Optical Biometry and IOL Calculation in a
Commercially Available Optical Coherence
Tomography Device and Comparison With
Pentacam AXL
PIOTR KANCLERZ, KENNETH J. HOFFER, NATASZA BAZYLCZYK, XIAOGANG WANG, AND GIACOMO SAVINI
• PURPOSE: Optical devices are the gold standard for
ocular biometry; however, they are unable to obtain
high-quality optical coherence tomography (OCT) im-
ages. The current study aimed to evaluate ocular mea-
surements and intraocular lens (IOL) calculation used in
an anterior/posterior segment OCT device and to com-
pare the results with those of a validated biometer.
• DESIGN: Prospective evaluation of a diagnostic tool.
• METHODS: This study enrolled healthy subjects at the
Hygeia Clinic, Gdańsk, Poland, between October 2021
and November 2021. All individuals had ocular biome-
try measured with a validated biometer (Pentacam AXL)
and with a new module of an anterior/posterior segment
OCT device (Revo 80, Optopol Technologies). All IOL
calculations were performed for the right eye with kerato-
metric values from the Pentacam for one IOL: the Alcon
AcrySof IQ SN60WF, with plano target setting.
• RESULTS: The mean age of the 144 participants was
25.23 ± 7.15 years. The axial length measured with Revo
was longer than with Pentacam AXL (24.08 ± 1.13 vs
23.98 ± 1.13; P < .0001), a 0.10 ± 0.04 mm difference.
This translated into a significantly lower IOL power to
achieve emmetropia for all formulas (–0.34 ± 0.15, –0.32
± 0.13, –0.34 ± 0.19, and –0.30 ± 0.15 for the Hof-
fer Q, Holladay I, Haigis, and SRK/T formulas, respec-
tively). The study showed high agreement between the
devices: nearly 90% of eyes were within ±0.50 diopters
for all of the analyzed formulas (r > 0.99).
• CONCLUSIONS: The present study demonstrates that
the results of IOL calculation with the OCT biometer
have a very strong correlation with those obtained with
the Pentacam AXL; however, axial length measurements
Supplemental Material available at AJO.com.
Accepted for publication September 30, 2022.
From the Hygeia Clinic (P.K., N.B.), Gdańsk, Poland; Helsinki
Retina Research Group Faculty of Medicine (P.K.), University of Helsinki,
Helsinki, Finland; Stein Eye Institute University of California (K.J.H.),
Los Angeles, California, USA; St. Mary’s Eye Center (K.J.H.), Santa
Monica, California, USA; Shanxi Eye Hospital (X.W.), Shanxi Medical
University, Taiyuan, Shanxi, China; G.B. Bietti Foundation I.R.C.C.S
(G.S.), Rome, Italy
Inquiries to Piotr Kanclerz, Hygeia Clinic, Gdańsk, Poland; e-mail:
p.kanclerz@gumed.edu.pl
236 © 2022 ELSEVIER INC. ALL RIGHTS RESERVED.
and calculated IOL power cannot be considered inter-
changeable. (Am J Ophthalmol 2023;246: 236–241.
© 2022 Elsevier Inc. All rights reserved.)
P
recise measurement of ocular distances is
essential for excellent refractive outcomes, both in
cataract surgery and in refractive lens exchange.
More than 22 years ago, the first optical biometer (IOL-
Master, Carl Zeiss Meditec) was introduced; since then
more than 10 commercially available optical instruments
have been developed. These devices might use partial co-
herence interferometry (PCI) (e.g., IOLMaster 500 [Carl
Zeiss Meditec], AL-scan [Nidek Co. Ltd.]), or Pentacam
AXL [Oculus Optikgeräte]) low-coherence optical reflec-
tometry (LCOR) (e.g., Lenstar LS-900 [Haag-Streit AG],
Aladdin [Topcon Corporation], or Galilei G6 [Ziemer Oph-
thalmic Systems AG]), and swept-source optical coher-
ence tomography (SS-OCT) (e.g., IOLMaster 700 [Carl
Zeiss Meditec], OA-2000 [Tomey Corporation], Argos
[Movu Inc.] or Anterion [Heidelberg Engineering GmbH]).
