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IOLMaster biometry: refractive results of 100 consecutive
H Eleftheriadis

Br J Ophthalmol 2003;87:960–963

amounts of pressure exerted on the eye by the transducer
Aims: To study the refractive outcome of cataract surgery during applanation ultrasonography, the latter is used widely
employing IOLMaster biometry data and to compare it for ocular biometry. Ultrasound biometry AL measurement
with that of applanation ultrasonography in a prospective errors have been demonstrated to be responsible for 54% of
study of 100 eyes that underwent phacoemulsification with the predicted refraction errors after IOL implantation,1 with a
intraocular lens implantation. postoperative refractive error of 0.28 dioptres (D) resulting
Methods: The Holladay formula using IOLMaster data from an AL shortening of 0.1 mm.1 10
was employed for the prediction of implanted intraocular In the past several years an optical imaging technique, opti-
lenses (IOLs). One month after cataract surgery the refrac- cal coherence tomography (OCT), has been developed that
tive outcome was determined. Preoperative applanation uses infrared laser light for high precision and high resolution
ultrasonography data were used retrospectively to biometry and tomography.11–16 A dual beam version of the OCT,
calculate the IOL prediction error. The two different bio- partial coherence interferometry (PCI), which is insensitive to
metry methods are compared. longitudinal eye movements, as it uses the cornea as reference
Results: 100 patients, 75.42 (SD 7.58) years of age, surface, has been demonstrated to measure with high
underwent phacoemulsification with IOL implantation. The precision and accuracy the AL of normal17 and cataractous
optical axial length obtained by the IOLMaster was signifi- eyes.18 The measured optical distances are divided by the group
cantly longer (p<0.001, Student’s t test) than the axial refractive indices to obtain geometric distances.19 20
length by applanation ultrasound, 23.36 (SD 0.85) mm v A commercially available optical biometry equipment, IOL-
22.89 (0.83) mm. The mean postoperative spherical Master (Carl Zeiss Jena, Germany), based on the principle of
equivalent was 0.00 (0.40) D and the mean prediction dual beam PCI was produced recently.21 It uses infrared light
error −0.15 (0.38) D. The mean absolute prediction error (λ = 780 nm) of short coherence for the measurement of the
was 0.29 (0.27) D. 96% of the eyes were within 1 D from optical AL, which is converted to geometric AL by using a
the intended refraction and 93% achieved unaided visual group refractive index.18 Furthermore, it measures the corneal
acuity of 6/9 or better. The Holladay formula performed curvature, the anterior chamber depth, and the corneal diam-
better than the SRK/T, SRK II, and Hoffer Q formulas. eter and it calculates the optimum IOL power by the acquired
Applanation ultrasonography after optimisation of the sur- biometry data, employing several IOL power calculation
geon factor yielded a greater absolute prediction error formulas built into its computer software. The high precision,
than the optimised IOLMaster biometry, 0.41 (0.38) D v resolution, accuracy, and reproducibility of the AL measure-
0.25 (0.27) D, with 93% of the eyes within 1 D from the ments of the IOLMaster have been demonstrated.21–23
predicted refraction. In this study the AL measurements obtained by the
Conclusion: IOLMaster optical biometry improves the IOLMaster were compared to those of the applanation
refractive results of selected cataract surgery patients and ultrasound in a cohort of 100 consecutive patients who
is more accurate than applanation ultrasound biometry. underwent cataract surgery. The postoperative refractive accu-
racy was determined and compared to that of applanation

