ARTICLE

Variability of axial length, anterior chamber depth, and lens thickness in the cataractous eye
Renu Jivrajka, BS, Maya C. Shammas, MD, Teresa Boenzi, AS, Mike Swearingen, OD, H. John Shammas, MD

PURPOSE: To review and evaluate the biometry measurements in 750 eyes (first eye developing cataract) of 750 consecutive patients with no retinal pathology. SETTING: Private practice, Lynwood, California, USA. METHODS: All measurements were performed with the I3 system A-scan (Innovative Imaging, Inc.) using an immersion technique. The axial length (AL), anterior chamber depth (ACD), and lens thickness (LT) measurements were evaluated in relation to each other and in relation to age, sex, and keratometric readings. RESULTS: The mean AL was 23.46 mm G 1.03 (SD), the mean ACD was 2.96 G 0.45 mm, and the mean LT was 4.93 G 0.56 mm. Men presented for surgery at an earlier age than women (mean 73 G 9.41 years versus 75 G 8.55 years) with a longer AL (23.76 G 1.00 mm versus 23.27 G 1.01 mm). The AL tended to be longer in younger patients (r Z 0.127; P<.001); the ACD tended to be deeper in younger patients (r Z 0.250; P<.001) and in longer eyes (r Z 0.423; P<.001). The LT tended to be thicker in older patients (r Z 0.385; P<.001) and in shorter eyes (r Z 0.179; P<.001), with large scatter in the distribution. CONCLUSIONS: There was a positive correlation between AL and ACD and an inverse correlation between AL and LT. Also, AL was inversely correlated with age and corneal power. J Cataract Refract Surg 2008; 34:289294 Q 2008 ASCRS and ESCRS

The largest study to evaluate the biometry of cataractous eyes was published in 1980 by Hoffer.1 Multiple studies have since been published, with an emphasis on hyperopic or myopic eyes or on specific ocular components such as axial length (AL) measurement, anterior chamber depth (ACD), or lens thickness (LT). The purpose of this study was to review the biometry measurements in 750 eyes of 750 patients

scheduled for cataract surgery to evaluate AL, ACD, and LT measurements. The results were then compared with previously published data. PATIENTS AND METHODS
The biometry data of 750 cataractous eyes of 750 consecutive patients with no retinal pathology were reviewed. To avoid data duplication, only measurements taken from the first eye of each patient scheduled for surgery were included. All measurements were performed with the I3 system A-scan (Innovative Imaging, Inc.) using an immersion technique.2 Three independent measurements were taken in each eye by a highly skilled technician, and the best echogram was used for intraocular lens (IOL) power calculation. The following biometric measurements were recorded for each patient (Figure 1): (1) AL in millimeters, defined as the axial distance between the anterior corneal surface and the anterior retinal surface; (2) ACD in millimeters, defined as the axial distance between the anterior surface of the cornea and the anterior surface of the lens; and (3) LT in millimeters, defined as the axial distance between the anterior surface of the lens and the posterior surface of the lens. The readings were taken from the ultrasound unit. The unit converts the measurements from microseconds to millimeters internally, using an average velocity of 1532 m/s in the anterior chamber and in the vitreous cavity and
0886-3350/08/$dsee front matter doi:10.1016/j.jcrs.2007.10.015

Accepted for publication October 5, 2007. From the Department of Ophthalmology (Jivrajka, H.J. Shammas), Keck School of Medicine, University of Southern California, Los Angeles, and a private practice (Boenzi, Swearingen, H.J. Shammas), Lynwood, California; and the Department of Ophthalmology of the Joan and Sanford I. Weill Medical College of Cornell University (M.C. Shammas), New York, New York, USA. No author has a financial or proprietary interest in any material or method mentioned. Corresponding author: H. John Shammas, MD, 3510 Martin Luther King Jr. Boulevard, Lynwood, California 90262, USA. E-mail: hshammas@aol.com.
Q 2008 ASCRS and ESCRS Published by Elsevier Inc.

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200 180 160

180 156

Number of patients

140 120 100 80 60 40 20 0 1 12 30 14 6 5 3 2 1 3 73 51 107 106

Figure 1. Ultrasound display of the echo spikes during immersion biometry, identifying the initial spike (IS), which represents reverberations at the tip of the probe; the cornea (C); the anterior lens surface (L1); the posterior lens surface (L2); the retina (R); the sclera (S); and orbital tissues (O).

21

Figure 3. Axial length distribution.