1–3
Currently, optical biometry is considered as the gold
standard for preoperative biometry. Although several of
these devices use wavelengths similar to that used in OCT
(780-1050 nm), they are not designed to obtain fully di-
agnostic images of the posterior segment of the eye. On
the contrary, the Revo (Optopol Technologies) is an ante-
rior/posterior segment diagnostic spectral domain spectral
domain (SD) OCT device, which recently was expanded
to obtain optical biometry measurements and intraocular
lens (IOL) calculation.
Our previous studies have reported the outcomes of op-
tical biometry obtained with the new module of Revo.4–6
In this current study, we aimed to evaluate the IOL calcu-
lations obtained with the device and to compare the results
with a validated biometer.
METHODS
This prospective evaluation of a diagnostic examination
enrolled healthy subjects at the Hygeia Clinic, Gdańsk,
0002-9394/$36.00
https://doi.org/10.1016/j.ajo.2022.09.022
Poland, between October 2021 and November 2021. Be-
fore the examination, all eyes underwent a complete oph-
thalmological examination, which included subjective re-
fraction assessment, tonometry, a slit lamp examination
and ophthalmoscopy. Individuals with any ocular disease
(including cataract), with corrected distance visual acuity
worse than 20/25, or having undergone ocular surgery or
experienced trauma were excluded. The study adhered to
the tenets of the Declaration of Helsinki for the use of hu-
man participants. The study protocol was approved by the
local bioethical committee (Komisja Bioetyczna przy Izbie
Lekarskiej w Gdańsku, approval KB 27/21).
The Revo is a spectral-domain (SD) OCT device, with
a superluminescent laser diode (830 nm) used as the light
source. The device has an axial resolution of 5 mm, trans-
verse resolution of 12 mm, and single scan depth of 2.4 mm.
For each measurement, the device performs 10 scans to ob-
tain ocular distances. The device used for this study (Revo
80, S/N 1550633/16) was a different unit from the one used
in our first study (Revo NX, S/N 1560333/10, v. 8.0.3),5
and the one used in our second study (Revo NX, S/N
1560481/13, v. 9.01).4 It also worked on the new version
of the software (v. 11.0.1), which has the IOL calculation,
corneal diameter (CD), and pupil size assessment enabled.
The biometry module of the Revo device does not measure
keratometric values; instead, they have to be entered manu-
ally for the calculation or copied from the corneal tomogra-
phy module. To date, Revo allows the use of the Haigis, Hof-
fer Q, Holladay I, and SRK/T formulas (and the SRK II for-
mula which is obsolete and commonly not available in new
biometers).7 Pentacam AXL is a validated optical biometer
that combines a rotating Scheimpflug camera (wavelength
475 nm) for obtaining corneal tomography images, and a
PCI (880 nm) for optical biometry.8 For this study, software
version 1.25r15 (build 100) was used. Both Revo and Pen-
tacal AXL obtain the axial length (AL) by using a single
assumed refractive index, similar to PCI devices.
Measurements were carried out with the 2 devices in ran-
dom order; only results for the right eyes were used in the
study. All examinations were conducted between 15:00 and
20:00, after calibration of both devices with the dedicated
tools. For each patient, results were considered valid if the
quality mark on the scan was assessed as OK for biometry,
and it was possible to obtain keratometric values. Only 1
measurement was taken, and if it was of insufficient quality,
