Clinical science
Br J Ophthalmol: first published as 10.1136/bjophthalmol-2017-311706 on 31 March 2018. Downloaded from http://bjo.bmj.com/ on January 4, 2020 at AAO/BJO. Protected by copyright.
1
Department of Biomedical
Sciences, College of Medicine,
Seoul National University, Seoul,
South Korea
2
HanGil Eye Hospital, Catholic
Kwandong University College of
Medicine, Incheon, South Korea
3
Department of Ophthalmology,
Seoul National University
Hospital, Seoul, South Korea
Correspondence to
Dr Young Suk Yu, Department of
Ophthalmology, Seoul National
University Hospital, Seoul 110-
744, South Korea; ​ysyu@​snu.​
ac.​kr
Received 5 December 2017
Accepted 10 March 2018
Published Online First
31 March 2018
To cite: Lee BJ, Lee S-M,
Kim JH, et al. Br J Ophthalmol
2019;103:106–111.
106
Predictability of formulae for intraocular lens power
calculation according to the age of implantation in
paediatric cataract
Byung Joo Lee,1 Sang-Mok Lee,2 Jeong Hun Kim,1,3 Young Suk Yu3
Abstract
Aims  To analyse the predictability of diverse
intraocular lens (IOL) power calculation formulae in
paediatric patients with congenital cataract.
Methods  The medical records of patients who
underwent cataract surgery and posterior chamber IOL
implantation (in-the-bag) for congenital cataract before
17 years of age were reviewed retrospectively. Target
refractions calculated by Sanders-Retzlaff-Kraff (SRK)/II,
SRK/T and Hoffer-Q formulae were compared with the
actual refraction. Patients were subgroup according to
the age at IOL implantation (age group 0–24 months,
25–60 months, 61–120 months, 121–203 months),
and we compared mean prediction error (PE) and mean
absolute error (AE) for each formula. Corrected AE was
obtained by linear regression analysis.
Results  Totally 481 eyes were included in the final
analysis. Both SRK/II and SRK/T yielded the lowest mean
AE in the age group 0–24 months and SRK/II yielded
the lowest mean AE in the age group 25–60 months.
For every formula, the mean PE was positive during the
first five years of age, which converged to zero according
to age as IOL implantation increases. The tendency for
immediate postoperative overcorrection in younger
patients (<6 years) could be improved by corrected
formulae based on the linear regression equation.
Conclusions  Patients with congenital cataract who
underwent IOL implantation within 5 years of age
showed higher AE than the older ones did. Among the
three formulae evaluated, SRK/II consistently provided
the best predictive result in these patients. For patients
aged >10 years, all three formulae showed favourable
predictive abilities.
Introduction
The calculation of exact intraocular lens (IOL)
power in childhood is very complicated. Technical
problems encountered in biometric measurement
of paediatric eyes and different biometric profile of
paediatric eyes from that of adults (steeper cornea
and shorter axial length) make accurate prediction
difficult. Currently used IOL power calculation
formulae have been designed on the basis of the
biometric database of adult eyes, making selection
of an adequate formula an important issue with
paediatric eyes. Although there are several previous
studies comparing the predictabilities of commonly
used formulae for IOL power calculation for
paediatric patients, they have several limitations
such as small study population and heterogeneity
of patients.1–6 A consensus on the best predictive
Lee BJ, et al. Br J Ophthalmol 2019;103:106–111. doi:10.1136/bjophthalmol-2017-311706
formula under specific clinical circumstance in
patients with paediatric cataract is still missing.
In this study, we aimed to compare the predict-
ability of three commonly used formulae for IOL
power calculation (Sanders-Retzlaff-Kraff (SRK)/II,
SRK/T and Hoffer-Q) for paediatric patients with
congenital cataract who received IOL implanta-
tion in the capsular bag during their first 16 years
of life. Moreover, we aimed to find clinical factors
affecting the predictability of these formulae and to
provide a best-fit regression equation which would
help improve the predictability of each formula.
