander 1973;
V¼ ð2Þ
d Fyodorov et al. 1975; Binkhorst 1975,
where V ¼ vergence of paraxial rays in
dioptres, d ¼ distance in metres from
vergence plane to focal point and n ¼
refractive index of the material.
When a refractive system (i.e. a
lens) of power F is added to a bundle
of rays of vergence V1, the vergence
V2 of the rays leaving the lens can be
calculated by addition:
V2 ¼ V1 þ F ð3Þ
‘Thin lens’ IOL power calculation
formula
Assuming the corneal power (K), the
axial length (Ax), the effective lens
plane (d) and the refractive index (n)
of the eye are known, what power of
IOL is needed for emmetropia?
Answer
When incoming (parallel) rays leave
the cornea, the focal distance is given
by 1 ⁄ K. When the ray bundle enters the
effective lens plane, the focal distance
is reduced by the distance d ⁄ n1 where d
is the effective anterior chamber depth
(ACD) in metres and n1 is the refractive
index in the anterior segment. The ver-
gence V1 at the front surface of the lens
plane can therefore be calculated as the
reciprocal of the new focal distance
according to equation 2:
1
V1 ¼ ð4Þ
ðK1  nd1 Þ
In order to be focused on the retina,
rays leaving the lens plane must have
a vergence V2 defined by the distance
from the lens plane to the retina,
that is:
n2
V2 ¼ ð5Þ
ðAx  dÞ
in metres, d is the effective ACD in
metres and n2 is the refractive index in
the posterior segment.
According to equation 3, the power
P0 of the IOL can now be found by
subtracting the two vergences V2 and
V1 to give:
n2 1
P0 ¼  1 d ð6Þ
ðAx  dÞ ðK  n Þ
1
Equation 6 is a thin lens formula,
identical in format to the early
so-called ‘theoretical’ IOL power cal-
1979). Although the format looks
rather simple, it involves several
unknowns that should be dealt with if
the formula is to be applied in clinical
practice. Some of these unknowns
include the refractive index, how to
accurately calculate the corneal power,
how to predict the effective lens plane,
the correction of principal planes of a
‘thick lens’ model, the accuracy of
axial length measurements, and the
significance of higher-order aberra-
tions, etc.
In general, optical formulas used
for power calculation can be ranked
into orders of increasing complexity:
(1) thins lens formulas using sim-
plified thin lens models for the cornea
and the lens;
(2) thick lens formulas that regard
the cornea and lens as having finite
thicknesses with separate curvatures
on their surfaces (paraxial ray trac-
ing), and
(3) exact ray tracing (wavefront
techniques), including higher orders of
aberrations of the cornea and lens.
The statistical
(regression) approach
In the first years of IOL power calcula-
tion, the accuracy of early theoretical
formulas was unconvincing; better
results were reported with a statistical
regression approach, first represented
by the Sanders)Retzlaff)Kraff
(SRK I, SRK II) formulas (Sanders &
Kraff 1980; Sanders et al. 1988). (Note
that the latest version, the SRK ⁄ T
formula [Sanders et al. 1990] is not a
regression formula but, rather, a modi-
fied Binkhorst formula with modified
ACD-prediction algorithms.)
The advantage of any empirical
approach is that the formula is based
on actual measurements, which, to
some extent, eliminates the need to
make assumptions on, for example,
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Acta Ophthalmologica Scandinavica 2007

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

A numerical example
To investigate the accuracy of a statis-
tical regression approach on a modern
dataset, the records of 1000 recent
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
P0 ¼ intraocular lens power for emmetropia (D), K ¼ the keratometry reading of corneal
power (D) and Ax ¼ axial length as measured by optical biometry (in mm). Obs Rx ¼
observed refraction error; Predicted Rx ¼ predicted refraction error.

474
 Acta Ophthalmologica Scandinavica 2007

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

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

475
Acta Ophthalmologica Scandinavica 2007
where D12 ¼ total dioptric power of
the thick lens, D1 ¼ dioptric power of
the front surface, D2 ¼ dioptric power
of the back surface, T ¼ thickness of
the lens (in metres) and n ¼ refractive
index.