up to 3 measurements were taken until a valid result was
obtained. The following biometric parameters were com-
pared: AL, anterior chamber depth (ACD, from corneal ep-
ithelium to the anterior lens surface), central corneal thick-
ness (CCT), pupil size, and CD. Within the provided soft-
ware, the Pentacam AXL did not automatically measure
lens thickness, so it was not compared between the devices.
All IOL calculations were performed for the AcrySof IQ
SN60WF lens (Alcon Laboratories) with plano target set-
ting and using an A constant of 119.0. The Revo corneal to-
mography module was not enabled in the device, so the ker-
VOL. 246 IOL CALCULATION IN AN ANTERIOR/POSTERIOR SEGMENT OCT DEVICE
atometry values obtained with the Pentacam were entered
into the Revo instrument. Moreover, we used the same val-
ues for both biometers to exclude the influence of the ker-
atometric differences.
Statistical analysis was conducted using Medcalc sta-
tistical software v. 14.0 (Medcalc Software). Results are
presented as the mean ± SD. Comparison between the
devices was performed using correlation coefficients, the
Bland−Altman method,9 and a paired t test (as all param-
eters were normally distributed as per the Kolmogorov–
Smirnov test). Correlation coefficient values between 0
and 0.3 were considered weakly positive, between 0.3 and
0.7 moderately positive, and between 0.7 and 1.0 strongly
positive linear relationships.10 Agreement between the de-
vices was also analyzed by comparing the percentage of eyes
whose IOL power was within ±0.25, ±0.50, ±0.75, and
±1.00 diopters (D) for each formula. Differences with P val-
ues of less than .05 were considered statistically significant.
Only 1 eye per patient was investigated.
RESULTS
We enrolled 145 patients; 1 patient was excluded because of
technical failure. The results of 144 patients (65% women
[n = 93]) were analyzed. The mean age was 25.23 ± 7.15
years. The mean spherical equivalent (SE) refraction was –
1.35 ± 2.18 D, and the refractive cylinder was –1.68 ± 2.23
D. The simulated flat keratometry value was 42.83 ± 1.67
D, and the mean steep keratometry was 43.86 ± 1.50 D.
The AL measured with Revo was 0.10 ± 0.04 mm greater
than with Pentacam AXL (24.08 ± 1.13 mm vs 23.98 ±
1.13 mm; p < 0.0001) (Table 1). This translated into a sig-
nificantly lower IOL power in order to achieve emmetropia
for all of the analyzed formulas (–0.34 ± 0.19; –0.34 ± 0.15;
–0.32 ± 0.13; and –0.30 ± 0.15), namely the Haigis, Hof-
fer Q, Holladay I, and SRK/T formulas, respectively. The
Bland−Altman plot for AL is presented in Figure 1 and for
IOL calculations in Figures 2 through 5. There was a statis-
tically significant difference between Revo and the Penta-
cam AXL in all measured parameters and formulas, except
CCT (P = .4489). The pupil size and CD measurements
were higher when measured with Revo than with the Pen-
tacam AXL (mean difference 2.82 ± 1.09 mm, and 1.03
± 0.04 mm, respectively). The correlation between the de-
vices was very strong for AL measurements and IOL cal-
culation among all analyzed formulas (r > 0.99), whereas it
was moderate for pupil size and CD (r = 0.4986 and 0.5779,
respectively). Figure 3–5
Notwithstanding the higher AL measurements obtained
with Revo, our data showed good agreement between the
IOL power calculated by the 2 devices: in nearly 90% of
eyes, the difference was within ±0.50 D with the Haigis,
Hoffer Q, Holladay 1, and SRK/T formulas (Table 2).
237
FIGURE 1. Bland−Altman plot of agreement in axial length measurements between Revo and Pentacam AXL.