Methods
We performed a retrospective review of medical
records of patients who underwent IOL implan-
tation surgery for congenital cataract at Seoul
National University Children’s Hospital during
1999–2014. Only the patients who received poste-
rior chamber IOL implantation into the capsular
bag before 16 years of age and the eyes with the
record of preoperative biometry, and postopera-
tive refraction 4–10 weeks postoperatively, were
included. All surgical procedures and perioperative
management of the patients were performed by
an experienced paediatric ophthalmologist (YSY).
Patients with a history of ocular trauma and those
who had been diagnosed with posterior lenticonus/
lentiglobus, or persistent fetal vasculature (PFV)-re-
lated lens opacity, were excluded. Patients who
received IOL implantation in the ciliary sulcus were
also excluded.
All biometric assessments were performed within
4 weeks before surgery. Keratometric value was
measured with KR-8100 automated keratometer
(Topcon, Tokyo, Japan) and axial length was eval-
uated by a standard applanation technique using
A-scan ultrasound. Intraocular pressure (IOP) was
measured with a non-contact tonometer (Pulsair-
2000, Keeler, Pennsylvania, USA) preoperatively.
Biometry measurement was performed at least two
times especially in uncooperative patients who need
general sedation, and the mean value was used for
IOL power calculation. In patients with signifi-
cant intersession variability (≥0.5 mm for axial
length, ≥1 dioptre (D) for mean K), we measured
biometry again.
In case of primary IOL implantation, lens material
was removed using bimanual irrigation and aspira-
tion instrument after mechanical anterior capsu-
lorhexis was performed using Ocutome through
a superior scleral tunnel incision. For secondary
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Br J Ophthalmol: first published as 10.1136/bjophthalmol-2017-311706 on 31 March 2018. Downloaded from http://bjo.bmj.com/ on January 4, 2020 at AAO/BJO. Protected by copyright.
IOL implantation surgery, the adherent anterior and posterior
Table 1  Overall characteristics of patients
capsular leaflets were separated by an MVR blade to reopen
capsular bag space from which reproliferated lens materials N (%) Mean±SD Range

were aspirated. Further, IOL was implanted into the distended Age at IOL implantation (months) – 43.64±30.06 11–201
capsular bag filled with viscoelastic materials. Single-piece  0–24 111 eyes (23.08%) 21.60±3.52 11–24
Poly (methyl methacrylate) (PMMA) IOLs were preferred for  25–60 283 eyes (58.84%) 36.38±10.94 25–60
eyes with secondary IOL implantation and foldable IOLs were  61–120 71 eyes (14.76%) 82.44±18.05 61–120
preferred for primary simultaneous IOL implantation cases.  121–203 16 eyes (3.33%) 152.75±26.61 121–201
During the study periods, four types of one-piece PMMA IOLs Sex
(811B/812C, Pharmacia & Upjohn, New  Jersey, USA; LK55A,  Female 156 (46.15%) – –
Lucid Korea, Seoul, Korea; and MZ60BD, Alcon Surgical,  Male 182 (53.85%) – –
Texas, USA) and one type of one-piece acrylate IOL (SA60AT, Laterality of cataract
Alcon Surgical) were used. For IOL power calculation, we used  Bilateral 239 (70.71%) – –
the A-constants provided by the respective manufacturers. After  Unilateral 99 (29.29%) – –
implantation of IOL into the capsular bag, concurrent posterior AL (mm) – 21.38±1.72 15.17–27.51
capsulectomy and anterior vitrectomy were routinely performed Average K (D) – 43.66±2.25 36.25–51.06
in patients aged <5 years. Scleral tunnel incision was repaired Primary/secondary IOL
with absorbable suture material, following which the viscoelastic implantation
material was removed.  Primary IOL implantation (eyes) 280 (58.21%) – –
Manifest refraction was routinely performed during the  Secondary IOL implantation 201 (41.79%) – –
period between the first and the second postoperative months. (eyes)

The spherical equivalent (SE) of actual postoperative refraction IOL power (D) – 24.19±4.83 8–35.5
was calculated. IOP was measured in the first postoperative AE (D)
month and then at every regular follow-up visit.  SRK/II 481 (100.00%) 1.40±1.24 0.01–6.73
Prediction error (PE) and absolute error (AE) of each case  SRK/T 481 (100.00%) 1.50±1.47 0.00–10.13
were calculated in the following manner:  Hoffer-Q 481 (100.00%) 2.09±2.10 0.01–17.94
PE=predicted refraction – actual postoperative refraction AE, absolute error; AL, axial length; D, dioptres; IOL, intraocular lens; K, keratometric value;
AE=│predicted refraction – actual postoperative refraction│ SRK, Sanders-Retzlaff-Kraff.