ataract surgery is perhaps the most frequently per-

C formed surgical procedure. In the last five decades
innovations such as ocular biometry, phacoemulsifica-
tion, and intraocular lens (IOL) power prediction formulas
Selection criteria
Patients who underwent uncomplicated cataract surgery by
phacoemulsification with IOL implantation through a tempo-
have improved considerably the refractive outcome of cataract
surgery. This outcome depends on the accurate prediction of ral clear corneal incision were included in the study. All eyes
the power of the implanted IOL, which in turn depends mainly had no other ocular pathology apart from age related cataracts
on preoperative biometry data, IOL power calculation formu- and no history of ocular surgery. Eyes whose axial length
las, and manufacturer IOL power quality control. The most could not be measured with the IOLMaster, because of dense
important step for an accurate calculation of the IOL power is ocular media opacities such as corneal scars, high density, or
the preoperative measurement of the ocular axial length posterior subcapsular cataracts, were excluded from the study.
(AL).1 A-scan ultrasonography, with a reported longitudinal Eyes with more than 0.75 D of “with the rule” or 1.00 D
resolution of approximately 200 µm and an accuracy of “against the rule” or oblique keratometric astigmatism were
approximately 100–150 µm,2–4 is routinely employed in the also excluded as different from temporal clear corneal incision
measurement of the ocular AL. Ultrasound biometry however and additional astigmatism management were employed in
requires physical contact of a transducer with the eye either such eyes.
directly (contact or applanation) or through an immersion
bath of normal saline (immersion). Although differences in Preoperative biometry
the AL between immersion and applanation ultrasonography AL measurements were first performed by IOLMaster (ALM)
up to 0.36 mm5–9 have been reported, owing to various followed by applanation ultrasonography (CompuScan AB,

1. approximately 1 month following the the ALM and ALUS. Ultrasound Hence for each method an optimised SF was calculated retro- biometric sound velocities of 1532 m/s were taken for the spectively to obtain a mean prediction error of zero. The biometry prediction error (also known as deviation from intended refraction) was defined as the difference between the intended refraction determined from preoperative biometry data and the spherical equivalent of the postoperative subjective refraction. significantly longer (p <0.26 A foldable silicone IOL (SI40 NB.41) −1.00 D Holladay −0. KM and ALM were used for the calculation of implanted IOLs.05 was eye was used.00 to +4. was performed by the same experienced surgeon (HE).40 0.25 D) and the mean prediction error The visual results are expressed as the percentage of eyes that −0.50 to +1.31)† 81% 95% 99% 100% SRK II −0. with correlation coefficient 0.24 Results of the study are presented as mean (SD) values and Ten AL measurements were obtained by both methods measured ranges indicating minimums and maximums.26 D). Allergan. those derived from systematic errors in biometry. The refractive results prediction error was 0. p<0.39)‡ 67% 90% 98% 100% Hoffer Q −0. or the formula).29 (0. the comparison of the two biometry methods it was necessary to optimise the SF in order to correct any offset errors (that is.00 D 1.57 0. 2. p<0.36 (0.50 D.00 (0.16 mm). employing a stop and chop technique.26 0.22 (0. www.002. Autorefraction of the eyes and longer than 25 mm in 4%.50 D 2. At least three mal distribution and therefore the non-parametric Wilcoxon measurements were obtained and after they were checked for test for paired differences was used. A p value less than 0.001) than the ALUS 22.IOLMaster biometry 961 are given as spherical equivalent (SE) in dioptres (D).27) D.29 (0. and percentage of patients with biometry prediction errors of less than 0.bjophthalmol. and 2. ‡Holladay v SRK II.26–25. 