FIGURE 2. Bland−Altman plot of agreement in the Haigis formula between Revo and Pentacam AXL.

FIGURE 3. Bland−Altman plot of agreement in the Hoffer Q formula between Revo and Pentacam AXL.

238 AMERICAN JOURNAL OF OPHTHALMOLOGY FEBRUARY 2023

 TABLE 1. Mean Values, Mean Differences, 95% Limits of Agreement, and Correlation for the Differences Between Revo
(Spectral-Domain Optical Coherence Tomography) and Pentacam AXL (Low-Coherence Optical Reflectometry) Devices.

Parameter Device Mean ± SD Range Mean Difference ± SD 95% LoA Correlation Coefficient r P value
(p)

AL (mm) Revo 24.08 ± 1.13 21.96 to 28.11 0.10 ± 0.04 0.02 to 0.17 0.9994 (< .0001) <.001
Pentacam AXL 23.98 ± 1.13 21.92 to 28.00
ACD (mm) Revo 3.63 ± 0.30 2.73 to 4.33 0.00 ± 0.04 –0.04 to 0.08 0.9942 (< .0001) .1954
Pentacam AXL 3.63 ± 0.31 2.67 to 4.37
CCT (μm) Revo 548.25 ± 34.10 473.00 to 681.00 0.46 ± 7.27 –13.69 to 14.81 0.9772 (< .0001) .4489
Pentacam AXL 547.79 ± 32.59 469.00 to 624.00
PS (mm) Revo 6.38 ± 1.23 4.00 to 8.91 2.82 ± 1.09 0.68 to 4.96 0.4986 (< .0001) <.001
Pentacam AXL 3.55 ± 0.82 2.08 to 6.60
CD (mm) Revo 12.85 ± 0.61 9.90 to 14.10 1.03 ± 0.04 0.95 to 1.12 0.5779 (< .0001) <.001
Pentacam AXL 11.82 ± 0.40 10.3 to 12.9
Emmetropia: Revo 20.05 ± 3.43 8.25 to 28.66 –0.34 ± 0.19 –0.71 to 0.03 0.9986 (< .0001) <.001
Haigis (D)
Pentacam AXL 20.40 ± 3.46 8.71 to 29.76
Emmetropia: Revo 19.75 ± 3.55 7.44 to 28.32 –0.34 ± 0.15 –0.63 to –0.05 0.9991 (< .0001) <.001
Hoffer Q (D)
Pentacam AXL 20.09 ± 3.56 7.87 to 28.76
Emmetropia: Revo 19.74 ± 3.41 7.68 to 27.33 –0.32 ± 0.13 –0.57 to –0.07 0.9993 (< .0001) <.001
Holladay I (D)
Pentacam AXL 20.05 ± 3.41 8.12 to 27.75
Emmetropia: Revo 19.68 ± 3.26 8.35 to 26.58 –0.30 ± 0.15 –0.59 to –0.01 0.9989 (< .0001) <.001
SRK/T (D)
Pentacam AXL 19.99 ± 3.26 8.77 to 26.98

ACD = anterior chamber depth (from epithelium to lens); AL = axial length; CCT = central corneal thickness; CD = corneal diameter;
D = diopter; LoA = limits of agreement; PS = pupil size.

FIGURE 4. Bland−Altman plot of agreement in the Holladay I formula between Revo and Pentacam AXL.

translated into a significantly lower IOL power for the cal-

DISCUSSION
This study presents the results of IOL calculation imple-
mented into a commercially available anterior/posterior
segment SD-OCT device. The AL measured with Revo was
greater than with Pentacam AXL by 0.10 ± 0.04 mm; this
culated IOL. Previous studies have also shown differences
in AL measurements between optical biometers.5 Goebels
et al found greater AL measurements with the PCI IOL-
Master 500 than with the SS-OCT Tomey OA-2000 by
0.05 ± 0.09 mm.11 Another study by Ortiz et al showed
that AL measurements with the Lenstar LS 900 and Top-

VOL. 246 IOL CALCULATION IN AN ANTERIOR/POSTERIOR SEGMENT OCT DEVICE 239

FIGURE 5. Bland−Altman plot of agreement in the SRK/T formula between Revo and Pentacam AXL.

TABLE 2. Percentage of Eyes Showing Intraocular Lens Power Difference Between Revo and Pentacam AXL.

Formula Within ±0.25 D Within ±0.5 D Within ±0.75 D Within ±1.0 D

Haigis 27.1% 87.5% 98.6% 98.6%

Hoffer Q 27.1% 89.6% 99.3% 99.3%
Holladay I 32.6% 91.0% 100% 100%
SRK/T 32.6% 91.7% 99.3% 100%

D = diopter.

