INTRAOCULAR LENS CALCULATION

 Previously, a standard +18.00 or +19.00 D lens was attached.

 In 1960, ultrasound was introduced for measuring the axial length of the eye.
o Later, Fyodorov introduced a theoretical formula for vergence.
o In 1990, optical interferometry was introduced, with the IOL Master 500.
 Biometry measurement of eye lengths.
 Eye dimensions:
o Axial length = 23.46mm
o Range = 22 - 24.5 mm.
o Difference between right and left eye = <0.3 mm; repeat the study.
o Anterior chamber depth = 3.24 mm (+/- 0.44 mm).
o Lens thickness = 4.63 mm (+/- 0.93 mm).
 The pseudophakic eye is an optical system composed of:
o 2 lenses: cornea and IOL.
o 5 refractive media: air, cornea, aqueous humor, IOL and vitreous.
o Distances between refractive surfaces: corneal thickness, pseudophakic anterior chamber, IOL thickness, pseudophakic
vitreous chamber.

Ultrasonic biometry

  Ultrasonic biometry is based on the fact that a sound wave has

propagation speeds that differ according to the density of the structures it passes
through.
 Shot quality:
o Axiality: correct pins on the oscilloscope.
 Corneal and retinal spikes equally amplified.
 Capsular spikes tall and symmetrical.
 Descending choroidal and retrobulbar spikes.
o Accuracy increases with undilated pupil.
o Measure both eyes.
o Remove silicone bubbles.
 Selection criteria in ultrasonic biometry:
o Eliminate the first echogram, the poorly aligned ones, the first shot, and those that show short anterior chamber depth.
o Standard deviation of all segments <0.05.
o Reassess with a difference of >0.3 mm in axial length of both
eyes without a history of amblyopia or anisometropia.
o Axial length >25 mm or <22 mm.
 Causes of error:
o Bad fixation.
o Bad parameters in the equipment (sound speed, wrong mode,
wrong technique, wrong gain, having silicone).
o Ocular anatomical changes (macular lesions, aphakia, retinal
detachment, posterior staphyloma, narrow anterior chamber,
impregnated hyaloid).
o Dense cataract.
o Silicone in vitreous cavity.
Optical biometry
 IOL Master (Zeiss): partial coherence interferometry .
o Multimode 780 nm diode laser on a Michelson
interferometer.
o It measures from the corneal epithelium to the retinal
pigment epithelium.
o Advantages: non-contact technique, comfortable, fast.
o The constant A depends on the biometric method,
whether it is optical or ultrasonic.
 Lenstar (Haag-Streit): optical partial coherence reflectometry
(OLCR).
o 820 nm diode laser (LA, ACD, CCT, LT).
o Obtains the following measurements:
 Keratometry (32 points).
 Pachymetry.
 Pupilometry.
 Anterior chamber depth.
 Lens thickness.
 White-white distance.
 Axial length.
o Use the following formulas: Barret, Olsen, Barret toric, Hill RBF (artificial intelligence).
 Formulas after refractive surgery: Barret True K, Shammas no-history, Masket.
 T-cone toric platform.
o Hill-RBF (Radial Basis Function): self-validating tool based on artificial intelligence using pattern recognition and
sophisticated data interpolation for the choice of IOL to be implanted in cataract surgery that works well for short eyes ,
normal and long.
 IOL Master 700: swept-source OCT .
o Obtains the following measurements:
 Cornea-to-retina scan.
 Total keratometry (telecentric keratometry).
 Fixation verification.
 Interconnection with Lumera and Callisto eye.
o Uses the following formulas: Barret True K Universal II, Barret True K Toric, Z Calc, Haigis.
o Advantages:
 Compensates eye movement.
 No eye contact.
 Useful in vitreous cavities with silicone oil.
o Disadvantages:
 Opaque media.
 False measurements in pseudophakics.