1641 m/s for the LT. The corneal power was measured with an automatic keratometer that uses a keratometric index of 1.3375, and the readings were taken in diopters (D). The average keratometric (K) readings were used in this study. The AL, ACD, and LT values were evaluated in relation to each other and in relation to age, sex, and mean K readings. The Pearson product-moment correlation coefficient (r) was used to statistically evaluate each scattergram. The mean values (GSD) of all measurements were also calculated. Paired t tests were performed to establish whether there was a statistically significant difference between the values under study. A P value less than 0.05 was considered statistically significant.

RESULTS The study included 452 women (60%) and 298 men (40%). The mean age of the patients was 74.37 G 8.93 years (range 29 to 95 years) (Figure 2). The mean age of the men was 73 G 9.41 years and of the women, 75 G 8.55 years (P!.05). The mean AL was 23.46 G 1.03 mm (range from 20.01 to 32.41 mm). The AL distribution was skewed
250

toward the myopic side (Figure 3). The ACD showed a normal distribution, with a mean value of 2.96 G 0.45 mm (range 1.51 to 4.17 mm) (Figure 4).The LT also showed a normal distribution, with a mean value of 4.93 G 0.56 mm (range 3.03 to 6.41 mm) (Figure 5). Table 1 shows the mean measurements by sex. The mean AL was statistically significantly longer in men than in women (P!.001). The ACD was significantly deeper in men than in women (P!.001). The mean LT was almost identical between the 2 groups (PO.01). Figures 6 to 8 show the relationship of the AL, ACD, and LT to age. With advancing age, the mean AL (r Z 0.127; P!.001) and the mean ACD (r Z 0.250; P!.001) decreased, while the mean LT (r Z 0.385; P!.001) increased. Figure 9 shows the relationship of the AL to the K readings. There was a tendency toward steeper corneas in shorter eyes and flatter corneas in longer eyes (r Z 0.487; P!.001).
300

229 250 167

200

Number of Patients

Number of Patients

200 150 110 100 50 83

150 107 100

135

72 50 11 0 <50 14 29

21

10 >90 0

50-54 55-59 60-64 65-69 70-74 75-80 80-84 85-90

AGE

Figure 2. Age distribution.

Figure 4. Anterior chamber depth distribution

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.0 1. 4 .5 9 -2 22 1.9 .0 9 -2 22 2.4 .5 9 -2 23 2.9 .0 9 -2 23 3.4 .5 9 -2 24 3.9 .0 9 -2 24 4.4 .5 9 -2 25 4.9 .0 9 -2 25 5.4 .5 9 -2 26 5.9 .0 9 -2 26 6.4 .5 6 27 26. .0 99 -2 27 7.4 9 .5 -2 7. 99 >2 8. 0 21 -2

.0 0

<2 1

Axial Length (mm)

271

274

9 1.5-1.99 2.0-2.49 2.5-2.99 3.0-3.49 3.5-3.99

3 >4.0

Anterior Chamber Depth (mm)

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300 250 245 250

28 27 26 y = -0.0147x + 24.56 R2 = 0.0162

Number patients

Axial Length (mm)

15 6.0>

200 150 108 100 50 0 6 3.0-3.49 3.5-3.99 4.0-4.49 4.50-4.99 5.0-5.49 5.5-6.0 91

25 24 23 22 21 20

35

Lens Thickness (mm)

40

45

50

55

60

65

70

75

80

85

90

Figure 5. Lens thickness distribution.

Age (years)

Figure 6. Scattergram showing the relationship between age and AL.

Figures 10 and 11 show the relationship of the ACD and LT to the AL. The increase in AL was accompanied by a deeper ACD (r Z 0.423; P!.001) and a thinner LT (r Z 0.179, P!.001). DISCUSSION In this study, AL was measured with immersion A-scan biometry.2 With this technique, the ultrasound probe is kept 5.0 to 10.0 mm from the cornea and does not compress it, unlike the contact technique in which the probe comes in contact with the cornea. The absence of corneal compression during immersion A-scan biometry increases the accuracy of the measurements and decreases their variability. Furthermore, there is a systematic difference of 0.2 to 0.3 mm between the 2 techniques.3 Other systematic differences in AL measurement are often caused by the instruments used, whether there is built-in compensation to account for specific measurement techniques, the shape of the ultrasound beam (focused versus nonfocused), the choice of ultrasound velocities, or the way exact surface positions are identified.2 In our study, biometry was performed with the I3 A-scan. This unit uses high gain to obtain saturated peaks, and the position of a surface under examination
Table 1. Clinical data according to sex. Mean G SD Men (n Z 298) 23.76 G 1.00 3.05 G 0.46 4.93 G 0.58 Women (n Z 452) 23.27 G 1.01 2.90 G 0.44 4.93 G 0.55

