Review Intraocular Lenses

Effective Ocular Biometry and Intraocular

Lens Power Calculation
Magdalena Turczynowska,1 Katarzyna Koźlik-Nowakowska,2 Magdalena Gaca-Wysocka2 and Andrzej Grzybowski2,3
1. Department of Ophthalmology, Stefan Żeromski Specialist Municipal Hospital, Cracow, Poland; 2. Department of Ophthalmology, Poznan
City Hospital, Poland; 3. Department of Ophthalmology, University of Warmia and Mazury, Olsztyn, Poland

DOI: https://doi.org/10.17925/EOR.2016.10.02.94

S
ince the introduction of phacoemulsification, cataract surgery has evolved remarkably. The use of premium intraocular lenses (IOLs)
(aspheric, toric, multifocal), refractive lens exchange and patients after refractive surgery procedures require extremely precise
clinical measurements and IOL calculation formulas to achieve desired postoperative refraction. For many years, ultrasound biometry
has been the standard for measurement of ocular parameters. The introduction of optical biometry (fast and non-invasive) has replaced
ultrasound methods and is now considered as the clinical standard for ocular biometry. Recently, several modern optical instruments have
been commercially launched and there are new methods available, including the empirical, analytical, numerical or combined methods to
determine IOL power. The aim of this review is to present current techniques of ocular biometry and IOL power calculation formulas, which
will contribute to achieve highly accurate refractive outcomes.

Keywords Cataract surgery is currently the most frequently performed surgical technique worldwide. Since
Biometry, ocular biometry, optical biometry, the introduction of phacoemulsification by Kelman in 1967, surgical technology and construction of
optical biometry devices, intraocular lenses, implanted intraocular lenses (IOLs) have undergone considerable improvement. Small, sutureless
IOLs, IOL power calculation, IOL power incisions and the use of foldable intraocular lenses reduced the incidence of complications and
calculation formulas surgically induced astigmatism.1,2 Furthermore, the use of premium intraocular lenses (aspheric,
Disclosure: Magdalena Turczynowska, Katarzyna
toric, multifocal or a combination) allows the patient to become fully spectacle-independent.3
Koźlik-Nowakowska, Magdalena Gaca-Wysocka and The improvement of surgical treatment results in rising expectations of patients. The key issue is
Andrzej Grzybowski have nothing to disclose in relation
to this article. No funding was received in the publication
to achieve the desired refractive outcome. Essential for this purpose are precise measurements
of this article. This study involves a review of the literature of the eye and selection of the optimal IOL calculation formula. The aim of this article is to present
and did not involve any studies with human or animal
subjects performed by any of the authors.
current techniques of ocular biometry and IOL power calculation formulas, which will contribute
Authorship: All named authors meet the International
to achieve highly accurate refractive outcomes.
Committee of Medical Journal Editors (ICMJE) criteria
for authorship of this manuscript, take responsibility
for the integrity of the work as a whole, and have
Ocular biometry
given final approval to the version to be published. The first step to achieve satisfactory postoperative refractive outcome is accurate ocular
Open Access: This article is published under the biometry. Biometry enables the measurement of the various dimensions of the eye, including
Creative Commons Attribution Noncommercial License,
which permits any non-commercial use, distribution,
axial length (AL), anterior chamber depth (ACD), lens thickness (LT) or central corneal thickness
adaptation and reproduction provided the original (CCT). These values, together with the keratometry are essential for the IOL power calculation.
author(s) and source are given appropriate credit.
Precision of measurements is crucial, as a 0.1 mm error in AL results in a refractive error of
Received: 16 August 2016
about 0.27 diopter (D).4
Accepted: 18 September 2016
Citation: European Ophthalmic Review,
2016;10(2):94–100 Ultrasound biometry
Corresponding Author: Magdalena Turczynowska, For many years, the only way to measure the AL of the eye was with ultrasound biometry. This
Department of Ophthalmology, Stefan Żeromski Specialist technique measures the distance from the surface of the corneal apex to the internal limiting
Municipal Hospital in Kraków, os. Na Skarpie 66, 31-913
Kraków, Poland. E: [email protected] membrane (ILM). Good alignment along the ocular axis is important and that requires patient
cooperation (which can be difficult in children or patients with mental disorders). In cases where
a probe has direct contact with the cornea, there is a risk of a corneal damage or infection.
Therefore, a topical anaesthetic and proper disinfection of the probe are required. Occurring
inter-individual differences are highly dependent on the pressure exerted on the eye by
the ultrasound probe. High pressure results in corneal indentation and shortening of the AL.
Immersion ultrasound minimises the indentation of the cornea as it uses a saline-filled shell between
the probe and the eye. Clinical studies have shown that immersion biometry is more accurate and
more reliable than ultrasound biometry performed in contact mode.5–8 A limitation of ultrasound
biometry is low image resolution, as a consequence of using a long, low-resolution wavelength
(10 MHz) to measure small dimensions. In addition, differences in retinal thickness near the fovea
or the presence of other macular pathologies contribute to inconsistent measurements.9,10

Optical biometry
The introduction of optical biometry has steadily replaced ultrasound methods and is now
considered the clinical standard for ocular biometry. The results are comparable to those achieved

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 Effective Ocular Biometry and Intraocular Lens Power Calculation

Table 1: Currently available optical biometry devices and parameters they measure

