Biometry

Maj Farah Hossaini Kabir

Eye specialist
CMH Dhaka
 Definition

 Biometry is the method of determining

ideal intraocular lens power by measuring
two ocular parameters, keratometry and
axial (antero-posterior) length of the eye.
 History
1967-Fyodorov described the first ultrasonic
measurement of axial length.

Binkhorst, Coalenbrander added formulae of

calculation of AL, keratometry reading.

1982-regression method by Sanders, Retzlaff and

Krauff (SRK formulae)
Components of Biometry

Keratometry

Axial length
 Keratometry

• Keratometry involves determination of the

curvature of the anterior corneal surface
(flattest & steepest meridian), expressed in
diopters or in millimeters of radius of
curvature
 Tools for keratometry

Corneal
Manual Auto Topograph
keratometer keratometer y-
Pentacam
 Methods of measurement of AL

APPLANATION
ULTRASONIC

IMMERSION
AL
measureme
nt
IOL master

OPTICAL
Lenstar
 Tools for AL measurement

Optical-
Contact A Immersion Optical- IOL Lenstar
scan A scan Master
 A scan biometry

 Measurement of Axial eye length by ultrasound.

The sound beam must be aligned with the visual axis
for maximal precision.

Each reflecting surface is represented by a spike on

an oscilloscope display monitor.
Applanation Technique
Immersion technique
Immersion technique contd
IOL Power Formula

Theoretical

Regression

Refractive
 Generation

1st 2nd 3rd 4th

• Theoreti • SRK II • SRK/T • Hollada
cal- y II
Binkhors • Modifie • Hoffer
t d Q • Haigis
Binkhor
• Regressi st • Hollada • Olsen
on- SRK yI
Newer IOL calculation formulas
Barrett universal II formula
Olsen formula
Hill-RBF formula

These formula are still not widely available

in the IOL master or other biometry
software except Heig streit Lenstar
 SRK formula
SRK (1st SRK II (2nd generation)
generation)
P = A – 0.9K – P = A1 – 0.9K – 2.5L
2.5L
A constant Axial
length
A1 = (A – 0.5) 24.5mm
A1 = (A) 22 -
A1 = (A + 1) 24.5mm
A1 = (A + 2) 21 -22mm
A1 = (A + 3) 20 -21mm
<20 mm
IOL formula depending on AL
Circumstance Choice of
AL<20mm formula
Holaday II /HofferQ
20-22mm
22-24.5mm
Hoffer Q
24.5-26mm
SRK T, Holladay
>26mm
Holladay I
Haigis, Holladay II
Biometry in specific
situation
 Situations are challenging
• High myopic/hyperopic eye
• Paediatric eye
• Post vitrectomized eye
• Silicon oil filled eye
• Post refractive surgery status
• Eyes with corneal ectasia
• Aphakic eye
• Biometry for toric IOL
 High Myopic eyes
Low scleral rigidity
Posterior staphyloma
Accurate axial measurement is
critical.
Ultrasonic measurement in posterior
staphyloma give a refractive surprise
 High Myopic eyes contd

 Immersion or optical biometry (IOL Master 700) is the

options.

 Probe with fixation target can be used

 Addition of ACD and LT from A-scan to vitreous length
from B scan will give total axial length.

 Should aim for -0.50D to -1.00D postoperative refraction

as most elderly will prefer being near-sighted.
 High Hypermetropia
Issues-
 Corneal compression.
 Relative short ocular dimensions.
 Error from IOL formula

What to do?
 Immersion/ Optical biometry technique of choice
 Hoffer Q formula
 Optimization in Haigis formula
 Paediatric eyes
 Paediatric eye is not a miniaturized adult eye.

 It has shorter axial length, steeper cornea with higher

keratometry value and smaller anterior chamber depth.

 Errors in axial length measurement affect IOL power

calculation the most, it increases to 3.75 D per mm in

children.
 Paediatric eyes contd
Holladay II or HofferQ may be recommended for
paediatric IOL power calculation.

Simple rule of thumb- Target

refraction=7- age in years

20% under correction if the child is less than

age 2 years

15% under correction for age 2–5years .

 Paediatric eyes contd

Both eye must be measured.

AL and K reading must be taken
under G/A.
 Silicon filed eyes
 Refractive index of the oil is much less than
that of vitreous.
 Sound travels slower through Silicone oil.
 This low sound velocity makes axial length
becomes erroneously long.
 Difficulty of measuring AL can overcome by
increasing the system gain.
 Silicone filled eyes contd

Ultrasonic Measurement
• Axial length in sitting position.
• Application of correction factors.

Optical Measurement
• ‘Silicone filled eye’ mode should be selected.
 Biometry in post-refractive case
Basic concepts of Refractive surgeries:
 Ablative keratorefractive surgery flattens
anterior corneal radius but leaves
posterior corneal radius mostly
unchanged.
 The true corneal power following PRK
and LASIK is difficult to measure by
keratometry or corneal topography.
Biometry in post-refractive case contd

Contribution of IOL power errors:

 Inaccurate measurement/ calculation of
corneal power
 Incorrect estimation of ELP

Myopic-LASIK: underestimation of the IOL

power
Hyperopic-LASIK: overestimation of the
IOL power
 Post refractive cases
Methods relying on historical data:
 Clinical history method • Aramberri double K
 Feiz Mannis method modifications
 Corneal Bypass method • Masket formula
• Latkany formula
 Post kerato refractive online calculators
 Keratoconus
 Using K reading of such eyes will yield an
overestimated reading due to ELP
calculation error.