is on the rising edge (Figure 1). Other instruments use a lower gain so that the entire peaks are within the scan; in this case, the position of a surface is at the peak itself. These 2 approaches to identifying surface positions result in a minor but systematic difference. Axial length can also be measured by optical biometry using partial coherence interferometry.4 Original comparisons between acoustical and optical biometry show that both methods measure different distances in different directions. These comparative studies led to a calibration curve that was wired into the market version of the IOLMaster (Zeiss Meditec) so AL readouts can be directly compared with the results obtained by immersion ultrasound.4 In a study of 50 cataractous eyes,5 AL measurements by immersion ultrasonography and by optical biometry using the IOLMaster correlated in a highly positive manner (r Z 0.996). In our study, the mean AL was 23.46 G 1.03 mm, which is almost identical to previously published
4.00 3.80

Anterior Chamber Depth (mm)

3.60 3.40 3.20 3.00 2.80 2.60 2.40 2.20 2.00 y = -0.0126x + 3.8991 2 R = 0.0623 40 45 50 55 60 65 70 75 80 85 90

Measurement Axial length (mm) Anterior chamber depth (mm) Lens thickness (mm)

P Value !.001 !.001 O.1

Age (years)

Figure 7. Scattergram showing the relationship between age and ACD.

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6.00

4.00 3.80

Anterior Chamber Depth (mm)

5.50

3.60 3.40 3.20 3.00 2.80 2.60 2.40 2.20 y = 0.1844x - 1.3644 2 R = 0.1792

Lens Thickness (mm)

5.00

4.50

4.00

3.50 y = 0.0242x + 3.1351 2 R = 0.1484 3.00 40 45 50 55 60 65 70 75 80 85 90

2.00 21.00 21.50 22.00 22.50 23.00 23.50 24.00 24.50 25.00 25.50 26.00

Age (years)

Axial Length (mm)

Figure 8. Scattergram showing the relationship between age and LT.

Figure 10. Scattergram showing the relationship between ACD and AL.

data by Norrby et al.6 (23.44 G 1.33 mm), Haigis6 (23.48 G 1.67 mm), Olsen et al.7 (23.47 G 1.56 mm), Packer et al.5 (23.40 mm), and Shammas8 (23.45 G 1.48 mm). In his large series of 7500 eyes, Hoffer1 recorded a mean AL of 23.65 G 1.35 mm. A closer look at Hoffers study shows that 32.3% of his patients had an AL of 24.0 mm or longer compared with only 25.5% in our series (P!.001) and that 30.2% were younger than 65 years compared with only 12.0% in our series (P!.001). Hoffers series was based on consultations performed for other ophthalmologists between 1974 and 1979 (personal communication, February 8, 2007). We theorize that because IOL implantation was in its infancy, some eye surgeons at that time were more concerned about IOL power accuracy in younger patients and in patients with longer eyes. In a second study based on his own series of 450 eyes, Hoffer9 recorded a mean AL of 23.56 G 1.24 mm.

In our series, more women scheduled cataract surgery than men (60% versus 40%). Also, the women presented for surgery at an older age (mean 75 years versus 73 years) and with a shorter average AL (mean 23.27 mm versus 23.76 mm). The information, which is from a yearly report from the Centers for Disease Control (CDC) dating back to 1980, indicates that women have a longer life expectancy than men (Figure 12) (Table 27 in Health: United States, 2006 [online]. Available at: http://www.cdc.gov/nchs/ data/hus/hus06.pdf#027. Accessed November 5, 2007). The CDC report explains to a certain extent the larger number and the older age of women presenting for surgery compared with their male counterparts. Our study showed an inverse correlation between AL and age (Figure 6); patients presenting for surgery at a younger age had a longer mean AL. In 1980 and
6.00

y = -0.097x + 7.2082 R2 = 0.0321

48.00 47.00

y = -0.7144x + 60.376 R2 = 0.2371

5.50

Average K Readings (D)

46.00 45.00 44.00 43.00 42.00 41.00 40.00 20.00 21.00 22.00 23.00 24.00 25.00 26.00 27.00 28.00

Lens Thickness (mm) Axial Length (mm)

5.00

4.50

4.00

3.50 21.00 21.50 22.00 22.50 23.00 23.50 24.00 24.50 25.00 25.50 26.00

Axial Length (mm)

Figure 9. Scattergram showing the relationship between AL and the average K reading.

Figure 11. Scattergram showing the relationship between LT and AL.

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Figure 12. Life expectancy for men and women at birth and at 65 years (CDC report).