Hence, for a ‘standard’ cornea with
a 7.7-mm front surface and 0.5-mm
thickness, the calculation is straight-
forward (assuming the refractive indi-
ces of air, cornea and aqueous to be
1.0, 1.376 and 1.336, respectively):
ð1:376  1Þ  1000
D1 ¼ ¼ 48:83 D
7:7
ð13Þ
ð1:336  1:376Þ  1000
D2 ¼ ¼ 5:88 D
7:7  ð6:8=7:7Þ
ð14Þ
and hence
0:5
D12 ¼ 48:83  5:88 
1:376  1000
 48:83  ð5:88Þ ¼ 43:05 D ð15Þ
Note that the back surface of the
cornea has a negative power of about
) 6 D. Also note that the total power
is about 0.8 D lower than the value
obtained with the common keratome-
ter index calibration of 1.3375. If we
apply a refractive index to the front
surface that would produce the same
result as the thick lens calculation, the
index can be calculated by reversing
equation 10 as:
43:05  7:7
n¼ þ 1 ¼ 1:3315 ð16Þ
1000
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
Gullstrand ratio to range from 0.82 to
476
0.84. These new results may call for a
modification of the corneal power
model. However, before we simply
replace the old Gullstrand ratio with
the newer values, it may be necessary
to consider the aberrations of the cor-
nea, firstly, the spherical aberration.
Spherical aberration of the cornea
The effect of a (positive) spherical
aberration is to increase the effective
power of the cornea. For example, if
we assume the old Gullstrand ratio of
6.8 : 7.7 represents the back sur-
face : front surface of the cornea, and
subject this spherical model to an
exact ray tracing technique (wavefront
analysis), the Gullstrand cornea will
show a spherical aberration of almost
0.5 D for a 4-mm pupil (Fig. 3).
The biological cornea also shows
spherical aberration. However, as the
cornea flattens somewhat towards the
periphery the shape is more like a
prolate and the amount of asphericity
therefore has to be quantified. The
advent of various topography meth-
ods has resulted in a considerable
amount of data in the literature on
the front corneal surface but this is
insufficient because the posterior sur-
face may also contribute significantly
to total optical power.
Recent studies, particularly by
Dubbelman et al. (2002, 2006), using
Scheimpflug photography, have provi-
ded data for normal values of the
front and back surfaces of the cornea
and their dependency on age. Dubbel-
man et al. (2002, 2006) used regres-
sion analysis to derive the following
formulas to express:
Fig. 3. Spherical aberration of the Gullstrand cornea (front radius 7.7 mm) expressed as the
difference between the effective and paraxial power as a function of pupil size.
(1) corneal anterior asphericity (ka)
as a function of age:
ka ¼ 0:76 þ 0:003  age
and
(2) corneal posterior asphericity
(kp) as a function of age:
kp ¼ 0:76 þ 0:325  ka  0:0072  age
Using this model, the conic coeffi-
cients of the front and back surfaces
of the cornea can be estimated to be
) 0.06 and ) 0.37 on average in a 60-
year-old subject. Using exact ray trac-
ing, the total effective power of the
cornea can thus be calculated as a
function of pupil size, as shown in
Fig. 4. Note that effective corneal
power increases with pupil size as a
result of the spherical aberration.
To illustrate and compare different
cornea models, corneal power was cal-
culated using:
(1) the keratometry reading (refractive
index of 1.3375);
(2) paraxial ray tracing according
to the Gullstrand schematic eye, and
(3) exact ray tracing on the Dub-
belman aspheric cornea, assuming a
4-mm pupil and a 60-year-old subject.
Figure 5 shows the results.
As expected, the results show that
the standard keratometer reads the
corneal power about 0.75 D higher
than the Gullstrand value. The surpri-
sing result is, however, that the effect-
ive power of the Dubbelman aspheric
cornea is very close to that of the par-
axial Gullstrand spheric model. For a
7.8-mm cornea, the Dubbelman value
is 0.13 D higher than the Gullstrand
value! This result can be attributed to

Fig. 4. Dubbelman corneal power as a function of front radius and pupil size.
Fig. 5. Corneal power as a function of front central radius for three different corneal models:
common keratometry calibration using index 1.3375; Gullstrand paraxial model assuming the
ratio between the back and front curvature is 6.8 : 7.7, and exact ray tracing on the Dubbelman
aspheric corneal model, assuming the ratio between the back and front curvature is 6.53 : 7.79
and a 4-mm pupil.
the spherical aberration of the cornea,
which increases the effective power of
the cornea over the paraxial value.