AL-Scan Aladdin/Aladdin ARGOS Galilei G6 IOLMaster IOLMaster Lenstar LS 900 OA-2000 Pentacam
(Nidek) LT (Topcon) (Movu) (Ziemer) 500 (Zeiss) 700 (Zeiss) (Haag-Streit) (Tomey) AXL (Oculus)
Principle PCI OLCR SS-OCT OLCR PCI SS-OCT OLCR OLCR PCI
AL + + + + + + + + +
KM + + + + + + + + +
ACD + + + + + + + + +
WTW + + + + + + + + +
LT - -/+ + + - + + + -
CCT + -/+ + + - + + + +
PS + + + - - - + + -
ACD = anterior chamber depth; AL = axial length; CCT = central corneal thickness; KM = keratometry; LT = lens thickness; OLCR = optical low-coherence interferometry;
PCI = partial coherence interferometry; PS = pupil size; SS-OCT = swept source optical coherence tomography; WTW = white-to-white distance.

by immersion ultrasound biometry,11 but this new method is fast, easy surface. WTW and PS are obtained by analysing the image of the iris
to reproduce by different examiners, non-invasive and non-contact. and fitting the best circle with the lowest error square to the detected
Repeatability and reproducibility of measurements obtained using this edge. ACD and CCT are measured with an incorporated Scheimpflug
technique are high and the results are less dependent on operators’ camera with a 470 nm monochromatic light. The device was introduced
skills. However, it is difficult to obtain a measurement in the presence for clinical practice in Europe in 2012. Srivannaboon et al.20 compared
of a dense cataract or other opacities such as corneal scar and vitreous the repeatability and reproducibility of ocular biometry and IOL power
haemorrhage. Optical biometry measures the distance from the corneal obtained with AL-Scan and IOLMaster 500. AL-Scan provided excellent
surface to the retinal pigment epithelium (RPE). It may be associated repeatability and reproducibility for all measured parameters (AL, K,
with overestimation of measurements of about 0.15–0.5 mm.12 Optical ACD and WTW). Agreement with the IOLMaster 500 was good except
biometry can also be successfully performed in pseudophakic or silicone for the WTW. This can be caused by different algorithms used by these
oil-filled eyes. Furthermore, in high myopic eyes, due to the presence devices for edge detection around iris image. Furthermore, the light
of posterior staphyloma, it may give better results than conventional source used for WTW measurements is different: AL-Scan uses a green
ultrasound techniques for measuring the AL. light source (wavelength 525 nm) and IOLMaster uses an infrared light
source (wavelength 880 nm). Kaswin et al.21 evaluated the agreement in
Optical biometry devices AL, K, ACD measurements and IOL power calculations with AL-Scan and
New optical biometry devices provide measurements not only of AL IOLMaster 500. They reported excellent correlation in AL measurements
but also other important variables, such as: keratometry, ACD, LT, CCT, and K readings as well as good agreement in ACD measurements
pupil size (PS) or white-to-white distance (WTW). To measure the AL of between these two biometers. The IOL power calculations were also
the eye, currently available devices use different technologies. IOLMaster highly comparable between these devices.
500 (Carl Zeiss Meditec, Jena, Germany), AL-Scan (Nidek, Aichi, Japan)
and Pentacam AXL (Oculus, Menlo Park, California, US) use partial The Pentacam AXL device consists of a Scheimpflug camera which
coherence interferometry (PCI) technology. Lenstar LS 900 (Haag-Streit, rotates around the eye and a PCI-based optical biometer. It was
Koeniz, Switzerland), Aladdin (Topcon, Tokyo, Japan), Galilei G6 (Ziemer, introduced in autumn 2015. In addition to anterior segment tomography,
Port, Switzerland) and OA-2000 (Tomey GmbH, Nürnberg, Germany) ACD, CCT and WTW measurements, corneal topography, anterior and
use optical low-coherence interferometry (OLCR). Swept source OCT posterior corneal surface and spherical aberrations, it also has integrated
(ss-OCT), used by the IOLMaster 700 (Carl Zeiss Meditec, Jena, Germany) AL measurement. Calculation of toric IOLs is based on the total corneal
and ARGOS (Movu, Santa Clara, California, US) devices, is the newest refractive power and it takes into account the influence of the posterior
technology to be implemented in biometry. corneal surface. To our knowledge, no study has yet evaluated the
repeatability, reproducibility and accuracy of biometry measurements
The IOLMaster 500 was the first optical biometer and was introduced obtained using this device.
in autumn 1999. The device is based on the PCI principle and measures
AL using infrared light (λ=780 nm) of short coherence emitted by The Lenstar LS 900 biometer is based on OLCR. Using a 820 µm
semiconductor laser diode. Furthermore, it measures keratometry, superluminescent diode as light source, it allows the measurement of
analysing the anterior corneal curvature at six reference points at the AL, CCT, LT and ACD. The retinal thickness can also be determined
approximately 2.3 mm optical zone. The ACD is measured using slit-lamp from the scans, but this requires subjective alignment of a cursor. It also
illumination and is defined as a distance from the corneal epithelium and uses 950 µm light to assess by image analysis central corneal curvature
to the anterior lens surface. WTW is obtained by analysing the image of the using two rings of diameter 1.65 mm and 2.30 mm of 16 light spot each.
iris using an infrared light source (wavelength 880 nm). All measurements WTW and PS are obtained by fitting the best circle with the lowest error
are performed simultaneously. IOLMaster 500 is currently considered as square to the detected edge. Optional T-cone module complements
a gold-standard biometer.13–15 Its repeatability and reproducibility have this device with a Placido topography of the central 6 mm corneal zone.
been assessed in several studies.16–19 Several studies confirmed Lenstar’s repeatability, reproducibility and
agreement with other biometry devices. Generally, Lenstar provided
AL-Scan uses an 830 nm infrared laser diode for AL measurement with results that correlated very well with those of the IOLMaster. Excellent
PCI. It also measures keratometry (K) at 36 measurement points in two agreement has been shown between the AL measurements taken by
circles with diameters of 2.4 mm and 3.3 mm, reflected from the corneal Lenstar and IOLMaster,22–25 but only good22 or moderate24 agreement