1.43 to +1.15 ( .0001. SF 1. surgical Storz) (ALUS) by the two experienced technicians.00 D.35 (0.33 (0.73–25.49 (0.89 (0.28 to +1.974 to 0. 75. p=0.46 to +1. The stability of the postoperative refraction at the time of postoperative Postoperative visual and refractive results examination has been previously demonstrated.27–29 UCVA was 6/9 or better in 93% of eyes and BCVA was 6/9 or better in all eyes. §Holladay v Hoffer Q. aqueous and the vitreous humour and 1641 m/s for the lens. All surgeries were The ALM 23.37 (0.13 D). considered significant.27) 84% 96% 100% SRK T −0.50 D 1. Preoperative BCVA ranged from 6/6 to After informed consent. The ALM was shorter than 22 mm in 3% (BCVA) were tested using a Snellen chart. RESULTS The surgeon factor (SF) of the implanted IOLs was the one Demographic characteristics suggested by the IOL manufacturer.25 This was also considered was considered necessary in order to maintain the integrity of essential because of the systematic difference of the AL values the corneal epithelium.5. All patients (AutoRef-Keratometer RK-3.2 mm temporal self sealing clear corneal D (range −7. 1.38) D (range −1.28 to +1. incision.40) Data analysis D (range −1. The accuracy of IOL prediction for the two biom- etry methods was evaluated using the mean prediction error and the mean absolute prediction error (all errors positive) (MAE).00 D from intended refraction.19 (2.983 (95% CI operation unaided (UCVA) and best corrected visual acuity 0. 96% of the eyes were within Table 1 IOLMaster refractive results: comparison of various IOL power calculation formulas (Wilcoxon signed rank test) Prediction error Eyes within* Absolute prediction Mean (SD) Range error 0.82 mm).22). This order technique.75 to +1.40) −1.5. Although for the calculation of the implanted IOLs Figure 1 Correlation between the IOLMaster and ultrasound (US) the SF suggested by the manufacturer was used (SF 1.38) −1.15 (0. all patients had phacoemulsification counting fingers. The Keratometry readings (KM) were obtained by the automated distribution of the absolute error did not conform to the nor- keratometer incorporated in the IOLMaster. There was high correlation between At last follow up visit.83) mm Postoperative examination (range 20.22) was injected in the Axial length measurements capsular bag with the Unfolder (Allergan).58) years of age (range 43–88 years) were Surgery recruited in this study.50) −1.45 0. One hundred eyes of 100 patients (70 female and 30 male). Correlations were consistency the one closer to the astigmatic correction of the assessed using linear regression. for axial length measurements (Pearson correlation coefficient = 0. and 2. with data that could be described by normal distribution. which may be compromised inadvert- obtained by the IOLMaster and the ultrasound biometry.42 (SD 7. The mean preoperative SE was +0. ently by the contact with the ultrasound probe.16 (0.50 D.007.983). The IOL power determined by the ALUS and KM was also calculated ret- rospectively. The postoperative mean SE was 0. paired Student t test was used mean of at least three valid measurements was used as the AL. The mean absolute achieved UCVA and BCVA of 6/9 or better. †Holladay v SRK T. 1.85) mm (range 21.5 D.30)§ 84% 96% 100% *Percentage of eyes within 0. Canon) and subjective manifest preferred the IOLMaster to the applanation biometry. For according to the manufacturer’s recommendations and a the comparison of the means. The Holladay25 IOL power prediction formula was used for all calculations. refraction were performed by the same examiner.988) (Fig 1).42) through a two step 3. aiming for postoperative emmetropia in all eyes.