Corneal power after refractive surgery
A growing population of patients who
have undergone corneal refractive sur-
gery presents a considerable problem
for the calculation of IOL power. This
is due to changes in normal corneal
anatomy, which makes the calculation
of corneal power very difficult. For
example, if a cornea has undergone
radial keratotomy (RK), its topo-
graphic profile will have been altered
by the procedure, with flattening in
the central region and steepening in
the periphery. These topographic
changes will also be seen in a post-
photorefractive keratotomy (PRK) or
post-laser in situ keratomileusis
(LASIK) cornea, but, by contrast with
the post-RK case, a post-PRK
or post-LASIK case will also show
Acta Ophthalmologica Scandinavica 2007
changes in the corneal optic configur-
ation relating to the anterior and pos-
terior curvatures of the cornea.
Difficulties in the calculation of corneal
power can therefore be divided into:
(1) topographical problems com-
mon to all post-refractive cases, and
(2) problems relating to the corneal
model, which is abnormal in the
case of a post-PRK or post-LASIK
cornea.
Although the conventional keratome-
ter measures the central 3-mm zone of
the cornea, assuming the cornea to be
a spherocylinder, this assumption is
certainly not appropriate when the
corneal surface has been changed as a
result of refractive surgery. After myo-
pic keratorefractive surgery, the flat-
test area of the cornea is the central
area, which is not covered by the
keratometer. A better reading may be
obtained by corneal topography,
which usually gives more central
readings. However, even the best
topographer may not give reliable
readings in the very central area; most
topographers (and all keratometers)
tend to give readings that are too
steep for the effective central zone of
the cornea. This may result in a hyper-
opic error after IOL implantation.
Several methods have been pro-
posed to overcome this problem.
These comprise the clinical history
method, refraction-derived correction
according to Shammas et al. (2003),
the correcting factor according to
Rosa et al. (2002), the variable
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-
ticular myopia has developed). To cal-
culate post-surgical corneal power, the
observed increase in refraction (vert-
exed to the corneal plane) is subtrac-
ted from the preoperative corneal
power. This method therefore requires
preoperative K-readings.
Another method is the hard contact
lens technique (Holladay 1989;
cf. Haigis 2003), which determines the
difference between refraction with and
without a plano hard contact lens of
zero power and subtracts this differ-
ence from the base curve of the con-
tact lens. However, although it is
theoretically sound, the variability of
this method is difficult to control in
clinical practice (Joslin et al. 2005; Sa-
vini et al. 2006).
According to the refraction-derived
method of Shammas et al. (2003), the
keratometric value (using the 1.3375
index) can be calculated as Kc ¼
Kpost () 0.23*CR), where Kc ¼ correc-
ted keratometry, Kpost ¼ postoperative
keratometry and CR ¼ amount of
myopia corrected at the corneal plane.
A variant of this formula is the clinic-
ally derived correction Kc ¼
1.14*Kpost ) 6.8, which does not take
preoperative refraction into account.
477
Acta Ophthalmologica Scandinavica 2007
The method described by Rosa
et al. (2002) utilizes axial length in a
regression formula to account for the
induced refractive change. This for-
mula depends on the association of
axial length with myopia, which is
known to represent the strongest cor-
relation in the normal population.
According to Rosa et al. (2002), the
corneal radius as measured by topog-
raphy should be corrected by a factor
varying between 1.01 and 1.22 accord-
ing to the axial length of the eye. The
corneal power is then obtained using
the formula (1.3375–1) ⁄ rc, where rc ¼
the corrected corneal radius.
Other formulas use a variable
refractive index (Ferrara et al. 2004),
according to which the corrected
refractive index of the cornea
can be calculated as n ¼ ) 0.0006*
(Ax*Ax) + 0.0213*Ax + 1.1573,
where Ax ¼ axial length in mm and
n ¼ corrected refractive index of the
cornea, that assuming corneal
power ¼ (n ) 1) ⁄ r, where r ¼ the
measured central corneal curvature in
metres. This formula also assumes
that emmetropia is the result of the
refractive procedure and is based on
axial length being a strong predictor
of the preoperative ametropia.
Many of these methods use the pre-
operative status of the patient to cal-
culate the changes induced in corneal
anatomy. To help in evaluating the
post-LASIK patient for lens surgery,
it would be desirable if all refractive
surgeons kept records of preoperative
keratometry and refraction values and
gave this information to the patient,
as is the case with implant surgery. In
addition, it would be helpful if axial
length was measured at the time of
refractive surgery in order to compen-
sate for the possible development of
lenticular myopia, which might ham-
per the calculation of induced corneal
change using the history method.