con Aladdin were lower than with the IOLMaster 500 (by
–0.04 ± 0.26 mm, and –0.04 ± 0.13 mm, respectively).12
Although in such a case it is obvious that the results of mea-
surements obtained with both devices cannot be considered
interchangeable, IOL constant optimization could be con-
sidered to obtain the same IOL power in a clinical scenario.
The differences between the devices used in this study could
presumably be associated with the use of a dissimilar group
refractive index to convert the optical path length into ax-
ial distances.13 Other potential reasons include the different
optical wavelengths used by the devices or a distinct tech-
nique for automatic structure border detection. However,
these issues should play no significant role in the usefulness
of the device.
The present investigation demonstrated a nonsignificant
difference between the devices in CCT measurements. Ev-
idently, greater difference has been shown in studies com-
paring results of scanning-slit corneal tomography (Orbscan
II) and Scheimpflug imaging. In those studies, the results
of CCT measurements obtained with the Orbscan II were
on average from 13.98 to 20 µm lower than for the Pen-
tacam14 , 15 and 18 µm lower than those obtained with the
Galilei.15 In another study, the corneal thickness measured
with Orbscan II was greater than with and an anterior seg-
ment OCT device (Visante, Carl Zeiss Meditec) by +14.44
± 9.14 µm.16 These discrepancies could have not only sta-
tistical but also clinical relevance, and should be taken into
account in patients screened preoperatively in refractive
surgery.
This study found a significant difference in pupil size
measurements, which was 2.82 ± 1.09 mm greater for Revo
than for the Pentacam AXL. This difference in pupil size
is likely related to the illumination of the eye by the de-
vice during pupil size assessment. However, the illumina-
tion levels during the measurements have not been spec-
ified by the producers. Our previous study has found that
pupil size measurements with the Nidek ARK-1 are signif-
icantly greater than those with the Lenstar LS-900, both
obtained in a scotopic environment (5.15 ± 0.95 vs 4.38 ±
0.79 mm, respectively; P < .01).17 The difference in CD is
less prominent, but also clinically relevant. Several investi-
gations found a significant discrepancy for CD assessment
with automatic methods,3 , 18-20 with differences reaching
0.40 mm3 and 95% limits of agreement of nearly 3.0 mm.20
This high variability in CD among instruments can be sig-
nificant in implantable contact lens sizing, but not likely for
in-the-bag IOL placement.
The main limitation of this study is that it included only
older-generation IOL formulas. It is known that newer for-
mulas employ additional parameters to more precisely esti-
mate the postoperative effective lens position.21 In the cur-
rent version of the Revo software, only the analyzed formu-
las are available. This limitation can be resolved by using
online IOL calculators. Second, we did not evaluate the

240 AMERICAN JOURNAL OF OPHTHALMOLOGY FEBRUARY 2023

postoperative outcome of the IOL calculation in patients
undergoing cataract surgery. The present study aimed to as-
sess the clinical utility of the new module by comparing it
with a currently used and validated method. This is neces-
sary for every newly developed device or module. However,
the results of this study can be considered promising.
In conclusion, the present study demonstrates the re-
sults of IOL calculation with the SD-OCT biometer have a
very strong correlation with those obtained with the Penta-
cam AXL; however, the AL measurements and calculated
IOL power using the 4 formulas cannot be considered in-
terchangeable.

Funding/Support: No funding was received for this study. The contribution of G.B. Bietti Foundation I.R.C.C.S. was supported by Fondazione Roma
and the Italian Ministry of Health. Financial Disclosures: K.J.H. licenses the registered trademark name Hoffer® to ensure accurate programming of his
formulas to Carl Zeiss-Meditec (IOLMasters), Haag-Streit (LenStar/EyeStar), Heidelberg Engineering (Anterion), Oculus (Pentacam AXL), Optopol
Technology (Revo NX), Movu (Argos), Nidek (AL-Scan), Tomey (OA-2000), Topcon EU/VisiaImaging (Aladdin), Ziemer (Galilei G6), and all A-scan
biometer manufacturers but not Alcon (Verion). P.K. reports grants from Alcon and nonfinancial support from Visim and Optopol Technology, outside the
submitted work. G.S. has received personal fees from Alcon, Johnson & Johnson, Oculus, Staar Surgical, and Zeiss. The authors have neither proprietary
nor commercial interests in any medications or materials discussed. The other authors indicate no financial support or conflicts of interest. All authors
attest that they meet the current ICMJE criteria for authorship.

