Axial Length Measurement

( Biometry )

Dr. Tesfaye Haileselassie

IOL Power Calculation

1. Keratometry
2. A-Scan Biometry
3. IOL Formula
 A-Scan Biometry

Measurement of Axial Eye Length

by Ultrasound
 Average Axial Length of
Normal Eye
23.06 mm

Majority 22.0 to 24.5 mm

Accuracy of AL measurement
using A-scan ultrasound is
+ 0.1 mm
Difference in AL measurement
Between both eyes
+ 0.3 mm
Instrumentation
Examination Procedure

1. History Taking
2. Patient Preparation
3. Biometry Technique
 Biometry Technique

 Contact
- Applanation Method
- Hand-Held Method

 Immersion
 Values are 0.14 to 0.36 mm
longer with immersion technique
than with contact method
 Potential Sources of Error
with Contact Method

[Link] Compression
2. Fluid Excess
3. Misalignment of Sound Beam
4. Inappropriate Eye type
 Error caused by
1 mm Corneal Compression

Average eye 2.5 D

Long eye 1.75 D
Short eye 3.75 D
Potential Sources of Error
with Immersion Method

1. Air bubbles within fluid

2. Inappropriate eye type
 Instrument Setting

1. Measurement Mode
2. Gates
3. Gain
4. Eye Type
Measurement Mode

 Automatic
 Semiautomatic
 Manual
 Gates

Gates are electronic markers on the

screen that provide measurement of
distance between 2 or more anatomic
interfaces .
 Gain Setting

Initially high gain setting should be

used to assess the overall appearance
of the echogram , then gain should
be reduced to a medium level to
improve resolution of spikes .
 Error can occur when the gain
is set too high or too low .

Very high gain short reading

Very low gain long reading
 Eye Type
( Sound Velocity )

1. Phakic
2. Aphakic
3. Pseudophakic
Use of average sound velocity ,although
sufficient in normal phakic eye , may
result in slight error when the lens is
inordinately thin or thick or when the
eye is very short or very long .
The use of individual sound velocity
may provide more consistent and
accurate AL reading .
 Aphakia & Pseudophakia

Manual measurement mode is

better to help ensure alignment
of sound beam .
If an incorrect eye type is used
an erroneous measurement will
occur .
For determination of correct value
Velocity Conversion Equation
should be used .
 Velocity Conversion Equation

True AL = V c /Vm x Apparent AL

 Biometry
in
Special Cases
[Link] Patient Fixation

 Low Vision
 Nystagmus
 Blepharospasm
 Strabismus
2. Posterior Staphyloma

Posterior staphylomas often causes

an irregular shape of the ocular wall
resulting in an inability to display a
distinct , high retinal spike , leading
to a significant error in A-scan
measurement .
Deepest portion of the staphyloma
may be located eccentric to macula
thus te measurement may be longer
than true AL along the visual axis .
B-scan can be used to demonstrate
the shape of posterior ocular wall
and the relationship of macula to
the staphyloma .
Probes with fixation light
are preferable
3. High Hyperopia

Immersion technique
is preferable .
4. Macular Lesions
 RD
 Edema
 DMS
 Tumor
The presence of an elevated macular
lesion may prevent the display of a
distinct retinal spike and often causes
a shortened AL measurement .
5. Vitreous Lesions

 Asteroid Hyalosis
 Vitreous Hemorrhage
 Gas Bubble
6. Dense Cataract

Strong sound attenuation produced

by a very dense cataract can
significantly impair the ability to
display spikes from the various
interfaces along the visual axis .
 Maximum gain setting may be
required to obtain spikes of
sufficient height from the
posterior lens capsule and retina .
Semiautomatic mode should be
used in eyes with dense cataract
7. Silicone Oil

Sound velocity in silicone oil

1040 m/s 5000 cs
980 m/s 1000cs
This low sound velocity can result
in pronounced sound attenuation
and difficulty in identifying the
retinal spikes .
If proper sound velocity are not
used , erroneously long AL
measurement will be obtained .
For accurate AL measurement ,
various ocular components should
be measured separately with
appropriate sound velocity .
If biometer provides only preset
sound velocity , AL measurement
can be obtained using velocity
conversion equation .
The least preferred method is
use of average sound velocity

Average sound velocity in eyes with

average length (23.5 mm)

1,139 m/s phakic eye

1,052 m/s aphakic eye
Due to strong sound attenuation
AL measurement often can not be
obtained from an eye containing
emulsified silicone oil .
IOL Master
 Zeiss IOL Master

 Axial Length
 ACD
 Corneal Power
 IOL Power Calculation
Hoffer-Q , SRK/T ,Holladay 1, Haigis
Keratometry

A second person should confirm measurements prior to A-scan

ultrasonography if: The corneal power is less than 40.0 diopters, or
greater than 47.0 diopters.

If there has been prior keratorefractive surgery. In this case the corneal
power will need to be estimated by either the historical, or the contact
lens method.

The average corneal power difference between the two eyes is greater
than 1.00 diopter.

The patient cannot fixate, as seen with a mature cataract, or macular hole.

The amount of corneal astigmatism by keratometry, or topography,

correlates poorly with the amount of astigmatism on the most recent
manifest refraction.

The corneal diameter is less than 11.00 mm.

There is any problem with patient cooperation, or understanding.