 Hoffer Q formula- K reading has less of

this effect .
 Haigis formula- Overestimation is not a
factor, since it does not use the k reading in
estimating the lens power.
 Aphakic eyes
Medium Sound velocity
(m/sec)
Cornea 1,641
Aqueous/ Vitreous 1,532
Crystalline lens 1,550 (average)
Solid tissue 1,550
Silicone oil:
1000 cs 980
5000 cs 1,040
Sound travel at uniform speed
1532m/sec
 Aphakic eyes
 Two lens spikes are replaced by single spike-anterior
vitreous face and posterior lens capsule.
 Immersion technique/ optical biometers is the method of
choice.
 Velocity Conversion Equation
True AL = V(correct)/ V(measured) x A AL
 In ACIOL, sulcus or Scleral fixated IOL, the appropriate A
constant is used.
 Biometry for Toric IOL

Commonly used calculations are-

Holladay IOL consultant Toric
planner
Barret Toric calculator
ASSORT calculator
 Dense cataract
Issues-
Strong sound attenuation can significantly impair the ability
to display spikes from the various interfaces.
Optical biometer may not work

What to do?
Maximum gain setting may be required to obtain spikes of
sufficient height from the posterior lens capsule and retina
 Scleral buckle

 Scleral buckle increases axial length by 0.75 to

1.25 mm without changing the ACD

What to do?
 IOL power calculated has to be reduced by 0.50
if the IOL power is > +14.00D
 Piggyback IOL

• Very high
Hypermetropia-
Primary Piggyback IOL
is needed.
• Correction of residual
refractive error-
secondary piggyback
IOL is needed.
Secondary piggyback IOL for
pseudophakia

 Holladay 2 formula
 Can be calculated easily based on
existing refraction.
Myopic correction:
P= 1.0 x Refractive Error
Hyperopic Correction:
P= 1.5 x Refractive Error
 Corneal Transplantation
 If a triple procedure is planned, it is
suggested that K readings of
another eye be used.
 An alternative option is to use the
average k readings from a series of
previous transplants.
 Corneal scar
Faulty ELP estimation
Optical biometry may not
work.

• Corneal Topography.
• K reading of another eye.
• Formula using only AL and
ACD (Hoffer Q and Haigis).
 Take home massage

Always compare with other eye, fundus

findings and refraction findings

No single reliable method for accurate

calculation of IOL power

Meticulous and careful Biometry can

give a satisfoctory outcome
 Silicone filled eyes

Axial length can be calculated from

- VCD true = VCD oil x 0.64
- Then, AL = ACD + LT + VCD true

• Alternatively, AL true = AL oil x 0.72

• Velocity Conversion Equation

True AL = V (correct)/ V(measured) x A AL
 Choice of IOL in location

1:1 relationship with the A constants

A decreases by 1 D, IOL power decreases
by 1D
 Primary piggybac

• Haigis or Hoffer Q
• Ideally 1 acrylic and 1 silicon IOL to avoid
interlenticular opacification.
• Usually, single piece in the bag and 3 piece
in the sulcus
• Divide the power between IO and reduce D
for sulcus
 Holladay 2 (4th generation)

Invention of an easy-to-use program that allowed for data

entry of the new variables and instant calculation of
Effective Lens Position (ELP) and the

appropriate IOL power selection (aka HIC.SOAP).

Lead to a new paradigm of evaluating eyes by both their

axial length (short, normal, long) and their anterior
segment size (small, normal, large).
Recommended formula use
• SRK II
The ‘constants’
A-constant
are
variable
• SRK/T A-constant

• Holladay Surgeon’s Factor

• Hoffer Q pACD

• Haigis a0, a1, a2

• IOL formula needs to be chosen accordingly
• Minus IOL powers have to be chosen
carefully by reducing amount of minus
power
• Surgeon should aim for -0.50D to -1.00D
postoperative refraction as most elderly will
prefer being near-sighted.
 Haigis formula (4th generation)

d = a˳ + (a1 × ACD) + (a2 × AL)

d = Effective lens position

ACD = Measured anterior chamber depth of the eye (corneal vertex to the anterior lens capsule)
AL = axial length of the eye ( the distance from the cornea vertex to the vitreoretinal interface)
a˳ = Moves the power prediction ˳ curve up/ down
a1 = Measured anterior chamber depth
a2 = Measured axial length
Methods using current
measurements:

1. Contact lens over correction method.

2. Modified Maloney
3. Haigis-L
4. Intraoperative refractions
Clinical history method:

First described by Holladay later by Hoffer as

Ka = Kp+ Rp – Ra

Ka = Corneal power after surgery

Kp = Average keratometry power before surgery
Rp = Spherical equivalent before surgery
Ra = Stable spherical equivalent after surgery
Post kerato refractive online
calculators:

ACRS post kerato refractive online

calculator
For myopic LASIK, Hyperopic LASIK and
prior radial keratometry
 keratoconus

Using K reading of such eyes will yield an

overestimated reading due to ELP calculation error.
THANK YOU