For the calculation of predicted refraction, we used the A-con-

stant provided by the manufacturers. Actual postoperative refrac-
tion was defined as the SE of postoperative refraction which was
performed between the 4th and the 10th postoperative weeks.
The correlations between the clinical variables and PE were
assessed using Pearson’s correlation analysis. Statistical differ-
ences between the mean values of AE calculated by two different
formulae were evaluated using paired t-tests and that of three
different formulae were assessed by one-way analysis of variance
(ANOVA). We performed linear regression analysis to determine
a best-fit line which could provide a corrected IOL power calcu-
lation formula. SPSS statistical software (V.21, IBM) was used for
the statistical analyses presented in this study. Statistical signifi-
cance was defined as a p value <0.05.
Results
In total, 481 eyes of 338 patients which met the inclusion and
exclusion criteria were identified. The clinical characteristics
of subjects are summarised in table 1. The mean age at IOL
implantation was 43.64±30.06 (range, 11–201) months. The
PE for SRK/II, SRK/T and Hoffer-Q formula were 0.81±1.69,
1.12±1.77 and 1.90±2.28 D, respectively, and the mean AE
for SRK/II, SRK/T and Hoffer-Q formula were 1.40±1.24,
1.50±1.47 and 2.09±2.10 D, respectively. The mean values of
AE obtained from three formulae were significantly different
(p<0.001, one-way ANOVA) and SRK/II gave the lowest AE
among the three formulae.
For calculating adequate IOL power for paediatric
aphakic patients, the age at the time of IOL implantation, axial
length and mean keratometric value have been considered as the
major determinants of PE. However, which factors affect the PE
under certain clinical circumstances continues to be a controver-
sial question.2 3 We performed Pearson’s correlation analysis to
address the association of these factors with the PEs calculated
by SRK/II, SRK/T and Hoffer-Q formula (figure 1). Only the age
Lee BJ, et al. Br J Ophthalmol 2019;103:106–111. doi:10.1136/bjophthalmol-2017-311706
at IOL insertion showed significant correlation with PEs from
all three formulae. Axial length was only associated with the PEs
of SRK/T and Hoffer-Q formulae. Both SRK/T and Hoffer-Q
formulae resulted in remarkable overcorrections for patients
with short axial length. In contrast, mean keratometry was not
related to the PEs of all three formulae evaluated.
Therefore, we subgrouped our patients according to their age
at IOL implantation and compared the predictability of each
formula (figure 2). In the age group 0–24 months, mean AE
calculated with SRK/II (1.97±1.48 D) and SRK/T (2.12±1.80
D) was significantly lower than that of Hoffer-Q (3.12±2.60 D).
In the age group 25–60 months, SRK/II was the most predictive
formula. Average AE of Hoffer-Q formula (2.04±1.97 D) was
significantly higher than that of SRK/II (1.36±1.21 D) and SRK/T
(1.50±1.41 D) in this group. In the age group 61–120 months,
SRK/II and SRK/T showed superior predictability than Hoffer-Q
did. Mean AE of SRK/II (0.86±0.58 D) and SRK/T (0.81±0.57
D) were significantly lower than Hoffer-Q (0.96±0.82 D). In
patients >10 years of age, the mean AE of SRK/II (0.93±0.57
D), SRK/T (0.95±0.60 D) and Hoffer-Q (1.04±0.62 D) did
not show statistically significant differences. The distribution
of AE of each formula according to age group is demonstrated
in figure 3. In the age group 0–24 months, more than half of
the patients showed unsatisfactory refractive outcome (AE >2.0
D) when the IOL power was calculated by Hoffer-Q formula.