Measurement of axial
length
Measurement of axial length remains
one of the most crucial steps in IOL
power calculation. As a 0.1-mm error
in axial length is equivalent to an
error of about 0.27 D in the spectacle
plane (assuming normal eye dimen-
sions), accuracy within 0.1 mm is
necessary. For comparison, other
478
Table 3. Deviation from the mean values of
different variables and corresponding refrac-
tion errors.
Variable Error Rx error
Corneal radius 1.0 mm 5.7 D
Axial length 1.0 mm 2.7 D
Postoperative ACD 1.0 mm 1.5 D
IOL power 1.0 D 0.67 D
Rx error ¼ refraction error; ACD ¼ anterior
chamber depth; IOL ¼ intraocular lens.
measurement errors and their influ-
ence on refractive error are shown in
Table 3. The conversion from IOL
power error to error in the spectacle
plane is about 1.5 (cf. equation 8).
For many years ultrasound was the
only technique by which the length of
the eye could be measured in clinical
practice. What is really measured by
ultrasound is the transit time taken by
the ultrasonic beam to travel through
the ocular media while it is deflected
from the internal structures of the eye.
The best signal is obtained when the
ultrasonic beam strikes a surface at
normal incidence that gives rise to a
steep spike on the echogram. With
good alignment along the ocular axis,
it is possible to detect a corneal signal
(sometimes a double-spike), the front
and back surfaces of the lens and the
retina at the same time. The ‘retinal’
spike is generally assumed to arise at
the internal limiting membrane of the
retina. This may call for correction to
account for retinal thickness when the
readings are to be used in an IOL
power formula.
It is important to know the velocity
of ultrasound in order to calculate the
distances in question. For the normal
phakic eye, velocity is generally
assumed to be 1532 m ⁄ second for the
anterior chamber and the vitreous and
1641 m ⁄ second for the lens (Jansson
& Kock 1962). In an average eye, this
is equivalent to 1550 m ⁄ second for the
whole eye. However, if we assume a
constant lens thickness, this average
velocity is lower in a long eye and
higher in a short eye, and should be
corrected to obtain an unbiased pre-
diction in these unusual eyes (Olsen
et al. 1991).
The pitfalls of ultrasound measure-
ments are numerous: readings should
be coaxial with the ocular axis. This
requires a steep spike from the retina
as well as good spikes from the anter-
ior and posterior surfaces of the lens.
Some eyes do not have perfectly par-
allel structures, however, and readings
can be difficult to obtain in eyes with
dense cataracts and eyes with poster-
ior staphyloma. Care should be taken
not to indent the cornea if contact
measurements are used. For this rea-
son immersion readings are generally
considered more accurate than contact
measurements.
The introduction of optical biome-
try using partial coherence interferom-
etry (Drexler et al. 1998)
(commercially available as the Zeiss
IOLMasterª) has significantly
improved the accuracy with which
axial length can be measured. The fact
that the retinal pigment epithelium is
the end-point of an optical measure-
ment, whereas the interface between
the vitreous and the neuroretina is the
end-point of an ultrasonic measure-
ment, makes measurements by PCI
longer than those taken with ultra-
sound.
However, just as distance measure-
ments taken with ultrasound are
dependent on the assumed ultrasound
velocity, optical biometry is dependent
on the assumed group refractive indi-
ces of the phakic eye. The indices used
by the Zeiss IOLMasterª were estima-
ted by Haigis (2001) and were partly
based on extrapolated data. There is
some evidence, however, that index
calibration of the phakic eye may
need some modification in order to
ensure consistency between preopera-
tive and postoperative readings (Olsen
& Thorwest 2005) and more studies
may be needed to investigate the index
calibration of the PCI technique.
It should be acknowledged that
readings taken with the commercial
version of the Zeiss IOLMasterª do
not provide a direct measure of the
true optical path length of the eye. In
order not to change the system of
A-constants and other formula
constants that have been used for
years with ultrasound, readings taken
with the commercial version of the
Zeiss IOLMasterª were calibrated
(Haigis et al. 2000; Haigis 2001)
against immersion ultrasound accord-
ing to the formula:
ALðZeissÞ ¼ ðOPL=1:3549  1:3033Þ
=0:9571 ð17Þ
where AL(Zeiss) ¼ output reading of
the Zeiss instrument and OPL ¼ the

optical path length measured by PCI.
