Clinical Application

IOL Calculation
Eye Cubed Sales Training 2012
Points for discussion
IOL – What & why
Modern IOL formulas
History & characteristics
Eye types & recommended formulas
Eye Cubed IOL formulas
Ingredients for IOL calculation
Sources of error in IOL calculation
Conclusion
IOL characteristics
3 Main locations in the eye
• Anterior Chamber
• Iris Plane
• Posterior Chamber

Manufactured in variety of sizes and configurations

2 Components
• Optic – Transmits light to retina
• Haptic – Fasteners to secure optic
What is an intra-ocular lens (IOL)?
Intra-ocular lenses, or IOLs, are the artificial
lenses that replace the eye's natural lens that is
removed during cataract surgery

IOLs have been around since the mid-1960s

The first FDA (US) approval for one occurred

in 1981
Lens implants
Lens implants replace focusing power of the natural lens
Why lens implants?
Crystalline lens provides 1/3 of the optical
power of the eye

The cornea provides about 2/3

Lens is removed with cataract surgery

Lens
Why lens implants?
Aphakia (absence of a lens) results in significant hyperopia (+8 to
+12)

Without lens implant, patient must wear contact lens or aphakic

spectacles
Measurements
Used to determine:
• Focal length of the eye
• Power provided by the cornea
• Location of implanted lens
- Effective lens position (ELP)
What size of lens do we need?

Doctor knows a lens is needed,

but what size, power and position
(ELP).

Axial length measurements in

conjunction with formula will
give the doctor this information.
Modern IOL formulas
“Third and Fourth Generation”
• Holladay-1
• Holladay-2
• Hoffer-Q
• Haigis
• SRK-T
Formulas: Holladay I
Produced by Jack Holladay MD in 1988

Uses Axial Length and Keratometry to determine ELP

Works best for eyes between 24.5 to 26mm (medium long)

Formulas: Holladay I

Takes into account AC depth, lens thickness, and corneal radius

Useful for axial myopia and high corneal curvature (>45 D)

Formulas: Holladay II
Uses seven variables to predict lens position and is derived from
myopic and hyperopic eyes from 35 surgeons (30,000 cases)

In addition to Axial Length and Keratometry – used in Holladay I,

also must measure horizontal “white to white”, corneal diameter,
ACD, lens thickness, refraction and age of patient.
Formulas: Holladay II
Most accurate for eyes with an axial length between 22 and 26mm

Calculations for piggyback IOLs, post-refractive surgery patients, and

personal constants for the surgeon

Available in Holladay IOL software, requires the pre-op refraction, the

anterior chamber depth, the lens thickness, and the "horizontal white-to-
white" as well as the K's and axial length

The software costs $1800 and can be ordered on internet

Formulas: Hoffer Q
Created by Kenneth J Hoffer, MD – UCLA

Studies showed that the Hoffer Q formula is more accurate in eyes

less than 22mm (short)

Also good for average length eyes

Formulas: Haigis formula
IOL power based on three variable functions

•A constant

•effective lens position

•geometry lens

Can be adjusted for each surgeon/IOL combination

! The Haigis formula should be only used on Pseudophakic eyes in

the process of an IOL exchange
Formulas: SRK T
Most commonly used formula

Good for axial lengths between 22-24 mm

Ideal for long eyes > 25 mm

Formulas: SRK
PLENS = ACONST - .9 x KAVG – 2.5 x ALENGTH
• PLENS: Power of lens implant to use
• ACONST: A constant of lens implant used
• KAVG: Average keratometric readings
• ALENGTH: Axial length
IOL formulae

SRK2 (mal practice) replaced by SRK T

 Review: Eye types & recommended formulas
by the British Royal College of Ophthalmology
Formula accuracy based on eye length

Short ≤22.0mm Hoffer Q or Holladay II

Average 22.1mm – 24.4mm HofferQ, Holladay I or SRKT

Med Long 24.5mm – 25.9mm Holladay I

Long ≥26.0mm SRKT or Holladay II

Eye Cubed

Built-in IOL power calculations:

• Holladay I
• SRK T
• Hoffer Q
• Haigis (included in the price,
available on request)
Ingredients for IOL calculation
(depending on formula)

Keratometry (input into Eye Cubed)

Axial length (accurately measured by Eye Cubed)

Lens thickness (accurately measured by Eye Cubed)

Anterior chamber depth-ACD (accurately measured by Eye Cubed)

Corneal diameter
What is Keratometry?
Used to measure the radius of curvature on the anterior corneal surface

Performed in conjunction with A-scan biometry to calculate the IOL power for
cataract surgery

K readings should be obtained PRIOR

to AEL measurement

Machine should be calibrated frequently

Patient should not be wearing contact

lenses
Corneal power
Measured in diopters of power

Cornea typically provides 2/3 of refractive power of the eye

Example: 43.5/45.3 @ 125º

Formulas use only average power

Measured by
• Manual Keratometer
• Automated Keratometer
• Topography (simulated K’s)
Axial length
Can be measured with
• Contact ultrasound Axial Length
- Accuracy +/- 0.25 mm
• Immersion ultrasound
- Accuracy +/- 0.01 mm
• Laser interferometer (IOL master)
• Accuracy +/- 0.02 mm
Axial length
Distance from corneal surface to retinal surface

Measured in mm

Normal range: 22 to 25 mm

Increased in myopia

Decreased in hyperopia
Other measurements
Used by 4th Generation Formulas
• Anterior chamber depth
• Corneal diameter
• Lens thickness
Anterior chamber depth
Distance from surface of the cornea to anterior lens surface

Measured in mm

Helps determine ELP

Measured by
• Ultrasound
• IOL master
Corneal diameter
Horizontal distance from limbus to limbus in mm

“White to White” (WTW)

Avg. adult corneal dia: 11.71 +/- 0.42

Lens thickness
Distance between ant/post capsules

Measured with Ultrasound

• Helps to determine ELP expected lens
position

Lens Thickness
Emmetropia and ammetropia
Emmetropia (plano) is not always the desired after cataract surgery.
Some people want to be nearsighted or farsighted in one or both eyes.

Most IOL calculators will give you the IOL power needed for an
ammetropic result of up to 0.5 D.

Notice that there is not a one-to-one relationship between IOL power

and the refractive result.
Problem with the 3rd generation
formulas
SRK-T ; Holladay ; Hoffer-Q
Before doing the the IOL calculation, these formulas calculate the effective
lens position from the Keratometry.
Refractive surgery changes the K and the AC
Post refractive biometry

Change in corneal curvature between corneal epithelium and

endothelium results in inaccuracies in corneal plane

Use of conventional formulae results in axial hyperopia by 1-4 D

IOL master
Advantages:
• Multiple measurements with same device
• Much easier than immersion U/S for the in-experienced tech.

Disadvantages:
• Ease may belie importance
• Cannot read through many cataracts
Accuracy
Accuracy critical for multifocal accommodative IOLs

Additional cost/ high expectations

Can’t they just wear glasses?
Refractive errors after cataract surgery are the most common reason
for lawsuits against ophthalmologists

Patients who pay up to 2,500 US$ for one advanced technology IOL
expect perfect vision
Importance of back calculations
Refine surgeon’s factor
• Technique vs formula
• Aggressive vs passive
• Speed vs precision
• Phaco vs I&A

Trends
• Specific IOL results
• Adjust A-constants for surgeon
Today’s challenges
New IOL designs
• Multifocals
• Torics
• Accomodative
• Custom

Post-refractive surgery
• RK « nightmare »
• Lasik
• K’s vs topography
• The Berkeley challenge
Holladay IOL Consultant-
Surgical Outcome Assessment Program

Freestanding program

Only available through Dr Holladay’s website

Ideal complement to accurate measurements

Quality Input = Quality Output
Trained monkey vs trained staff

Ellex training and continuing education

• Courses
• Individual sessions
• Education center on ellex.com

Pick up the phone!

Thank you