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 Review Intraocular Lenses

between these two devices in ACD measurements. In some cases, small IOLMaster 700 is a biometry device based on swept-source OCT
but statistically significant differences in K and ACD measurements technology that enables full-eye length tomography, providing good
were reported.24 However, in a few studies, the AL measurements taken fixation control. It uses high-frequency 1,055 nm tunable laser source
by Lenstar were slightly higher than the IOLMaster measurements, for AL, LT, ACD and CCT measurements. Keratometry measurements
but the differences were not clinically significant.22,23 The Lenstar was are distance-independent. Light is projected onto the cornea at three
unable to take measurements due to lens opacities in a similar number zones (1.5, 2.5 and 3.5 mm). PS and WTW are obtained using an LED
of patients to the IOLMaster.23 light source. Furthermore, the device provides a 1.0 mm horizontal scan
of the retina to ensure that the measurements are on the visual axis by
Aladdin is an optical biometer based on OLCR with an 830 nm super using the presence of foveal pit.32 According to Srivannaboon et al.,32
luminescent diode and Placido topography system. It allows to perform the measurement speed of IOLMaster 700 was statistically significantly
eight measurements in one acquisition: AL, keratometry, corneal faster than IOLMaster 500 (p<0.05). In several studies, IOLMaster 700
topography, ACD, pupillometry, WTW, CCT and LT, although the last two showed very high repeatability and reproducibility and good agreement
parameters (measured by OLCR) are available only on the Aladdin LT. with IOLMaster 500 and Lenstar,32–34 although repeatability and
Pupillometry can be measured in three modes: dynamic, photopic and reproducibility of ACD measurements obtained by IOLMaster 700 were
mesopic. Corneal topography is based on the reflection of 24 Placido better than those from the IOLMaster 500.32 In addition, studies showed
disc rings with a diameter of 8.0 mm. Topography-based keratometry is that IOLMaster 700 penetrated the opaque media better and measured
obtained by analysing approximately 1,024 data points of four dedicated the AL with fewer dropouts compared with the Lenstar and IOLMaster 500
Placido rings whose diameters range between 2.4 mm and 3.4 mm. even in dense cataracts.32,34
Aladdin provides also Zernike analysis and keratoconus screening. In
several studies, Aladdin provided good agreement and repeatability Argos biometer uses a 1,060 nm wavelength and 20 nm bandwidth
compared with the IOLMaster. According to Huang et al.,28 repeatability swept-source technology to collect two-dimensional OCT data
and reproducibility for AL, ACD and K measurements was found to be of the full eye (SS-OCT). It measures AL, LT, ACD and CCT with
excellent. However, the precision of WTW measurements was lower in ss-OCT. Keratometry values are generated by illumination from a ring of
eyes with cataract. In addition, Aladdin is equipped with Placido-disc 16 infrared LEDs. In addition, the device measures PS by analysing the
corneal topographer and can provide information that is not available two-dimensional OCT image. Shammas et al.35 evaluated the repeatability
on the IOLMaster, such as corneal map and corneal asphericity, and reproducibility of the measurements obtained with the Argos
which were recently shown to influence the IOL power refractive biometer and compared them with the results obtained with the
prediction error.29 IOLMaster 500 and the Lenstar LS 900 biometers. The study showed
high repeatability and reproducibility of measurements obtained by
OA-2000 combines Placido-disc topography and OLCR biometry. It Argos biometer. AL measurements with the new SS-OCT biometer were
measures AL, CCT, LT and ACD using the OLCR technique. Corneal comparable to PCI and OLCR measurements, with a faster and higher
curvature is measured by Placido-disc topography with nine rings acquisition rate, even in the presence of a dense nuclear or posterior
each 256 points in a 5.5 mm zone projected onto the cornea. It also subcapsular cataract.
measures WTW and PS. Goebels et al.30 compared the OA-2000 device
with the Lenstar and IOLMaster. In this study, the OA-2000 biometer Optical measurements differ from measurements obtained by
generated the most accurate results that correlated very well with the ultrasound methods. Therefore, individual optimisation of constants
measurements obtained by Lenstar and IOLMaster. Excellent correlation is necessary. This can be achieved by thorough analysis of pre- and
among all three devices was shown for AL measurements. Although postoperative clinical data. In October 1999, an independent group of
three different techniques to achieve K values were used, the correlation scientists and users, working in the field of optical biometry founded
between the different devices was very high. For ACD measurements, the User Group for Laser Interference Biometry (ULIB). One of the
good correlation was found, with the highest correlation between OA- most important purposes of this group is the optimisation of lens
2000 and Lenstar devices (both use OLCR). The ACD values were highest constants for the IOL power calculation. The results of this optimisation
with the OA-2000 and lowest with the IOLMaster. All differences were are published on the ULIB website (http://ocusoft.de/ulib/index.htm).
statistically, but not clinically, significant. Optimised IOL constants are currently available for the IOLMaster
500 and 700, Lenstar LS 900, AL-Scan, Aladdin and recently also for
Galilei G6 combines OLCR optical biometry, dual-Scheimpflug imaging and Pentacam AXL.
Placido-disc topography measures AL, LT, ACD, CCT, corneal topography,
PS and WTW. In addition to biometry, Galilei G6 provides high-definition Intraocular lens power calculation formulas
pachymetry, total corneal wavefront, curvature and astigmatism data The original first-generation formulas are either theoretical, based on
of the anterior and posterior cornea – complete data required to plan an optical model of the eye and mathematical principles, such as the
cataract or refractive surgery. Shin et al.31 compared Galilei G6 with Binkhorst formula, published in 1975,36 or regression formulas, based on
Lenstar biometer. All parameters measured by the Galilei G6 were highly analysis of postoperative patient refractions, such as the SRK formula
repeatable. There were no statistically significant differences between K developed by Sanders, Retzlaff and Kraff in 1980.37
and ACD measurements obtained by these two devices, however, the
measurements for AL, LT and WTW were significantly different. The K, Binkhorst’s formula: D=1336 (4r-a)/(a-d) (4r-d)
AL, ACD, LT and WTW showed good correlations (all p<0.001), however,
the agreements of LT and WTW were not good between the two devices. D = power of IOL in aqueous humor; 1336 = index of refraction of vitreous
The IOL powers using the SRK/T, Holladay 1, Hoffer Q and Haigis formulas and aqueous; r = radius of curvature of the anterior surface of the cornea;
were compared – they did not show statistically significant differences (all a = axial length of the eye; d = distance between surface of the cornea
p>0.05), however, agreements between the IOL powers were not strong. and the IOL