In patients who received IOL implantation under the age of 6
years, average PE calculated by all three formulae had positive
values. As the age at IOL implantation increased, the PE nearly
converged to zero, invariably (figure 2).
As the postoperative refraction tends to result in myopic shift
from the predicted refraction (positive mean PE) by all three
formulae in young patients aged <6 years, we performed linear
regression analysis to reduce PE calculated by each formula
(figure 4). PEs calculated by all three formulae had a significant
107
 Clinical science
Figure 1  Scatter plot of prediction errors calculated by each intraocular lens (IOL) power calculation formula versus (A–C) age at IOL implantation,
(D–F) axial length and (G–I) mean corneal power. SRK, Sanders-Retzlaff-Kraff.
linear relationship with the age at IOL implantation surgery. We
propose the corrected formulae for each original IOL calculation
formula, which can be adopted for patients aged <6 years, based
on the linear regression equation.
For SRK/II, corrected predicted refraction=redicted refrac-
tion+0.055 × [age at IOL] − 2.784
For SRK/T, corrected predicted refraction=predicted refrac-
tion+0.060 × [age at IOL] – 3.261
For Hoffer-Q, corrected predicted refraction=predicted
refraction+0.085 × [age at IOL] – 4.947
When we calculated the corrected AE using each formula, the
mean value of corrected AE was significantly lower than that of
the original AE in all three formulae evaluated: from 1.51±1.32
to 1.25±1.02 D for SRK/II (p<0.001, paired t-test), from
1.64±1.56 to 1.30±1.10 D for SRK/T (p<0.001, paired t-test)
and from 2.34±2.22 to 1.53±1.51 D for Hoffer-Q (p<0.001,
paired t-test) formula. The mean corrected AE calculated by SRK/
108
Br J Ophthalmol: first published as 10.1136/bjophthalmol-2017-311706 on 31 March 2018. Downloaded from http://bjo.bmj.com/ on January 4, 2020 at AAO/BJO. Protected by copyright.
II (p<0.001, paired t-test) and SRK/T (p<0.001, paired t-test)
were still significantly lower than that calculated by Hoffer-Q
formula in patients who received IOL implantation within their
first five years of life. The average AEs of corrected SRK/II and
SRK/T formula did not show significant difference (p=0.166,
paired t-test).
Because we have used both PMMA IOL (811B, 811C, 812C,
LK55A, MZ30BD and MZ60BD) and acrylic foldable IOL
(SA60AT) during the study periods, we performed a subgroup
analysis according to the IOL used. In the PMMA IOL group,
the mean AE of Hoffer-Q formula (2.34±2.26 D) is significantly
larger than that of SRK/II (1.51±1.31 D; p<0.01) or SRK/T
(1.66±1.56 D; p<0.01) formula. The mean AE of SRK/II was
significantly smaller than that of SRK/T (p<0.01). In acrylic fold-
able IOL group, the mean AE of Hoffer-Q formula (1.38±1.30
D) is  significantly larger than that of SRK/II (1.07±0.94 D;
p<0.01) or SRK/T (1.02±0.99 D; p<0.01) formula. There was
Lee BJ, et al. Br J Ophthalmol 2019;103:106–111. doi:10.1136/bjophthalmol-2017-311706
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Figure 2  Comparison of absolute error and prediction error of each intraocular lens (IOL) power calculation formula according to the age at IOL
implantation: (A, E) 0–24 months, (B, F) 25–60 months, (C, G) 61–120 months and (D, H) 121–203 months. In box and whisker plots for prediction
error, outliers to 5th and 95th percentile are demonstrated as dots (E–F). *P<0.05; paired t-test. NS, not significant; SRK, Sanders-Retzlaff-Kraff. 