This formula makes the reading
achieved with the commercial version
of the Zeiss IOLMasterª equal to that
obtained by immersion ultrasound in
the average case. This need not be the
case with contact ultrasound, how-
ever, as ultrasound measurements may
be confounded by indentation of the
cornea.
Equation 17 can be rearranged to
give the optical path:
OPL ¼ ðALðZeissÞ  0:9571 þ 1:3033Þ
 1:3549 ð18Þ
Assuming a refractive index of
1.3574 for the phakic eye (Haigis
2001), we can obtain the true axial
length according to:
ALðTrueÞ ¼ ðALðZeissÞ  0:9571
þ 1:3033Þ  1:3549=1:3574
ð19Þ
The above considerations are valid
for phakic eyes with normal vitreous
compartments. In pseudophakic eyes
and ⁄ or silicone-filled eyes the axial
length should be deduced with regard
to the altered ultrasonic velocity or
refractive index of the eye in question.
In the case of silicone oil in the pos-
terior segment, the situation is further
complicated by the fact that the opti-
cal path length of the posterior seg-
ment is altered and the refractive
effect of the posterior surface of the
(posterior convex) IOL may be
reduced (see next section). In such
cases it might be necessary to use a
thick lens formula with a corrected
refractive index for the vitreous cavity
and corrected calculation of the diop-
tric power of the posterior surface of
the lens. As a rule of thumb, the
refractive power of the IOL needs to
be increased by an amount that com-
pares with the clinical observation of
an average + 6-D shift in the refrac-
tion of the silicone-filled phakic eye.
Another option would be to use a
planoconvex IOL with all the refrac-
tion on the front surface.
The refractive effect of
the IOL
The refractive effect of the IOL
depends on the optic configuration
Acta Ophthalmologica Scandinavica 2007
(shape factor) of the IOL, its position
within the eye, the power of the
implant and the amount of spherical
aberration.
The optic configuration of the IOL
determines the effective lens plane,
which represents the principal plane
when dealing with paraxial ray trac-
ing. All the dioptric power of a plano-
convex lens is on one surface and thus
that surface represents the effective
lens plane. With a biconvex lens, the
effective lens plane is ‘inside’ the lens.
For example, an IOL with a 2 : 1
biconvex optic configuration has a
radius of curvature on the front sur-
face which is twice the radius of cur-
vature on the back surface. In other
words, the power of the back surface
is twice the power of the front sur-
face.
The optic design and hence the
position of the principal plane have
significant influence on the refractive
effect of the IOL. Table 4 shows the
effect of varying the design on the
refractive effect of the IOL in an aver-
age eye, assuming a constant position
of the anterior surface of the IOL.
The changes in refraction will trans-
late into an equivalent change in the
A-constant of a given lens. For
example, if the design of one lens
changes from a 1 : 2 configuration
to a 2 : 1 configuration, the total
refractive effect in the spectacle
plane is about 0.26 + 0.18 D, thus ¼
+ 0.44 D, which is equivalent to a
0.44*1.5 D ¼ 0.66 D change in IOL
power. This value would be the
corresponding correction needed for
the A-constant.
In addition to the shift in principal
planes, the amount of spherical aber-
ration of the IOL may also have signi-
ficant influence on the refractive effect
of the IOL. As IOL power according
to the American National Standards
Institute (ANSI) definition refers to
paraxial power, the more aspheric the
IOL, the higher the labelled IOL
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).
22 D IOL 2 : 1 configuration
Refractive effect + 0.26 D
(spectacle plane)
IOL ¼ intraocular lens.
power to produce the same refractive
effect in the spectacle plane.
Prediction of
postoperative anterior
chamber depth
At the time when early theoretical for-
mulas were being developed, very little
was known about the actual position
of the implant after surgery. For
example, the Binkhorst I formula
(Binkhorst 1979) used a fixed ACD
value to predict the position of the
implant in each case. It soon became
obvious, however, that the fixed ACD
model was inappropriate because it
resulted in predictions that were actu-
ally worse than empirically derived
formulas. Modern progress in IOL
power calculation formulas largely
reflects advances in methods of pre-
dicting the position of the implant
after surgery based on preoperative
measures.