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Table 2: Currently available optical biometry devices and incorporated intraocular lens power calculation formulas

AL-Scan Aladdin ARGOS Galilei G6 IOLMaster IOLMaster Lenstar LS 900 OA-2000 Pentacam AXL
(Nidek) (Topcon) (Movu) (Ziemer) 500 (Zeiss) 700 (Zeiss) (Haag-Streit) (Tomey) (Oculus)
First and Binkhorst SRK II SRK II SRK II
second SRK
generation SRK II
formulas:
Third HofferQ, HofferQ, HofferQ, HofferQ, HofferQ HofferQ, HofferQ, HofferQ, HofferQ,
generation Holladay1, Holladay1, Holladay1, Holladay1, Holladay1 SRK/T Holladay1, Holladay1, Holladay1,
formulas: SRK/T SRK/T SRK/T SRK/T SRK/T SRK/T SRK/T SRK/T
Fourth Haigis Haigis Haigis Haigis Haigis Haigis Haigis Haigis Haigis
generation Camellin- Camellin- Shammas Shammas Holladay2 Holladay2 Olsen Optimized, PotvinShammasHill
formulas: Calossi Calossi No-History No-History Haigis-L Barrett Universal II, OKULIX PotvinHill
Shammas PL Haigis-T Barrett True-K, Easy IOL SRK/T Double K
Barrett Toric Shammas PL, HofferQ Double K
Calculator SRK/T Double K Holladay1 Double K
Masket, Meridional analysis
Modified Masket, based on Total
Shammas No-History Cornea Refraktiv
OKULIX Power (TCRP)
Hill-RBF Calculator OKULIX
Phaco Optics®

SRK formula: P=A-2.5L-0.9K 1992 depends on personalised ACD, AL and K in order to calculate the
postoperative effective lens power.43 The Holladay1 formula, published in
P = power of lens for emmetropia; A = A-constant of the IOL; L = axial 1988, requires a surgeon factor, which is the distance between the iris
length; K = average keratometry and the IOL, where the distance between the cornea and iris plane is
calculated as the height of the corneal curve.44
Refractive outcomes after the use of first-generation formulas were quite
accurate for patients with average eye length, but often led to refractive The SRK/T formula introduced in 1990 requires an estimated ACD as a
errors in the case of very short or very long eyes.38 The SRK formula tends function of corneal curvature and AL with A-constant.45 A constant is a
to calculate stronger than optimal IOL power for long eyes and weaker theoretical value, which connects IOL power to AL and keratometry and
IOL power for short eyes. depends on many factors such as manufacturer, style and location of
the IOL. It is specific to the design of the IOL and its intended orientation
Further analysis of clinical data was necessary. It enabled the in the eye.
development of more precise SRK II formula (second-generation
formula) in 1988.39 This formula include a modified A constant, related Fourth-generation formulas have promulgated since the 1990s and
to the length of the eye: include the Haigis, Holladay2, Olsen and Barrett Universal II. These
require more variables for IOL power calculation. One thing they have
if AL<20 mm A1 = A + 3 in common is the need to predict the non-measurable, virtual factor –
21 mm>AL≥20 mm A1 = A + 2 effective lens position (ELP), not the anatomical one.
22 mm>AL ≥ 21 mm A1 = A + 1
The Haigis formula uses three constants: a0, a1 and a2 to calculate ELP,
24.5 mm>AL≥22 mm A1 = A
where:
24.5 mm>AL A1 = A – 0.5
d = a0 + (a1 × ACD) + (a2 × AL)
Despite this improvement, first- and second-generation formulas are
now considered to be obsolete and should be avoided in clinical practice. AL and anterior depth chamber, which are measured, rather than
Third- and fourth-generation formulas should be chosen instead. estimated, are required, in contrast to other formulas. The Haigis formula
for intraocular lens calculation requires corneal radii of curvature in
Third-generation formulas, including Hoffer Q, Holladay1 and the SRK/T, millimeters instead of keratometry in diopters.46
are a merger of the regression and theoretical formulas. They all use a
thin-lens model that treats IOLs as thin lenses with only one effective In Olsen’s formula, the ELP is predicted primarily through a concept called
lens plane. These formulas rely on two variables (AL and K) and can the C constant, where accurate, ray tracing-assisted measurements
be optimised by adjusting by a suitable factor – the ‘surgeon factor’ – of LT and ACD are combined in order to calculate ELP in the most
for the Holladay1 formula, the ACD-constant for the Hoffer Q formula effective way.47 The Holladay2 formula was proposed in 1993, when a
and the A-constant for SRK/T formula. Terzi et al.,40 Haigis41 as well as new theory about biometry using AL and anterior segment appeared.48
Petermeier et al.,42 have proven that the optimisation of lens constants This formula needs seven variables to calculate effective lens positon:
has made the IOL power calculation more accurate and has decreased AL, keratometry, WTW, preoperative refraction, ACD, LT and patient age,
the postoperative refractive error. The Hoffer Q formula developed in in order of importance.49