Optical keratometry
 Formula r = 2dh'/h.
o r = radius of curvature.
o d = image-object distance.
o h = size of the object.
o h' = image size.
 Range = 36- 52 D.
 Standard keratometric index = 1.3375.
 Measurement area:
o Helmholtz (fixed object) = 2.6 - 3.65 mm. + used.
o Javal-Schiotz (variable object) = 3.3 - 3.5 mm.
  Error sources:
o Explorer accommodation.
o Poor patient fixation.
o Corneal irregularity.
o Tear film alterations.
o Lack of calibration.
o Contact lens molding.
o Previous exploration maneuvers.

Automated keratometry
 Fast (<.1 seconds).
 Measurement area = 3.0 - 3.3 mm.
 It only measures the front side.

Placido Topography
 Reflection of concentric ring discs.
 The flatter the cornea, the greater the separation of the rings.
 Arc Step algorithms: greater curvature and height of each point from the center to the periphery.

Scanning slit topography

 Orbscan Ilz.
 Disc reflection of concentric rings and projection of 40 light slits at 45º.
 The central 5 mm are measured twice by overlapping slits.
 Analyzes 900 points in 1.5 seconds.
 Measurements:
o Pachymetric map.
o Sim K.
o White-white distance.
o Pupilometry.
o Depth of the anterior chamber.
o Kappa angle. optic and pupillary axis
o Irregularity indices.
 Carry out a theoretical calculation to know the radius of curvature of the rear face.

Scheimpflug tomography
 Pentacam.
 Rotating camera.
 Photography with a front light slit.
 Measures the anterior segment in two seconds and takes 50 images.
 Evaluate the following:
o Quick report.
o Topographic and tomographic classification of keratoconus.
o Refractive maps.
o Corneal densitometry.
o Glaucoma screening (anterior chamber angle, anterior
chamber volume, IOP adjustment by pachymetry).

Pentacam AXL adds optical coherence tomography to the Scheimpflug

camera.
Anterior with image of the anterior segment.

Gullstrand's schematic eye

 It assumes a radius of curvature greater than the actual one, with an
anterior curvature of 7.7 mm and a posterior curvature of 6.8 mm
(actual 6.4 mm).
 The refractive index 1.3375 is based on Gullstrand's schematic eye despite the error in posterior curvature.
o The corrected refractive index should be 1.3315.

Calculation formulas
 They determine the refractive power of the IOL that will produce an emmetropic eye. The position of the IOL within the eye must be
calculated.
 Snell's law of internal reflection: when light falls on a medium with a lower refractive index, the ray deviates from the normal, and the
exit angle is greater than the incident angle.
o The exit angle will reach 90º for some critical angle of
incidence and, for all angles of incidence greater than
this critical angle, the internal reflection will be total.

 Formulas based on geometric optics : according to the laws

of reflection and refraction.
o It analyzes the propagation of light as the rectilinear transmission of one or several rays of light that progress by changing
direction depending on the angle of incidence on the refractive surface and the refractive indices of the media it passes
through.

 Formulas based on paraxial (Gaussian) geometric optics.