1993, Hoffer1,9 statistically proved that cataracts requiring surgery occur earlier in eyes with longer ALs. This was also noted by Kubo et al.10 In another study of cataractous eyes with high axial myopia (AL over 25.0 mm), Tsang et al.11 found that 46.6% of patients were younger than 65 years (versus 12.0% in our study). Shammas and Milkie12 report 7 patients with unsuspected unilateral axial myopia who developed cataract in the longer eye. The eye that developed the cataract was at least 3.0 mm longer than the fellow eye in all 7 cases. Vision deteriorated between the ages of 40 years and 55 years in all cases, and the mean age at the time of cataract surgery was only 47 years. The inverse correlation between age and AL is difficult to explain. However, the present study corroborates that high myopia with increased AL predisposes to the development of a cataract at a younger age. Immersion ultrasonography is commonly used to measure ACD. In our study, the mean ACD was 2.96 G 0.45 mm. The ACD tended to be deeper in younger patients and in longer eyes. However, the graphs in Figures 7 and 10 show a large scatter of ACD. In 2 comparative studies, Nemeth et al.13,14 found a mean ACD measurement of 2.87 G 0.4 mm in 1 study and 2.95 G 0.34 mm in the other. Both studies used immersion ultrasonography. Nemeth et al. also noted that these ultrasound ACD measurements correlated highly with measurements taken with the Scheimpflug-based Pentacam (Oculus), with which the mean ACD was 2.89 G 0.49 mm. However, they obtained slightly higher values (3.12 G 0.33 mm) when the ACD was measured using an anterior segment optical coherence tomography method (Visante, Zeiss Meditec). The ACD can also be measured clinically using a slitlamp ACD measurement attachment,15 by scanning-slit topography1517 (Orbscan II), by magnetic resonance imaging,17 or using the IOLMaster.18,19 The IOLMaster4 evaluates a slit image of

the anterior segment of the eye using sophisticated image-analysis software that produces ACD measurements that are equivalent to immersion ACDs. On the other hand, contact ultrasonography consistently yielded shorter measurements in comparative studies.16,18,19 The sources of errors with this technique include potential corneal indentation and off-axis measurements. In our series, the mean LT was 4.93 G 0.56 mm and tended to be thicker in older patients and shorter eyes. This confirms Hoffers20 analysis of the axial dimension of the human cataractous lens in 600 cataractous eyes, also measured by immersion ultrasound. The LT was directly proportionate to age and inversely proportionate to the AL. However, Hoffer found a slightly thinner mean axial LT of 4.63 G 0.68 mm. Holladay21 also reports that LT increases with age, and in an effort to more accurately measure the sound velocity within the lens, he proposed calculating the LT using a simplified equation based on age, where LT Z 4.0 C (0.01 age). Our data agrees with those of Holladay; that is, that the mean thickness of the lens increases with age but that there is a large scatter of LT values. In our study, the K readings were taken from an automatic keratometer. The keratometer measures the anterior corneal radius by reading 4 points within the central zone and uses an arbitrary index of refraction of 1.3375 to calculate the corneas back vertex power. Other keratometers use a 1.3315 index and measure the total corneal power.22 The difference between using either of the 2 indices will result in a systematic difference between the instruments of 0.7 to 0.8 D. Other systematic differences are also obtained if the corneal power is measured by computerized corneal topography,23 optical coherence tomography,24 or by Scheimpflug imaging of the cornea.25 When the AL was correlated to the K readings, there appeared to be a definite tendency toward steeper corneas in shorter eyes and flatter corneas in longer eyes. Our data confirm the emmetropizing relationship between the AL and the corneal curvature.1 All newer formulas2628 depend on the AL, ACD, and LT measurements, as well as on the K readings, for accurate IOL power calculations. Due to the systematic differences between instruments and measurement techniques, we encourage ophthalmologists to personalize the formulas constants and to use instrumentation that is consistent with that used in the development of the respective formulas. REFERENCES
1. Hoffer KJ. Biometry of 7,500 cataractous eyes. Am J Ophthalmol 1980; 90:360368; correction, 890 2. . In: Shammas HJ, ed, Intraocular Lens Power Calculations. Thorofare, NJ, Slack, 2004; 95111