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Table 3: Classic intraocular lens power calculating formulas and variables they require

IOL Formula Generation: II III IV

SRK II SRK/T Holladay1 Hoffer Q Haigis Holladay2 Olsen Barrett Universal II
K + + + + Corneal radii [mm] + + +
AL + + + + + + + +
ACD + + + +
LT + + +
WTW + + +
Age +
Preoperative refraction +
ACD = anterior chamber depth; AL = axial length; K = keratometry; LT = lens thickness; WTW = white-to-white diameter.

Barrett Universal II is a thick lens formula, in which ELP is characterised There are also formulas designed exclusively for particular devices, for
by LF (lens factor) and anatomic chamber depth. The LF is influenced by: example, PotvinShammasHill and PotvinHill formulas. They use data from
keratometry, AL, ACD, LT and WTW, in order of importance. This formula the Pentacam device, specifically the true net power in a 4.0 mm zone
notifies the change in planes, which is connected with different IOL centered on the corneal apex, to calculate IOL power in post-myopic
powers. It recognises the negative value of lens factor in the presence of LASIK eyes (PotvinShammasHill formula) and after radial keratotomy
negative-powered type of IOL, which has to be taken into consideration (PotvinHill formula).56
when calculating the ELP.50
Recently, a new software using numerical ray tracing for IOL power
A major challenge is IOL power calculation in patients who have undergone calculation became available (e.g., Okulix, EasyIOL, PhcoOptics). The
refractive surgery, as it is difficult to measure the true corneal power accuracy of numerical ray tracing is independent of AL. Therefore, very
and estimate the ELP. After myopic refractive surgery (photorefractive long or very short eyes can gain the most from the higher accuracy of
keratectomy [PRK], LASIK, radial keratotomy [RK]), both keratometry and this approach. For average-size eyes, however, the results of ray-tracing
corneal topography tend to overestimate corneal power. This problem methods were as accurate as theoretical thin-lens formulas.57,58
can be remedied by double-K modifications of third-generation formulas:
SRK/T, Hoffer Q or Holladay1. Double-K methods use the preoperative K One of the most recent calculation methods was released in June 2016:
values for the ELP calculation and the postoperative K values for the IOL the Hill-RBF on-line calculator. It is an advanced, self-validating method
power determination.51 One of the drawbacks of these methods is ELP using artificial intelligence and pattern recognition to select an IOL for a
calculation dependence on the central corneal power. patient. The calculator is entirely data-driven and is independent of the
limitations of theoretical vergence formulas. It has been optimised for
Other formula used for IOL power prediction after LASIK or PRK is the use with the Lenstar LS 900, but may also be used with data from other
Masket method. This formula omits the double K step required by other optical biometers.59
pre-LASIK/PRK K-dependent methods and simply adjusts the power of
the IOL using the knowledge of the surgically induced refractive change. It has not been proven that any of the recent formulas are better than
It is particularly useful when corneal power before refractive surgery is the others, however, first and second generation formulas such as
unavailable, but the refractive change is known (even if uncertain).52 More SRK II should not be used any longer, as they have minimal theoretical
reliable methods of determining IOL power after refractive surgery do value.47 The new formulas are more precise than previous ones, but
not rely on historical data, which may be inaccurate or unavailable, for their advantage can be noticed clearly in IOL calculation of non-
example, Shammas no-history, Haigis-L and Camellin-Calossi. typical eyes.60 Modern IOL power calculations have similar outcomes
in eyes with average AL but they are less accurate in eyes with long
The Shammas no-history formula was first published in 2007. It is a or short AL.43
post-LASIK modification of a previously described formula, in which the
average corneal power, K, is replaced by the corrected mean corneal Apparently, there is no multipurpose formula for every type of eye, the
power, Kc and where Kc=1.14 Kpost-6.8, with Kpost being the post-LASIK use of a particular formula depends on several parameters, such as the
K-readings in diopters.53 eye’s AL, astigmatism, previous refractive surgery and differs in phakic
and pseudophakic eyes.51 According to Wang et al., the Haigis, Hoffer Q,
The Haigis-L formula, designed in 2008, using corneal radius measured Holladay1 and SRK/T formulas are equally accurate for calculating the IOL
in mm generates a corrected corneal radius, which is then used by the power in phakic eyes between 22 mm and 24.5 mm length.61
regular Haigis formula to calculate the IOL power.54
In a group of patients with AL below 22 mm, getting a precise
The Camellin-Calossi formula, first published in 2006, is one of the postoperative refraction is more difficult than amongst other patients,
most recent formulas used commonly for calculating IOL power in as short eyes usually need a high-power intraocular lens. In 2012, Day
eyes which have undergone refractive surgery. This formula is based on et al.62 showed that the Hoffer Q formula had the lowest absolute mean
modified Binkhorst II formula and empirically adjusts corneal power and error in eyes with AL from 20.00 to 20.99 mm and Hoffer Q and Holladay1
calculates ELP regardless of corneal keratometry (K). According to Suto formulas had made more accurate calculations than SRK/T formula. Carifi
et al., the Camellin-Calossi formula can be also used for calculating IOL et al.63 compared the refractive results among various formulas (Hoffer
in normal cataractous eyes and its accuracy is equivalent to common Q, Holladay1, Holladay2, Haigis, SRK-T and SRK-II) in patients undergoing
IOL formulas: SRK/T and Haigis.55 phacoemulsification cataract surgery with a single highly powerful IOL