Immersion A-scan Ultrasonography

A second person should re-measure both eyes if: The axial length is less
than 22.00 mm, or greater than 25.00 mm in either eye.

The axial length is greater than 26.0 mm, and there is a poor retinal spike,
or wide variability in the readings.
There is a difference in axial length between the two eyes of greater than
0.33 mm that cannot be correlated with the patient's oldest refraction.

Axial length measurements do not correlate with the patient's refractive

error. In general, myopes should have eyes longer than 24.0 mm and
hyperopes should have eyes shorter than 24.0 mm. Exceptions to this rule
involve steep, or flat corneas. Be sure to use the oldest refractive data.

There is difficulty obtaining correctly positioned, high, steeply rising

echoes, or wide variability in individual axial length readings for either
eye.
There is a difference in axial length between the two eyes of greater
than 0.33 mm that cannot be correlated with the patient's oldest refraction.

Axial length measurements do not correlate with the patient's refractive error.
In general, myopes should have eyes longer than 24.0 mm and hyperopes
should have eyes shorter than 24.0 mm. Exceptions to this rule involve steep,
or flat corneas. Be sure to use the oldest refractive data.

There is difficulty obtaining correctly positioned, high, steeply rising echoes,

or wide variability in individual axial length readings for either eye.
Intraocular Lens Power

A second person should repeat the axial length measurements, keratometry

readings and re-run the IOL power calculations for both eyes if: The IOL
power for emmetropia is greater than 3.00 diopters different than
anticipated.

There is a difference in IOL power of greater than 1.00 diopter between the
two eyes.

If the patient has had prior keratorefractive surgery and the calculated IOL
power for standard phacoemulsification is less than +20.0 D or greater than
+23.0 D.
 Formula
for
IOL Power Calculation
IOL Power Formula

 Theoretical
 Regression
 Refractive
Theoretical Formulas

These are derived from

geometrical optics
 Regression Formulas

Actual postop refractive results

of many lens implantations are
used to predict IOL power
 Theoretical Formula

These formulas contain many

assumptions including values of
postop ACD , refractive index of
cornea and ocular humors , retinal
thickness
 Theoretical Formula

These formulas are reliable for

average AL , but overestimates
in short eyes and underestimates
in long eyes
 Refractive Formulas

IOL power calculation without

determination of axial length
 SRK I
(Sanders,Retzlaff,Kraff)

P = A – 2.5L – 0.9K

It generally undercorrects short eyes

and overcorrects long eyes
 SRK II

A1 = A + 3 AL < 20mm
A1 = A + 2 AL 20-21
A1 = A + 1 AL 21-22
A1 = A AL 22-24.5
A1 = A – 0.5 AL >24.5
 SRK/T

It is a nonlinear theoretical optical

formula empirically optimized for
postop ACD , retinal thickness ,
corneal refractive index .
It combines advantages of theoretical
and regression formulas .
 Generations of IOL Formulas

1st Generation
Fyodorov , Colenbrander ,Hoffer , SRK I
2nd Generation
Binkhorst , SRK II
3rd Generation
Holladay 1 , Hoffer-Q , SRK/T
4th Generation
Holladay 2 , Haigis
There are currently three IOL constants in use: The
SRK/T formula uses an "A-constant."

The Holladay 1 formula uses a "Surgeon Factor."

The Holladay 2 formula, and the Hoffer Q formula,

both use an "Anterior Chamber Depth." aka: ACD.
 Haigis Formula

d = the effective lens position, where ...

d = a0 + (a1 * ACD) + (a2 * AL)

* The a0 constant basically moves the curve up,
or down, in much the same way that the A-
constant, Surgeon Factor, or ACD does for the
Holladay 1, Holladay 2, Hoffer Q and SRK/T
formulas.

* The a1 constant is tied to the measured

anterior chamber depth.

* The a2 constant is tied to the measured axial

length. The way the a0, a1 and a2 constants are
derived is by generating a set of surgeon, and
IOL-specific
Formula Choice
AL < 19 mm (<0.1%)
Holladay 2
AL 19-22 mm (8%)
Holladay 2 , Hoffer-Q

AL 22-24.5 mm (72%)
SRK II , Hoffer-Q ,Holladay 1

AL 24.5-26 mm (15%)
Holladay 1 , Hoffer-Q
AL > 26 mm ( 15%)
SRK/T
Axial Length in mm Haigis Hoffer Q Holladay 1 Holladay 2 SRK/T
unoptimized

20.00 to 21.99 0.25 D 0.25 D 0.25 - 0.50 D 0.25 D 0.51 - 1.0 D

22.00 to 24.49 0.25 D 0.25 D 0.25 D 0.25 D 0.25 D

24.50 to 25.99 0.25 D 0.25 D 0.25 D 0.25 D 0.25 D

26.00 to 28.00 0.25 - 0.50 D 0.25 - 0.50 D 0.25 D 0.25 D 0.25 D

28.00 to 30.00 0.25 - 0.50 D 0.25 - 0.50 D 0.25 D 0.25 D 0.25 - 0.50 D

Minus power IOLs 0.51 - 1.0 D 0.51 - 1.0 D 0.25 - 0.50 D 0.25 D 0.25 - 0.50 D
 Haigis formula
may be appropriate for all
ranges of axial lengths