no significant difference between the mean AE of SRK/II and
SRK/T (p=0.21). Because there was no significant difference
between the mean age at IOL implantation of the PMMA IOL
group (42.77±28.99 months) and that of the acrylic foldable
IOL group (46.15±33.10 months), we postulated that the types
Figure 3  Predictive accuracy of Sanders-Retzlaff-Kraff (SRK)/II, SRK/T
and Hoffer-Q formula for each age group. AE, absolute error; D, dioptres.
Lee BJ, et al. Br J Ophthalmol 2019;103:106–111. doi:10.1136/bjophthalmol-2017-311706
of IOLs might be a variable, which can affect the predictability
of IOL power calculation formula.
Discussion
According to our results, in paediatric eyes with congenital cata-
ract, PE calculated by each formula is consistently affected by
the age at IOL implantation for all three formulae, whereas axial
length is correlated only to the PE of two theoretical formulae.
Keratometry is not related to the PE. While the longitudinal
growth of axial length persists throughout adolescence, the flat-
tening of corneal curvature is known to occur mostly during the
first year of life.7 In our series, all participants were aged >1 year,
except for one. We postulated that among our study participants
corneal curvature had less influence on the PEs calculated by
commonly used IOL power calculation formulae for this reason.
As short axial length is the representative biometric feature
for paediatric eyes, IOL power calculation formulae which give
the best prediction in short eye were expected to yield a better
refractive outcome. In adults with short axial length, Hoffer-Q
formula, a third-generation IOL formula which determines the
personalised anterior chamber depth (ACD) considering both
axial length and corneal curvature of each patient,8 has been
reported to outperform other formulae such as SRK/II, SRK/T
and Holladay I.9 10 However, Hoffer-Q formula was found to
109
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Figure 4  Deducing corrected intraocular lens (IOL) power calculation formulae from regression equation for patients who underwent surgery
during the first five years of age. Regression equations for prediction error calculated by Sanders-Retzlaff-Kraff (SRK)/II, SRK/T and Hoffer-Q formula
and the age at IOL implantation were derived (A–C). The mean values of absolute prediction error (PE) calculated by original formulae and corrected
formulae are compared (D). NS, not significant.

be the least predictive formula in patients who underwent IOL
implantation in our study, before 10 years of age. Short axial
length is a representative biometric feature for paediatric eyes,
but the ratio of anterior and posterior segments of the eye in chil-
dren is also different from that of adults. As the anterior segment
is disproportionately large in infancy,11 empirically modified
personalised ACD assuming strategy to optimise refractive
results in adult eyes might be inappropriate for these patients.
In addition, these results can be attributed to the phenomenon
of amplification of biometric error by IOL calculation formulae
in paediatric patients.12 Young and uncooperative patients who
need sedation for biometric measurement are more likely to
show greater biometric error because of lack of fixation. It has
been reported that in eyes with shorter axial length and steeper
cornea Hoffer-Q formula tends to be more sensitive to the
biometric errors than other theoretical formulae such as SRK/T,
Holladay I and Haigis formula, while SRK/II has an invariable
sensitivity to the size of biometric error.13
Results of previous studies are inconsistent regarding which
formula yields the best predictive results in paediatric cataract
surgery. Limited number of patients and heterogeneity of study
populations (especially in terms of the age at the time of surgery
110
and type of cataract) are the major shortcomings of the previous
studies. To our knowledge, this is the largest study ever to
compare the predictability of IOL power calculation formulae in
eyes of paediatric patients. Our study included sufficient number
of patients in each age group. Moreover, we included only the
patients with congenital cataract and adopted strict exclusion
criteria. Patients with a history of ocular trauma were excluded
because the effective lens position (ELP) could be affected by
previous trauma.13–15 The eyes with PFV were also excluded
because the presence of retrolental fibrous components could
result in shift of the lens–iris diaphragm16 to affect ELP. More-
over, eyes with posterior lenticonus or lentiglobus were excluded
because they usually show bulging of the posterior capsule,17 18
which could possibly affect the value of immediate postoperative
refraction.