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implanted in the capsular bag (range of powers +35.0 to +40.0 D). The calculation in patients with AL >26 mm using Haigis, HofferQ, SRK/T
study showed that none of the latest-generation formulas (Hofer Q, formulas, but it has been shown that SRK/T formula has the lowest
Haigis, Holladay1 and Holladay2) significantly outperformed the others mean error.68 Aristodemou et al.69 has also shown that the most suitable
(p=0.245). However, the SRK formulas yielded less accurate predictions formula for eyes longer than 27 mm is SRK/T. In 2015 it was shown
in these cases. The authors suggested that the SRK/T formula should not that Barrett Universal II, one of the most recent published formulas, is
been used in IOL power calculation in eyes with AL shorter than 22 mm. more accurate than other known formulas in long eyes with AL greater
Currently, the most recommended formulas for IOL power calculation for than 26 mm.70
short eyes are the third-generation formula Hoffer Q64,65,43 and the fourth-
generation formula Holladay2.66 According to the study conducted in 2014 Patients’ requirements concerning visual effect after cataract surgery are
by Eom et al.,43 the Hoffer Q and Haigis formulas are similarly accurate in rising. In order to increase the accuracy of IOL power calculation and
calculating IOL power in eyes with short AL, but the Haigis formula is more postoperative refractive outcome, an ideal calculation formula has been
precise in eyes with ACD <2.4 mm. Similar outcomes were presented by searched for for many years. A multipurpose formula, which can be used
Maclaren et al.67 in 2007, when they showed that the Haigis and Hoffer Q in every eye’s AL, is still to be found.
formulae performed well in eyes with long AL when using conventional
biometry methods and phacoemulsification. Conclusion
The latest biometry technologies and modern IOL power calculation
There are also difficulties in choosing the most appropriate IOL power formulas have significantly improved refractive outcomes after cataract
for patients with high myopia. The main problem is staphyloma, surgery. Well-calibrated devices, using optical rather than ultrasound
which makes the measurement of AL harder than usual, as well as biometry, optimised IOL constants and properly selected last-generation
restricted access to IOL power calculation formulas for those patients. IOL power calculation formulas that fit to a particular patient can provide
It was suggested that there are no significant differences in IOL power excellent refractive outcomes. q