o It assumes that light rays form very small angles with respect to the optical axis and travel very close to it.
o It extends to all rays the property of paraxial rays, which have no aberrations.
o Simplify Snell's law.
o Equate the sines and tangents of the angles by the values of the angles
themselves.
o Empirical formulas: formulas obtained from the statistical analysis of a series of
cases where the researcher determines the main predictive factors and calculates
adjustment coefficients to obtain the most precise result possible. There was a
large error rate at extreme lengths.
 SRK formula (Sanders, Retzlaff and Kraff) —> SRK formula II.
 SRK Formula: For biometrically normal eyes, NOT for extreme eyes or abnormal cases.
 SRK II formula: correction factor according to axial length.
 Constant A: different for each IOL model and used to characterize it.
 Its value depends on factors such as shape of the optic, haptic angulation, etc.
 Variable dependent on factors such as IOL, surgeon, keratometry and axial length.
 For empirical formulas, simple regression equations, the LIO constant is another factor in the
algorithm.
 For theoretical formulas, the IOL constant represents the mean cornea - principal plane distance of
the IOL (where refraction occurs in a thin lens).
 The constant A is different for optical and ultrasonic biometry.
 ULIB (User group for Laser Interference Biometry): page for querying constant A.
o Theoretical formulas: they calculate the refraction of light in the pseudophakic eye by applying the laws of geometric
optics.
 Most are optical vergence formulas.
 They can be applied to any case, as long as the physical characteristics (curvature, refractive indices) of the
eye under study are known.
 1st generation formulas:
 The ELP is a fixed value for each IOL model.
 Regression formulas = Binkhorst and SRK.
 Examples: Fyodorov, Colenbrander, Hoffer, Thijssen, Van Der Heijde, Binkhorst I.
 2nd generation formulas:
 Takes into account the effective position of the lens according to the axial length and anterior
chamber depth.
 He inferred that the anterior chamber in long eyes was larger and in farsighted people very short.
 The ELP changes as a function of the axial length. The greater the axial length, the greater the ELP.
  Examples: Shammas, Hoffer.
 3rd generation formulas:
 Take into account the effective position of the lens, axial length, keratometries and anterior chamber
depth (some formulas). Take all the variables into account.
 The ELP is calculated from the axial length and keratometry. The greater the axial length, the greater
the ELP; and higher keratometry, lower ELP.
 Examples: Holladay 1, SRK/T, Hoffer-Q, Haigis.
 4th generation formulas:
 The calculation is made from more than 2
factors.
 It takes into account factors such as age
(predictor of the anterior chamber or lens
thickness), white-to-white distance.
 Olsen formula estimates the ELP from four
variables (axial length, keratometry, anterior
chamber depth, lens thickness).
 Holladay Formula 2 uses seven variables (axial
length, keratometry, anterior chamber depth,
lens thickness, horizontal corneal diameter, preoperative refraction, age).
 5th generation formulas:
 They take into account axial length, anterior chamber depth, lens thickness, and keratometry.
 Employees at IOL Master and Lenstar.
 Examples: Haigis, Hoffer H-5 and Barret Universal II.
 The most used formulas are the third and fourth generation.
 The best formulas for calculating IOLs in short eyes are Hoffer Q, Haigis and Holladay II.
 The SRK/T has good prediction of ELP for normal-sized eyes. If the keratometry is high (>45 D) and the axial
length is high (>28 mm), the IOL is overestimated.
 At low keratometry values, the SRK/T formula estimates the lowest ELP of all the formulas, while Hoffer Q
estimates the highest.
 Differences between SRK/T, Hoffer Q and Holladay 1:
 In short eyes, Hoffer Q calculates the most powerful IOL and SRK/T calculates the least powerful
IOL.
 In long eyes, Hoffer Q calculates the least powerful IOL and SRK/T calculates the least powerful IOL.
 Holladay 1 calculates an intermediate power.
 In eyes with average keratometry values, the difference in predictions between the formulas is small
(0.50 - 0.75 D).

 Formula accuracy according to axial length:

 Short eyes (<22 mm) —> Hoffer Q, Holladay 2.
 Medium eyes (22-24.5 mm) —> all.
 Long eyes (24.5 - 26 mm) —> Holladay 1.
 Very long eyes (>26 mm) —> SRK/T.
Optical bimetry is recommended, do not use second generation formulas, preferably 4th generation, optimize and personalize the constants,
clinical correlation, always verify lengths >26 mm or <2 mm, verify K <40 or >47, each mess with its constant and specific calculation.

Eyes with normal lengths: any formula is suitable.

Very short eyes have a lot of room for error.

Short eyes use hoffer Q so as not to fall short with the IOL calculation.
For short eyes, you can still use Haigis.

long eyes
Sources of LA error, error in corneal measurement.
We seek to avoid hyperopia of the eyes.