Today, there is strong evidence that
postoperative ACD is positively corre-
lated with axial length. The fixed-
ACD model therefore predicted ACDs
that were too short in long eyes and
too deep in short eyes. As a conse-
quence, a myopic error would be pro-
duced in a short eye and a hyperopic
error in a long eye. To avoid this
effect, the prediction of postoperative
ACD should in some way be correc-
ted for axial length. The following
simple ACD formula was implemen-
ted in the Binkhorst II formula:
ACDpost ¼ ACDmean  Ax=23:45 ð20Þ
where ACDmean ¼ average ACD (so-
called ACD constant) of a given IOL
type, and Ax ¼ axial length in mm
(Ax < 26 mm).
The Binkhorst II ACD method was
an example of a method to avoid
large bias with the axial length. How-
ever, before we go further and use
more sophisticated methods, it might
1 : 1 configuration 1 : 2 configuration
0.00 D ) 0.18 D
479
Acta Ophthalmologica Scandinavica 2007

be worthwhile considering the follow-

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

480

base of the anterior spherical segment
as the reference plane (Fyodorov et al.
1975). This plane can be calculated
from the corneal curvature and corneal
diameter, the latter by taking an aver-
age value or by using the white-to-
white distance of the cornea. The Fy-
odorov formula was intended for iris-
clip lenses and was adopted by the
author for anterior chamber lenses
(Olsen 1986b) and later for posterior
chamber lenses (Olsen et al. 1990,
1992).
The Fyodorov corneal height for-
mula was reintroduced for the calcula-
tion of the so-called ‘surgeon’s factor’,
defined as the difference between the
corneal height and the effective optical
plane of the IOL (Holladay et al. 1988)
and was adopted at around the same
time as the SRK ⁄ T approach (Sanders
et al. 1990). However, recent work by
the author seems to indicate that there
is no significant information in corneal
height based on corneal diameter,
compared with corneal curvature itself.
Other predictors, such as axial length,
preoperative ACD and lens thickness,
have been found to be significantly
more important (Olsen 2006).
Preoperative ACD
Today, most newer generation IOL
power calculation formulas recognize
the importance of factors other than
axial length in predicting ACD. Pre-
operative ACD is one such predictor;
it has been used in formulas such as
the Haigis formula (Haigis 2004) and
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
dataset (n ¼ 7418). Note that the error increases five-fold from a long eye of 30 mm (about
0.1 D refractive error) to a short eye of 20 mm (about 0.5 D refractive error). Bars indicate
± 1 standard deviation.
Acta Ophthalmologica Scandinavica 2007
the Olsen formula (Olsen et al. 1992,
1995; Olsen 2006). The importance of
preoperative ACD is ranked second to
axial length in statistical significance
as shown by multiple regression analy-
sis (Olsen 2006).
Lens thickness
If we accept the importance of preop-
erative ACD to postoperative ACD, it
seems logical to assume that preopera-
tive lens thickness also has some influ-
ence. This is due to the thickening of
the lens with age and the statistical
negative correlation between ACD
and lens thickness in the normal eye.
Despite this logical assumption and
the fact that most ultrasound equip-
ment is capable of measuring lens
thickness, it is surprising how little
lens thickness has been used in ACD
prediction algorithms. One exception
to this rule is the Olsen formula,
which has used this predictor since
1995 (Olsen et al. 1995). More
recently, it has also been considered
by other authors (Norrby 2004; Nor-
rby et al. 2005). Recent studies on
large series have confirmed that lens
thickness is important to accurate
ACD prediction, especially in combi-
nation with preoperative ACD (Olsen
2006).
Whichever method is used in the
prediction of postoperative ACD, it
should be realized that the error in
refraction produced by an error in
postoperative ACD is strongly
dependent on axial length. This can
be clearly seen in Fig. 7, which was
constructed from an actual dataset
(number of observations: n ¼ 7418)
examined to establish the correspond-
ing IOL prediction error (spectacle
plane) resulting from a 0.25-mm error
in postoperative ACD versus axial
length. As Fig. 7 shows, the corres-
ponding prediction error increases
five-fold from a 0.1-D error in a
30-mm long eye to a 0.5-D error in
20-mm short eye. Accurate prediction
of ACD therefore remains much more
important in short eyes compared
with long eyes.