1. George R, Rupauliha P, Sripriya AV, et al., Comparison of 21. Kaswin G, Rousseau A, Mgarrech M, et al., Biometry and for high myopia and high hyperopia, J Cataract Refract Surg,
endothelial cell loss and surgically induced astigmatism intraocular lens power calculation results with a new optical 2009;35:1181–9.
following conventional extracapsular cataract surgery, manual biometry device: comparison with the gold standard, J Cataract 41. Haigis W, Intraocular lens calculation in extreme myopia,
small-incision surgery and phacoemulsification, Ophthalmic Refract Surg, 2014;40:593–600. J Cataract Refract Surg, 2009;35:906–11.
Epidemiol, 2005;12:293–7. 22. Hoffer KJ, Shammas HJ, Savini G, Comparison of 2 laser 42. Petermeier K, Gekeler F, Messias A, et al., Intraocular lens
2. Zheng L, Merriam JC, Zaider M, Astigmatism and visual recovery instruments for measuring axial length, J Cataract Refract Surg, power calculation and optimized constants for highly myopic
after ‘large incision’ extracapsular cataract surgery and ‘small’ 2010;36:644–8 eyes, J Cataract Refract Surg, 2009;35:1575–81.
incisions for phacoemulsification, Trans Am Ophthalmol Soc, 23. Buckhurst PJ, Wolffsohn JS, Shah S, et al., A new optical low 43. Eom Y, Kang S, Song J, et al., Comparison of Hoffer Q and Haigis
1997;95:387–410. coherence reflectometry device for ocular biometry in cataract Formulae for Intraocular Lens Power Calculation According to
3. Javitt J, Steinert R, Cataract extraction with multifocal patients, Br J Ophthalmol, 2009;93:949–53 the Anterior Chamber Depth in Short Eyes, Am J Ophthalmol,
intraocular lens implantation: a multinational clinical trial 24. Holzer MP, Mamusa M, Auffarth GU, Accuracy of a new 2014;157:818–24.
evaluating clinical, functional and quality-of-life outcomes, partial coherence interferometry analyser for biometric 44. Ghanem A, El-Sayed H, Accuracy of intraocular lens
Ophthalmology, 2000;107:2040–8. measurements, Br J Ophthalmol, 2009;93:807–10 power calculation in high myopia, Oman J Ophthalmol,
4. Basic and Clinical Science Course, Section 3: Clinical Optics. 25. Rohrer K, Frueh BE, Wälti R, et al., Comparison and evaluation of 2010;3:126–30.
(2011-2012 ed.) American Academy of Ophthalmology. pp. ocular biometry using a new noncontact optical low-coherence 45. Retzlaff JA, Sanders DR, Kraff MC, Development of the SRK/T
211–223. reflectometer, Ophthalmology, 2009;116:2087–92 intraocular lens implant power calculation formula, J Cataract
5. Ossoinig KC, Standardized echography: basic principles, clinical 26. Mandal P, Berrow EJ, Naroo SA, et al., Validity and repeatability Refract Surg, 1990;16:333–40.
applications and results. Int Ophthalmol Clin, 1979;19:127–210. of the Aladdin ocular biometer, Br J Ophthalmol, 2014;98:256–8. 46. Haigis W, Challenges and approaches in modern biometry and
6. Schelenz J, Kammann J, Comparison of contact and immersion 27. Hoffer KJ, Shammas HJ, Savini G, Huang J, Multicenter study of IOL calculation, Saudi J Ophthalmol, 2012;26:7–12.
technique for axial length measurement and implant power optical low-coherence interferometry and partial-coherence 47. Hirnshall N, Findi O, Intraocular Lens Power Calculation - Still
calculation, J Cataract Refract Surg, 1989;15:425–8. interferometry optical biometers with patients from the United Searching for the Holy Grail, Eur Ophthalmic Rev, 2015;9;13–6
7. Shamma’s HJF, A comparison of immersion and contact States and China, J Cataract Refract Surg, 2016;42:62–7. 48. Trivedi RH, Wilson ME, Reardon W, Accuracy of the Holladay 2
techniques for axial length measurements, J Am Intraocul 28. Huang J, Savini G, Wu F, et al., Repeatability and reproducibility of intraocular lens formula for pediatric eyes in the absence of
Implant Soc, 1984;10:444–7. ocular biometry using a new noncontact optical low-coherence preoperative refraction, J Cataract Refract Surg, 37:1239–43.
8. Olsen T, Nielsen PJ, Immersion versus contact technique in the interferometer, J Cataract Refract Surg, 2015;41:2233–41. 49. Mahdavi S, Holladay J, IOLMaster 500 and integration of the
measurement of axial length by ultrasound, Acta Ophthalmol, 29. Savini G, Hoffer KJ, Barboni P, Influence of corneal asphericity Holladay2 Formula for intraocular lens calculations, Eur
1989;67:101–2. on the refractive outcome of intraocular lens implantation in Ophthalmic Rev, 2011;5:134–5
9. Lee AC, Qazi MA, Pepose JS, Biometry and intraocular lens cataract surgery, J Cataract Refract Surg, 2015;41:785–9. 50. Barrett G, A formula for all seasons. The Barrett Universal II
power calculation, Curr Opin Ophthalmol, 2008;19:13–7. 30. Goebels S, Pattmöller M, Eppig T, et al., Comparison of 3 and True K and the Barrett Toric Calculator provide the best
10. Frings A, Dulz S, Skevas C, et al.,Postoperative refractive error biometry devices in cataract patients, J Cataract Refract Surg, results for toric, post refractive and standard cataract patients,
after phacovitrectomy for epiretinal membrane with and 2015;41:2387–93. Supplement to: Cataract & Refractive Surgery Today Europe,
without macular oedema, Graefes Arch Clin Exp Ophthalmol, 31. Shin MC, Chung SY, Hwang HS, Han KE, Comparison of Two October 2014.
2015;253:1097–104. Optical Biometers, Optom Vis Sci, 2016;93:259–65. 51. Aramberri J, Intraocular lens power calculation after corneal
11. Haigis W, Lege B, Miller N, Schneider B, Comparison of 32. Srivannaboon S, Chirapapaisan C, Chonpimai P, Loket S, refractive surgery: double-K method, J Cataract Refract Surg,
immersion ultrasound biometry and partial coherence Clinical comparison of a new swept-source optical coherence 2003;29:2063–8.
interferometry for intraocular lens calculation according to tomography-based optical biometer and a time-domain optical 52. Masket S, Masket SE, Simple regression formula for intraocular
Haigis, Graefes Arch Clin Exp Ophthalmol, 2000;238:765–73. coherence tomography-based optical biometer, J Cataract lens power adjustment in eyes requiring cataract surgery
12. Grzybowski A, Gaca-Wysocka M, Current knowledge of the Refract Surg, 2015;41:2224–32. after excimer laser photoablation, J Cataract Refract Surg,
lens, Przegląd Okulistyczny, 2014:4:1–4. 33. Kunert KS, Peter M, Blum M, et al., Repeatability and agreement 2006;32:430–4.
13. Drexler W, Findl O, Menapace R, et al., Partial coherence in optical biometry of a new swept-source optical coherence 53. Shammas HJ, Shammas MC, No-history method of intraocular
interferometry: a novel approach to biometry in cataract tomography-based biometer versus partial coherence lens power calculation for cataract surgery after myopic laser
surgery, Am J Ophthalmol, 1998;126:524–34. interferometry and optical low-coherence reflectometry, J in situ keratomileusis, J Cataract Refract Surg, 2007;33:31–6.
14. Packer M, Fine IH, Hoffman RS, Immersion A-scan compared Cataract Refract Surg, 2016;42:76–83. 54. Haigis W, Intraocular lens calculation after refractive surgery
with partial coherence interferometry: outcomes analysis, J 34. Kurian M, Negalur N, Das S, et al., Biometry with a new swept- for myopia: Haigis-L formula, J Cataract Refract Surg,
Cataract Refract Surg, 2002 Feb;28:239–42. source optical coherence tomography biometer: Repeatability 2008;34:1658–63.
15. Bhatt AB, Schefler AC, Feuer WJ, et al., Comparison of and agreement with an optical low-coherence reflectometry 55. Suto C, Shimamura E, Watanabe I, Comparison of 2 optical
predictions made by the intraocular lens master and ultrasound device, J Cataract Refract Surg, 2016;42:577–81. biometers and evaluation of the Camellin-Calossi Intraocular
biometry, Arch Ophthalmol, 2008;126:929–33. 35. Shammas HJ, Ortiz S, Shammas MC, et al., Biometry lens formula for normal cataractous eyes, J Cataract Refract
16. Kielhorn I, Rajan MS, Tesha PM, et al., Clinical assessment measurements using a new large-coherence-length swept- Surg, 2015;41:2366–72.
of the Zeiss IOLMaster, J Cataract Refract Surg, source optical coherence tomographer, J Cataract Refract Surg, 56. Potvin R, Hill W, New algorithm for intraocular lens power
2003;29:518–22. 2016;42:50–61 calculations after myopic laser in situ keratomileusis based
17. Lam AK, Chan R, Pang PC, The repeatability and accuracy of 36. Binkhorst RD, The optical design of intraocular lens implants, on rotating Scheimpflug camera data, J Cataract Refract Surg,
axial length and anterior chamber depth measurements from Ophthalmic Surg, 1975;6:17–31. 2015;41:339–47.
the IOLMaster™, Ophthalmic Physiol Opt, 2001;21 477–83. 37. Sanders DR, Kraff MC, Improvement of intraocular lens power 57. Preussner PR, Wahl J, Lahdo H, et al., Ray tracing for intraocular
18. Sheng H, Bottjer CA, Bullimore MA, Ocular component calculation using empirical data, J Am Intraocul Implant Soc, lens calculation, J Cataract Refract Surg, 2002;28:1412–9.
measurement using the Zeiss IOLMaster, Optom Vis Sci, 1980;6:263–7. 58. Jin H, Rabsilber T, Ehmer A, et al., Comparison of ray-tracing
2004;81:27–34. 38. Holladay JT, Prager TC, Chandler TY, et al., A three-part system method and thin-lens formula in intraocular lens power
19. Santodomingo-Rubido J, Mallen EA, Gilmartin B, Wolffsohn JS, for refining intraocular lens power calculations, J Cataract calculations, J Cataract Refract Surg, 2009;35:650–62.
A new non-contact optical device for ocular biometry, Br J Refract Surg, 1988;14:17–24. 59. Hill-RBF Calculator, IOL Power Calculations for Cataract
Ophthalmol, 2002;86:458–62. 39. Sanders DR, Retzlaff J, Kraff MC, Comparison of the SRK II Surgery. Available at: www.rbfcalculator.com (accessed 15
20. Srivannaboon S, Chirapapaisan C, Chonpimai P, Koodkaew S, formula and other second generation formulas, J Cataract September 2016).
Comparison of ocular biometry and intraocular lens power Refract Surg, 1988;14:136–41. 60. Section 03: Clinical optics. In: Basic and clinical science (Polish
using a new biometer and a standard biometer, J Cataract 40. Terzi E, Wang L, Kohnen T, Accuracy of modern intraocular edition), Poland: Elsevier Urban & Partner 2008-2009 pg
Refract Surg, 2014;40:709–15. lens power calculation formulas in refractive lens exchange 236–238, 325,328, 329.