48 to 0.00 (0.2 In conclusion.. parameters for the determination of the IOL position in the tion. Southend General Hospital. p<0. US biometry Opt = ultrasound biometry with optimisation of the SF. The accuracy of ultrasonic determination of axial length in characteristics as the IOLMaster utilises the same group pseudophakic eyes. come outliers still exist. mature or posterior subcapsular cataracts. Similar differences have been reported by other approximately 8– 0. thus providing comfort to The SF optimised retrospectively employing IOLMaster and the patient and preventing corneal abrasions and the ultrasound biometry data were 1. possibly due to the careful patient selection with regard to the corneal astigmatism and other ocular pathology.34 In this cohort the mean absolute prediction error of cohort.bjophthalmol.37) 0. the advent of the IOLMaster has not rendered onstrated to measure very accurately the AL with precision ultrasonic biometry obsolete as a significant number of eyes comparable to or even better than that of immersion still require ultrasound biometry. Acta Ophthalmol 1989.67:141–4.Eleftheriadis@btinternet.. Westcliff-on-Sea.56) 0. whereas during ultrasound biometry a misalignment between the measured axis and the visual axis DISCUSSION may result in erroneously longer AL measurements.18 19 33 The most important reason for this corneal scarring. IOLMaster biometry was found to be more mm22 32) to those of IOLMaster...50 D 2.19 Immersion ultrasound limitation of the IOLMaster is its inability to measure the lens minimises the indentation of the cornea and therefore thickness.. as the patient fixates at the SF and the comparison with the non-optimised results. Ophthalmic Surg 1981.30 tion it is easier to master its use. H Eleftheriadis.31 calculated from A-scan biometry with the Echo-Oculometer. However. This is especially important in eyes with posterior pole staphylomata Applanation ultrasonography remains the preferred method because of the more precise localisation of the fovea. It is a non-contact technique. which does not biometry require use of topical anaesthesia. The prediction errors for the SRK T. probe. www. which uses further Surg 1980. Bonney RC.15 (0. Prittlewell Chase.01 to 2. SS0 0RY.46 90% 96% 100% US biometry Opt 0. 1 Olsen T.50 D from intended refrac. 4 Schachar RA.. thus resulting in a Positioning also of patients with mobility problems on the difference that corresponds to the retinal thickness of the IOLMaster machine may occasionally be a problem. In addition.. which results in corneal indentation and shortening of eyes with non-optimal fixation as in cases of age related the AL. which is still essential in biometry. accurate in the measurement of the ocular axial length than The employment of the optical AL instead of ultrasound AL applanation ultrasonography.50 D IOLMaster −0. Moreover.00 D 1. immersion AL measurements are closer (0. have reported 100% being within 1 D from intended formulas are shown in Table 1. REFERENCES Nevertheless. Sources of error in intraocular lens power calculation.0001..565 respectively. SRK II formula was used and Rajan et al35 a 16% improvement Authors’ affiliations on retrospective IOL power calculations using the IOLMaster.41 (0. p=0.962 Eleftheriadis Table 2 IOLMaster refractive results: comparison with ultrasound biometry (Wilcoxon signed rank test) Prediction error Eyes within Mean prediction Abs prediction error error Range 0. ter at the retinal pigment epithelium.00 D 2. The mean absolute prediction error of this cohort (MAE H. p<0.0149..38)‡ 0.. In addi- of measuring the ocular AL in most ophthalmic practices.22 34 35 Dense ocular media—that is.50 D 1.38) 0. *IOLMaster v IOLMaster Opt. This may be due to various cataract 2 Olsen T. investigators.01 to 1. 1. Packer et al. J Cataract Refract Surg 1992.0001. Using an investigational prototype Drexler et al19 reported an improvement of about 30% when the .25 (0.. transmission of infections. The accuracy of ultrasonic measurement of the axial explanation is that the Holladay formula does not predict very length of the eye.00 D and all eyes were within 1. Levy NS.25 (0.27)* 0.27)† 0. despite the improvement of refractive out. refractive index for all cataract grades.01 mm31 and 0.. Another possible 3 Binkhorst RD.44 74% 93% 97% 99% 100% IOLMaster = IOLMaster biometry without optimisation.28 84% 96% 100% IOLMaster Opt 0. the presence of outliers indicates the need optimised IOLMaster biometry was significantly smaller for further improvements in the ocular biometry and IOL (p<0. Another fovea. difference is the pressure exerted on the eye by the ultrasound prevent acquisition of optical AL measurements.47 mm longer than the referral patterns of the practice. 0.25 (0. UK.. the ultrasound is reflected mainly at the macular degeneration may result in inaccurate AL measure- internal limiting membrane whereas the light of the IOLMas- ments as the measurements are not on the visual axis. Although this number depends on ALM measurements in this study were 0. IOLMaster Opt = IOLMaster biometry with optimisation of the SF.18:125–9. refraction.12:363–5.00 (0. ‡IOLMaster v US biometry Opt. It has improved significantly the has improved significantly the refractive results of cataract refractive results of cataract surgery in this carefully selected surgery. which is about 130 µm.. Ophthalmic employing the Holladay II formula.38) D (Table 2) ..27) v power prediction formulas.. This represents an improvement in the refractive outcome of 39%.22 31 32 every ophthalmic practice.0001) than that of optimised ultrasound 0.27) D) was significantly smaller than that reported by others32–34 (MAE 0.00 to 1. measurement beam. Essex. †IOLMaster Opt v US biometry Opt. SRK II.. which is required for the Holladay II formula.. Department of Ophthalmology. it is estimated that it is the ALUS.29 (0. and Hoffer Q eye.335 and 0. Accuracy of intraocular lens powers accurately the position of the IOL in the eye.53) using the Holladay formula and Accepted for publication 27 November 2002 optical AL. Furthermore it has greater Table 2 shows the mean prediction error and mean absolute accuracy than ultrasound biometry because it measures the prediction error of the two methods after optimisation of the ocular AL along the visual axis.. The PCI based prototypes and the IOLMaster have been dem- However.41 (0.11:856–8. The IOLMaster has simplified considerably the process of Comparison of the IOLMaster biometry with ultrasound ocular biometry.

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