It should be noted that the means
to predict postoperative ACD or ELP
to a large extent is based on the statis-
tical relationship between several pre-
operatively defined measures and the
actual position of the implant. This
requires the eye to exhibit a normal
anatomy. If normality is compro-
mised, as a result of keratorefractive
surgery (or the axial length has been
altered as a result of a scleral buckling
procedure), the statistical model
behind the prediction of ACD may no
longer be valid and it may be neces-
sary to ‘normalize’ the anatomy. This
is the rationale behind the ‘double
K-method’ reported by Aramberri
(2003).
Assuming the total prediction error
in IOL power calculation to be the
sum of the error associated with the
main variables, namely:
(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
to be less than the error from ACD
predictions (42%). This result con-
trasts with previous error estimation,
showing axial length measurements
481
Acta Ophthalmologica Scandinavica 2007
‘optimized’. Optimization means that
the numerical error of predictions
counting both negative and positive
deviations will average to zero for the
entire dataset. The IOL power calcula-
tion formula works at its best when
this is so, leaving only statistical
(measurement) errors to influence the
result. If a systematic error arises any-
where in the system, the Gaussian dis-
tribution of the predictions would
gather around a certain offset value.
Optimization aims to correct for this
Fig. 8. Breakdown of total intraocular lens error (Fig. 9).
power prediction error into the three main There are different sources of sys-
sources of error: axial length measurement by tematic error. Systematic deviations in
optical biometry (AX); measurement of cor- measurement error translate directly
neal power (K), and estimation of postopera-
into equivalent errors in IOL power
tive anterior chamber depth (IOL ACD). The
graph was constructed assuming average eye prediction (cf. Table 3) and should be
data and the current statistical measurement dealt with accordingly. If, for
error of each variable. RX ¼ refractive error. instance, ultrasound measurements are
compared with those of PCI, it is
with ultrasound to be responsible for likely that the readings will be some-
> 50% of total error. The reason for what longer with optical biometry.
the relatively lower contribution from Thus, if one surgeon achieves perfect
the axial length source and the higher results using a particular SRK A-con-
contribution from the ACD source is stant with ultrasound, it is likely that
the higher accuracy of the optical bi- he ⁄ she will need to increase the
ometry using Zeiss IOLMasterª. A-constant by the equivalent value of
Therefore, the degree of accuracy the shift in axial length measurement
with which postoperative ACD can be from ultrasound to optical biometry.
predicted is the major limiting factor To some surgeons this may seem sur-
in the accuracy of modern IOL power prising, as the A-constant is often
calculation. regarded as an IOL-related constant.
The truth is, however, that the A-con-
stant is a ‘black box’ that contains
Optimization and any offset errors that arise in the
entire clinical environment, as demon-
accuracy strated in the numerical example given
Most of what has been said in the above.
foregoing sections has been under the The introduction of optical biome-
assumption that predictions have been try by coherence interferometry has
Fig. 9. The distribution of prediction error with and without correction for an offset error of
0.5 D by optimization.
482
vastly improved conditions for greater
standardization in calculating IOL
power. For the first time, we now
have a highly accurate, observer-inde-
pendent technique by which axial
length can be measured. This allows
surgeons around the world to com-
pare results and exchange information
regarding the most appropriate
A-constant or other IOL constants. It
should be remembered, however, that
the A-constant by nature depends on
the population average. If, for exam-
ple, the population in one country has
on average longer eyes than that of
another region, this would call for an
adjustment of the A-constant,
although the axial length measure-
ments were made with the same
equipment.
Every IOL has its own refractive
effect depending on the optic configur-
ation, the amount of spherical aberra-
tion and the effective ACD (see
section above). The existence of a
‘personalized’ ACD may have been
viable in the old days, when surgeons
had different ways of opening the cap-
sule and therefore different ways of
anchoring the IOL in the eye. If, for
example, one surgeon implanted every
IOL within the capsular bag, while
another placed the IOL in the sulcus,
they would achieve different refractive
results. As anterior displacement of
the IOL enhances its refractive effect,
the sulcus surgeon would need to use
IOLs with a power 0.5–1.0 D lower
than those used by the in-the-bag sur-
geon in the average case. However,
since the introduction of the continu-
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
than its paraxial (labelled) power and
higher than that of an aspherical IOL

with negative spherical aberration. To
obtain the same refractive result with
an aspherical IOL as with a spherical
IOL, the surgeon would need to use a
higher labelled power. The amount of
‘extra’ power needed equals the
amount of corrected spherical aberra-
tion, which may be estimated from
the physical constants of the IOL (i.e.
the conic coefficients of the surfaces).