In our study, SRK/II was the most predictive formula across
all age subgroups, and Hoffer-Q was the least predictive one for
patients who received IOL implantation surgery during their
first decade of life. However, the predictability of Hoffer-Q
formula also improved as the age at IOL implantation increased.
Although a head-to-head comparison of the results of each study
is difficult, our result about the predictability of each formula is
Lee BJ, et al. Br J Ophthalmol 2019;103:106–111. doi:10.1136/bjophthalmol-2017-311706

in accordance with those of Kekunnaya et al4 and Neely et al,1
but is discordant with the report of Nihalani and Van der Veen.3
Neely et al analysed postoperative refractive outcome of 101
paediatric cataract eyes and concluded that SRK/II is the least
variable and Hoffer-Q is the most variable formula. However,
37% of the patients in their study had been diagnosed with poste-
rior lenticonus/lentiglobus, PFV or traumatic cataract. Nihalani
and Van der Veen have reported that among patients who under-
went IOL implantation for paediatric cataract before 18 years
of age Hoffer-Q is the most predictive formula. However, they
only excluded the eyes with traumatic cataract from their anal-
ysis. Moreover, they included only 22 (total 135) eyes which
underwent IOL implantation within the first two years of life.
In contrast, our series included 111 eyes which underwent IOL
implantation surgery within the first two years of age. The mean
age at IOL implantation in this study was much lesser than that
of Nihalani and Van der Veen (3.6 vs 6.4 years). The discordance
between our results and those of the previous reports can be
attributed to the age distribution of study population and the
strict exclusion criteria we adopted. Lack of fixation and inden-
tation of cornea during applanation A-scan biometric measure-
ment of younger children could result in an underestimation of
axial length and subsequent overcorrection. The tendency for
overcorrection in younger patients can be understood in this
context. Our results show a possibility of reducing AE by using a
best-fit regression model for each formula.
In summary, age at IOL implantation has significant correla-
tion with PE calculated by SRK/II, SRK/T and Hoffer-Q formula.
After  10 years of age, all three formulae have equally satisfactory
predictability. However, when choosing IOL calculation formula
in patients with congenital cataract before 10 years of age, SRK/
II formula consistently provides the most relevant prediction
among the three formulae evaluated. Younger patients tend to
have larger AE and there is a tendency towards overcorrection in
these patients, regardless of the formula used. Regression equa-
tion provided by our study can be helpful for reducing AE in
these patients.
Correction notice  This article has been corrected since it published Online First.
The affiliation of author Sang-Mok Lee has been corrected to ’HanGil Eye Hospital,
Catholic Kwandong University College of Medicine, Incheon, South Korea’ in the
PDF.
Contributors  BJL contributed to the acquisition, analysis and interpretation of
data and drafting the article. S-ML contributed to the conception of ideas and
design of study and critical revision of contents. JHK contributed to the conception
of ideas and design of study and critical revision of contents. YSY contributed to the
conception of ideas and design of study, critical revision of contents and provided
approval of version to be published.
Funding  This study was supported by the Seoul National University Hospital
Research Grant (23-2016-0080).
Lee BJ, et al. Br J Ophthalmol 2019;103:106–111. doi:10.1136/bjophthalmol-2017-311706
Clinical science
Br J Ophthalmol: first published as 10.1136/bjophthalmol-2017-311706 on 31 March 2018. Downloaded from http://bjo.bmj.com/ on January 4, 2020 at AAO/BJO. Protected by copyright.
Competing interests  None declared.
Patient consent  Detail has been removed from this case description to ensure
anonymity. The editors and reviewers have seen the detailed information available
and are satisfied that the information backs up the case the authors are making.
Ethics approval  The Institutional Review Board of Seoul National University
Hospital has approved this study.
Provenance and peer review  Not commissioned; internally peer reviewed.
© Article author(s) (or their employer(s) unless otherwise stated in the text of the
article) 2019. All rights reserved. No commercial use is permitted unless otherwise
expressly granted.
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