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3. Shammas HJ. A comparison of immersion and contact techniques for axial length measurement. Am Intra-Ocular Implant Soc J 1984; 10:444447 4. Haigis W. Optical biometry using partial coherence interferometry. In: Shammas HJ, eds, Intraocular Lens Power Calculations. Thorofare, NJ, Slack, 2004; 141157 5. Packer M, Fine IH, Hoffman RS, et al. Immersion A-scan compared with partial coherence interferometry; outcomes analysis. J Cataract Refract Surg 2002; 28:239242 6. Norrby S, Lydahl E, Koranyi G, Taube M. Comparison of 2 A-scans. J Cataract Refract Surg 2003; 29:9599 7. Olsen T, Corydon L, Gimbel H. Intraocular lens power calculation with an improved anterior chamber depth prediction algorithm. J Cataract Refract Surg 1995; 21:313319 8. Shammas HJ. A-scan biometry of 1000 cataractous eyes. Doc Ophthalmol Proc Ser 1987; 48:5763 9. Hoffer KJ. The Hoffer Q formula: a comparison of theoretic and regression formulas. J Cataract Refract Surg 1993; 19:700712; errata 1994; 20:667 10. Kubo E, Kumamoto Y, Tsuzuki S, Akagi Y. Axial length, myopia, and the severity of lens opacity at the time of cataract surgery. Arch Ophthalmol 2006; 124:15861590 11. Tsang CSL, Chong GSL, Yiu EPF, Ho CK. Intraocular lens power calculation formulas in Chinese eyes with high axial myopia. J Cataract Refract Surg 2003; 29:13581364 12. Shammas HJ, Milkie CF. Mature cataracts in eyes with unilateral axial myopia. J Cataract Refract Surg 1989; 15:308311 13. Nemeth G, Vajas A, Kolozsvari B, et al. Anterior chamber depth measurements in phakic and pseudophakic eyes: Pentacam versus ultrasound device. J Cataract Refract Surg 2006; 32:13311335 14. Nemeth G, Vajas A, Tsorbatzoglou A, et al. Assessment and reproducibility of anterior chamber depth measurement with anterior segment optical coherence tomography compared with immersion ultrasonography. J Cataract Refract Surg 2007; 33:443447 lcker HE. Measuring anterior 15. Auffarth GU, Tetz MR, Biazid Y, Vo chamber depth with the Orbscan Topography System. J Cataract Refract Surg 1997; 23:13511355 16. Reddy AR, Pande MV, Finn P, El-Gogary H. Comparative estimation of anterior chamber depth by ultrasonography, Orbscan II, and IOLMaster. J Cataract Refract Surg 2004; 30:12681271 17. Fea AM, Annetta F, Cirillo S, et al. Magnetic resonance imaging and Orbscan assessment of the anterior chamber. J Cataract Refract Surg 2005; 31:17131718

18. Kriechbaum K, Findl O, Kiss B, et al. Comparison of anterior chamber depth measurement methods in phakic and pseudophakic eyes. J Cataract Refract Surg 2003; 29:8994 meth J, Fekete O, Pesztenlehrer N. Optical and ultrasound 19. Ne measurement of axial length and anterior chamber depth for intraocular lens power calculation. J Cataract Refract Surg 2003; 29:8588 20. Hoffer KJ. Axial dimension of the human cataractous lens. Arch Ophthalmol 1993; 111:914918; correction, 1626 21. Holladay JT. Standardizing constants for ultrasonic biometry, keratometry, and intraocular lens power calculations. J Cataract Refract Surg 1997; 23:13561370 22. Haigis W. Corneal power after refractive surgery for myopia: contact lens method. J Cataract Refract Surg 2003; 29:1397 1411; erratum, 1854 23. Shammas HJ, Shammas MC, Garabet A, et al. Correcting the corneal power measurements for intraocular lens power calculations after myopic laser in situ keratomileusis. Am J Ophthalmol 2003; 136:426432 24. Tang M, Li Y, Avila M, Huang D. Measuring total corneal power before and after laser in situ keratomileusis with high-speed optical coherence tomography. J Cataract Refract Surg 2006; 32:18431850 25. Dubbelman M, Sicam VADP, van der Heijde GL. The shape of the anterior and posterior surface of the aging human cornea. Vision Res 2006; 46:9931001 26. Olsen T. The Olsen formula. In: Shammas HJ, eds, Intraocular Lens Power Calculations. Thorofare, NJ, Slack, 2004; 2738 27. Holladay JT. Holladay IOL Consultant Users Guide and Reference Manual. Houston, TX, Holladay LASIK Institute, 1999 28. Haigis W. The Haigis formula. In: Shammas HJ, eds, Intraocular Lens Power Calculations. Thorofare, NJ, Slack, 2004 4157

First author: Renu Jivrajka Department of Ophthalmology, Keck School of Medicine, University of Southern California, Los Angeles, and a private practice, Lynwood, California, USA

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