However, due to the Stiles)Crawford
effect, which tends to correct for the
spherical aberration of the ocular sys-
tem (Olsen 1993), the effective power
of an IOL may not be 100% dedu-
cible from its optical bench power.
Therefore, only by clinical studies is it
possible to evaluate the true effective
IOL power and obtain the necessary
IOL constants to optimize and fine-
tune IOL power calculations.
In the event of unexpected refrac-
tion after surgery, every effort should
be made to identify the error. A
recommended procedure would be to
verify all measurements by remeasur-
ing the corneal curvature and axial
length and comparing the results with
preoperative measurements. In most
cases this will reveal the error to be a
measurement error. However, other
errors, including labelling errors,
should also be considered. The author
has obtained good results by measur-
ing actual ACD in the pseudophakic
eye and comparing this with the pre-
dicted value. The measurement of act-
ual postoperative ACD together with
a repeat K-reading and (optical)
biometry makes it possible based on
the observed refraction to back-calcu-
late IOL power in situ within an accu-
racy of ± 1 D. This allows for the
diagnosis of a case of IOL mislabel-
ling with reasonable accuracy. The
mislabelling of IOLs has been a prob-
lem in some cases in the past (Olsen
& Olesen 1993), but it seems to have
been seldom reported in recent litera-
ture. The higher accuracy of optical
biometry has greatly improved mea-
suring conditions for diagnosing mis-
labelled IOLs.
Conclusions
Although IOL power calculation
began as an optical approach using
theoretical formulas, the majority of
methods used in clinical practice over
the past 25 years have been based on
Acta Ophthalmologica Scandinavica 2007
empirical methods that have used
‘fudged’ formulas to compensate for
the unknowns in the system. However,
the advent of better diagnostic equip-
ment and ever-improving surgical
techniques has decreased the number
of unknowns, and optical methods
now hold sway in IOL power calcula-
tion.
To conclude the discussion of
regression versus a theoretical
approach, it would be unfair to say
that the regression approach is inac-
curate as its accuracy is comparable
with that of the theoretical approach
in a normal dataset. The theoretical
approach does, however, give more
accurate predictions, as can be dem-
onstrated in a significant number of
observations under optimized condi-
tions. The disadvantages of the regres-
sion approach include the need for a
large series from which to derive the
empirical constants and the limitations
defined by the ‘normal’ population
and the clinical environment. If the
clinical environment changes, for
example by using a more accurate
device for axial length measurement
or by using a more standardized surgi-
cal technique, the offset value and
coefficients of the regression equation
are likely to change. The regression
formula will not work in extremes and
hence inaccurate predictions are likely
to occur in unusually long or short
eyes, in steep or flat corneas and in
combinations thereof.
Although paraxial ray tracing still
has an important role to play in the
description of IOL optics, wavefront
technology and exact ray tracing (Pre-
ussner et al. 2002) may in the future
represent better ways of describing the
optics of the pseudophakic eye, especi-
ally in cases of non-spherical post-
LASIK corneas, but also when deal-
ing with aspheric IOLs. However, if
we, as surgeons, are to treat the pseu-
dophakic eye as a truly optical system,
we need more information regarding
the physical properties of the IOL to
be implanted. The time when an
A-constant and power to the nearest
0.5 D could be regarded as sufficient
information on an implant to be
placed in someone’s eye for the rest of
his or her life is over. It would be
extremely helpful if manufacturers
would include other useful informa-
tion on the IOL label, such as the
IOL’s exact power, the exact curva-
tures of the front and back surfaces,
thickness, index of refraction, and
conic coefficients, etc. In the accurate
prediction of the optical properties of
the pseudophakic eye, whether the
optic configuration changes with
power, what the conic coefficients of
the aspheric surfaces are, and whether
the power varies by ± 0.5 D or
± 0.1 D from the labelled value mat-
ter greatly.
The average refractive prediction
accuracy that can be achieved with
modern methodology (using optimized
conditions and the latest generation
ACD prediction algorithms) is
< 0.5 D (absolute error). The stan-
dard deviation of the numerical error
is < 0.6 D, which means that about
90% of cases fall within ± 1.0 D and
99.9% within ± 2.0 D of their targets,
again assuming optimized conditions.
Prediction is more accurate in long
eyes and less accurate in short eyes.
The calculation and selection of
appropriate IOL power are among the
most significant tools in refractive sur-
gery today.
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