EUROPEA N OPH THALMIC RE VIE W 99

Grzybowski FINAL.indd 99 17/01/2017 16:54

 Review Intraocular Lenses

61. Wang J, Chang S, Optical biometry intraocular lens power regression formulas, J Cataract Refract Surg, 1993;19;700–712; 68. El-Nafees R, Moawad A, Kishk H, Gaafar W, Intra-ocular
calculation using different formulas in patients with different errata 1994;20;1677. lens power calculation in patients with high axial
axial lengths, Int J Ophthalmol, 2013;6:150–4. 65. Olsen T, Calculation of intraocular lens power: a review, Acta myopia before cataract surgery, Saudi J Ophthalmol,
62. Day A, Foster P, Stevens J, Accuracy of intraocular lens Ophthalmol Scand, 2007;85:472–85. 2010;24:77–80.
power calculation in eyes with axial length <22.00 mm, Clin 66. Hoffer KJ, Clinical results using the Holladay 2 intraocular 69. Aristodemou P, Knox Cartwright NE, Sparrow JM, Johnston RL,
Experiment Ophthalmol, 2012;40:855–62. lens power formula, J Cataract Refract Surg, Formula choice: Hoffer Q, Holladay 1, or SRK/T and refractive
63. Carifi G, Aiello F, Zygoura V, et al., Accuracy of the refractive 2000;26:1233–7. outcomes in 8108 eyes after cataract surgery with biometry
prediction determined by multiple currently available 67. Maclaren R, Natkunarajah M, Riaz Y et al., Biometry and by partial coherence interferometry, J Cataract Refract Surg,
intraocular lens power calculation formulas in small eyes, Am J Formula Accuracy With Intraocular Lenses Used for Cataract 2011;37:63–71.
Ophthalmol, 2015;159:577–83. Surgery in Extreme Hyperopia, Am J Ophthalmol, 2007;143: 70. Chong EW, Mehta JS, High myopia and cataract surgery, Curr
64. Hoffer KJ, The Hofer Q formula: a comparison of theoretic and 920–31. Opin Ophthalmol, 2016;27:45–50.

100 EUR OP EAN OPH TH A LMIC RE VIE W

Grzybowski FINAL.indd 100 17/01/2017 16:54