o Vergence formulas: they assume that the lenses of the system (cornea and IOL) are so thin that the optical power
derived from their thickness is negligible. Try to predict the focal point.
 They are based on the concept of light vergence on each refractive surface.
 The refraction of the pseudophakic eye can be determined by calculating the vergence of an object on the
cornea, IOL, and retina.
 Examples: SRK/T, Holladay, Hoffer-Q, Haigis.
 Thin lens formulas:
 When parallel rays pass through the
cornea, the focal length is given by
1/K.
 When the rays pass through the
effective plane of the IOL, the focal
length is reduced by the distance
d/N1.
 The vergence V1 of the anterior
surface of the lens can be
calculated as the reciprocal of the
new focal length.
 In order to be focused on the retina, the light beam leaving the IOL must have a vergence V2 defined
by the distance from the lens plane to the retina.
 Thick lens formulas: take
into consideration the
anterior and posterior
curvatures, and the
thickness of the lens.
 Exact ray tracing formula
(wavefront techniques):
include high-order
aberrations of biological
lenses.
 o Ray tracing formula: the propagation of one or more rays is analyzed, surface to surface, calculating the change in the
angle of incidence and refraction as well as the height of the ray.
 Combined use of two formulas.
 PhacoOptics:
 Exact ray tracking (Snell's law of refraction).
 Anterior chamber depth prediction algorithms (based on pre- and postoperative measurements).
 Okulix: computer package that allows calculating isolated rays using Snell's law.

o Artificial intelligence formulas

 Radial Basis Function (BRF): Hill-BRF.
 Advanced and self-validated method.
 Pattern recognition and data interpolation.
 Adaptive learning.
 It is continually updated.
 Neural network: computer program that predicts IOL powers from clinical data.
o Combined formulas (Ladas super formula): combines results obtained from two- and three-variable vergence formulas
with an artificial intelligence component.
 Formulas based on non-paraxial (exact) geometric optics
o Calculate the refraction of light with the exact application of Snell's law, taking into account aberrations.
o Positive spherical aberration has an important value by shifting the plane of best focus towards the IOL, myopizing the
eye.
o Important to determine the power of the IOL in altered corneas, after refractive surgery, scars, keratoconus, etc.
o Requires specific software.
 The effective position of the lens (Holladay) or current position of the lens (FDA) is the distance between the corneal vertex and the
effective point of the lens.
 Vergence: reciprocal of the “reduced” distance to the focal point.
 Aramberri nomogram: correction for negative intraocular lenses ( table XII ).
 Refractive translation of an error ( table VI ).
o 0.1 mm error = 0.34 D error in IOL calculation.
o This relationship depends on the axial length.
 Calculus on eyes with silicone oil:
o Emulsified oil may be impossible to measure.
o It has a higher refractive index.
o There are two types of oil:
 1000 centistokes (980 m/s).
 5000 centistokes (1040 m/s).
 Analyze what will happen to the silicone
o If the silicone oil is going to be left or replaced and I have
biometry without silicone, then I must modify it,
 Increase 3.5 D if a plana-convex IOL will be placed.
 Increase 5 D if a biconvex IOL will be placed.
 Calculus in eyes with refractive surgery (LASIK):
o It suggests the use of True Net Power in the 4 mm area centered on the corneal apex.
 Considers the anterior curvature of the cornea, the posterior curvature of the cornea, the refractive index of air
(1), the refractive index of the cornea (1.376) and the refractive index of aqueous humor (1.335).
 It does not take into account pachymetry or corneal aberrations ( which are considered by the Total Corneal
Refractive Power - TCRP map).
 In patients with a history of radiated keratotomy, sagittal (anterior face) and minimal pachymetry maps are
taken into account.
 What map is it seen on? Power distribution map
 o Haigis-L or Shammas formulas are recommended.

o Double K method: any factor that alters the predictor variables involved in the ELP prediction algorithm will generate an
error.
 Reprogram the formula algorithms so that the ELP predictor algorithm uses the preoperative K and the optical
calculation algorithm uses the postoperative K.
 It is used in corneas treated with refractive surgery (flatter keratometry).
 Simple mode formulas K = one K for both calculations.
 Formulas in double mode K = one K for each calculation.
 Calculus in eyes with keratoconus:
o It is recommended to use an average or standard keratometry (43.50 D), keeping in mind the possibility that a corneal
transplant will eventually be required.
o In mild-moderate cases (<55.00 D), use Pentacam or Javal to obtain keratometry.
o In mild cases, the SRK II formula gives the best results.

 Panacea Calculator: biometric utility program designed by David Flikier and which has represented one of the greatest advances in
the calculation of both spherical and toric IOLs by significantly taking into consideration the posterior surface of the cornea. Allows
you to enter data on the patient's posterior and aberrations.

Faco Elche

Trunet power
Tcrp