REFERENCES 12. Ortiz A, Galvis V, Tello A, et al. Comparison of three optical

1. Savini G, Hoffer KJ, Shammas HJ, Aramberri J, Huang J, Bar-
boni P. Accuracy of a new swept-source optical coherence to-
mography biometer for IOL power calculation and compari-
son to IOLMaster. J Refract Surg. 2017;33(10):690–695.
2. Huang J, Savini G, Hoffer KJ, et al. Repeatability and inter-
observer reproducibility of a new optical biometer based on
swept-source optical coherence tomography and comparison
with IOLMaster. Br J Ophthalmol. 2017;101(4):493–498.
3. Muzyka-Woźniak M, Oleszko A. Comparison of anterior seg-
ment parameters and axial length measurements performed on
a Scheimpflug device with biometry function and a reference
optical biometer. Int Ophthalmol. 2019;39(5):1115–1122.
4. Kanclerz P, Hoffer KJ, Przewłócka K, Savini G. Comparison of
an upgraded optical biometer with 2 validated optical biome-
ters. J Cataract Refract Surg. 2021;47(7):859–864.
5. Kanclerz P, Hoffer KJ, Rozema JJ, Przewłócka K, Savini G.
Repeatability and reproducibility of optical biometry imple-
mented in a new optical coherence tomographer and com-
parison with a optical low-coherence reflectometer. J Cataract
Refract Surg. 2019;45(11):1619–1624.
6. Kanclerz P. Optical biometry in a commercially available an-
terior and posterior segment optical coherence tomography
device. Clin Exp Optom. 2019;102(5):533–534.
7. Hoffer KJ. The Hoffer Q formula: a comparison of the-
oretic and regression formulas. J Cataract Refract Surg.
1993;19(6):700–712.
8. Kanclerz P, Khoramnia R, Wang X. Current developments
in corneal topography and tomography. Diagnostics (Basel).
2021;11(8). doi:10.3390/diagnostics11081466.
9. Bland JM, Altman DG. Statistical methods for assessing
agreement between two methods of clinical measurement.
Lancet. 1986;1(8476):307–310.
10. Ratner B. The correlation coefficient: its values range be-
tween +1/−1, or do they? J Target Meas Anal Mark.
2009;17(2):139–142.
11. Goebels S, Pattmöller M, Eppig T, Cayless A, Seitz B, Lan-
genbucher A. Comparison of 3 biometry devices in cataract
patients. J Cataract Refract Surg. 2015;41(11):2387–2393.
biometers: IOLMaster 500, Lenstar LS 900 and Aladdin. Int
Ophthalmol. 2019;39(8):1809–1818.
13. Haigis W, Lege B, Miller N, Schneider B. Comparison of im-
mersion ultrasound biometry and partial coherence interfer-
ometry for intraocular lens calculation according to Haigis.
Graefes Arch Clin Exp Ophthalmol. 2000;238(9):765–773.
14. Rosa N, Lanza M, Borrelli M, Polito B, Filosa ML,
De Bernardo M. Comparison of central corneal thick-
ness measured with Orbscan and Pentacam. J Refract Surg.
2007;23(9):895–899.
15. Crawford AZ, Patel DV, McGhee CNJ. Comparison and re-
peatability of keratometric and corneal power measurements
obtained by Orbscan II, Pentacam, and Galilei corneal tomog-
raphy systems. Am J Ophthalmol. 2013;156(1):53–60.
16. Li EYM, Mohamed S, Leung CKS, et al. Agreement
among 3 methods to measure corneal thickness: ultra-
sound pachymetry, Orbscan II, and Visante anterior
segment optical coherence tomography. Ophthalmology.
2007;114(10):1842–1847.
17. Kanclerz P, Przewłócka K, Wang X. Inter-device measure-
ment variability of vital data parameters for keratorefrac-
tive and cataract refractive surgery. Ther Adv Ophthalmol.
2021;13:25158414211045750.
18. Chan TCY, Wan KH, Tang FY, Wang YM, Yu M, Cheung C.
Repeatability and agreement of a swept-source optical co-
herence tomography-based biometer IOLMaster 700 versus a
Scheimpflug imaging-based biometer AL-scan in cataract pa-
tients. Eye Contact Lens. 2020;46(1):35–45.
19. Ferrer-Blasco T, Esteve-Taboada JJ, Martínez-Albert N, Al-
fonso JF. Montés-Micó R. Agreement of white-to-white mea-
surements with the IOLMaster 700, Atlas 9000, and Sirius sys-
tems. Expert Rev Med Devices. 2018;15(6):453–459.
20. Salouti R, Nowroozzadeh MH, Zamani M, Ghoreyshi M, Sa-
louti R. Comparison of horizontal corneal diameter measure-
ments using Galilei, EyeSys and Orbscan II systems. Clin Exp
Optom. 2009;92(5):429–433.
21. Xia T, Martinez CE, Tsai LM. Update on intraocular lens
formulas and calculations. Asia Pac J Ophthalmol (Phila).
2020;9(3):186–193.

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