Professional Documents
Culture Documents
Dennis Murphy
28 Jan 2011
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The anterior cornea measurements rely on Keratometry to measure the curvature of the front
surface of the cornea. This measurement however is only part of the optical path through the
entire eye. The path must also include the posterior curvature of the cornea as well as the
cornea thickness and its refractive index. The Keratometer gives an estimate of the total
corneal power based on the anterior surface curvature it measured and a posterior radius that
is estimated as a percentage of the anterior radius according to a “standard cornea” model. It
also uses a standardized corneal thickness as well as an assumed refractive index. Problems
can arise due to the fact that the dimensions of each cornea are not exactly same the same as
the “standard cornea”. In addition, if the patient has undergone any previous corneal
refractive surgery such as radial keratotomy, photorefractive keratectomy, LASEK or LASIK
procedures then these operations can change the assumed relationship between the anterior
and posterior corneal surface curvatures. The end result is that the estimated total corneal
power may be a little different to the real power.
The other major measurement needed is the axial length of the eye from the front of the
cornea to the retina. This is usually done using A-scan biometry. This technique uses
ultrasound and the measurement is based on knowing how long the sound wave takes to
travel from one point to the next in various tissues. As the sound pulse travels through the
eye, a certain amount of energy from the wave is reflected back to the probe at each interface
in the eye (e.g. cornea/aqueous/lens/vitreous/retina). The various spikes returned to the probe
are then used to calculate the distances through the cornea, the anterior chamber, the lens and
the vitreous body.
There are many structures (including the cataract itself) within the eye that reflect the
ultrasound energy. To get an accurate axial depth measurement the operator has to know
which of the many returned echo spikes represent the required points along the optic path.
These spikes are then tagged and the instrument applies the appropriate sound velocities
between each of the spikes of interest in order to accurately measure the cornea thickness, the
anterior chamber depth, the lens thickness and the vitreous chamber depth. In addition, the
ultrasound probe must be held exactly parallel to the optical axis of the eye, otherwise the
ultrasound path through the eye will not follow the actual path whose measurement is
required. Also if the probe is pressed too hard against the cornea it will cause the cornea to
deflect inwards and hence shorten the measured path. The end result of any errors in
identifying the correct return echo spikes, or any alignment or probe application force errors,
will mean that the measured total axial eye length will be different to the actual length.
There are various formulas used to calculate the required IOL power. Which one is used
depends on whether the patient’s eye length is close to the average length, or is shorter or
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longer. The actual calculation is generally done internally in the instrument based on the data
fed to it by the surgeon. While the actual forms of the various equations within the instrument
are complex, the general form for an average axial length eye (approx. 22mm to 24.5mm) is
shown below
P = A – 2.5L – 0.9K
Where:
All of the equations used to predict what IOL power is required to produce emmetropia in the
patient’s eye are examples of multiple regression analysis where we have several independent
input parameters (A, L & K). The object of regression analysis is to predict the “average”
value of the dependent output variable – which in this case is the required IOL power.
Several problems can arise from using a regression formula to predict the required IOL power
as opposed to doing an impractical (but much more accurate) ray-trace through the eye. The
first of these are the uncertainties in the measurement of both the true axial length of the eye
and the actual total corneal power as discussed at the start of this article.
Second, is the assumption in the various equations that the dimensions of the anterior and
posterior segments in the eye are always proportional to each other as per the standard model
eye. This is almost never exactly true and in some cases can be significantly different to the
“standard model”
The third potential problem arises because of uncertainty in exactly where the implanted lens
will actually sit in the capsular bag in the eye. The axial position of the implanted lens has a
major effect on the effective insitu power of the IOL. Any unexpected changes in this
position can lead to large refractive errors. There are two issues here.
To some extent the actual position of the implanted lens will also depend on each surgeon’s
operating technique. Depending on the actual circumstances of each eye and operation, the
axial position of the lens may vary from what the surgeon expects.
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A further difficulty lies in the allowable power tolerance range allowed on IOLs. This is
shown in the table below. Many ophthalmologists seem to be unaware of just how large the
power tolerance range of IOLs is. As the table shows, the tolerance becomes larger as the
dioptric power increases. This large tolerance band is a significant part of the problem in the
“refractive surprises” that occur after some cataract operations. This is because refractive
errors are much more likely to occur with higher dioptric power IOLs as axial position
accuracy is more important at higher powers. The fact that the power tolerances are much
larger on higher powered IOLs just compounds the problem.
Corneal refractive surgery using a LASIK type procedure is performed to correct the
surprise if the error is within about plus or minus 2 diopters.
Piggyback IOLs can be fitted in some cases where there is a large error and where corneal
surgery is not appropriate.
An IOL exchange can be done fitting a supposedly more accurate lens to correct the
refractive error. However many ophthalmologists see this as a last resort as the
replacement refractive error and complication rate can be higher than other corrective
procedures
Two newer types of adjustable IOLs are also being implanted to counter the possibility of
refractive errors.
The light adjustable IOL. Using this device the surgeon gets the chance after the surgery
to correct the dioptric power of the IOL by using a non-invasive UV light source to adjust
the light sensitive polymer of the lens and change its dioptric power. Astigmatic errors in
the cornea can also be compensated for. However, once the lens is “locked” in its final
geometric configuration it cannot be changed again.
the need for surgery. The disadvantage of the magnetic type is that they cannot safely be
exposed to high magnetic fields such as used in an MRI scanner.
The new lens assembly is made in such a way that the “sharp” (square) posterior edge of the
lens assembly is always held against the posterior capsule surface in order to minimize any
postoperative capsular opacification (PCO.)
The rotation direction and speed of the motor is powered and controlled by a unit that is
external to the eye. The motor is self-locking so that after adjustment the lens will not move
accidently. The ultrasonic power level is less than the intensity allowed by the FDA for safe
use in the eye.
Common examples of high volume usage MEMS devices in everyday use include the
accelerometers that are used in airbag control systems in cars and the inkjet print-head
technology used in printers for computers.
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The concept of using active manipulation of the lens by way of inbuilt MEMS technology is
much closer to how the eye actually works than the traditional passive IOLs which are in
current use. By using other versions of MEMS motors with built-in energy harvesting
systems and associated sub-miniature electronic control circuitry we will be able to produce
IOLs that can accommodate (focus) like the natural lens.
IOL design is now slowly but surely changing to make the next generation of lenses more
like the natural lens though the use of inbuilt MEMS technology. This will require companies
to employ engineers on their design staff who have the necessary experience and background
to design both the optical elements of the new IOLs as well as the drive and control
mechanisms needed for these new types of lenses.
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