J CATARACT REFRACT SURG - VOL 32, DECEMBER 2006

Accuracy of intraocular lens power

prediction using the Hoffer Q, Holladay 1,
Holladay 2, and SRK/T formulas
Julio Narváez, MD, Grenith Zimmerman, PhD, R. Doyle Stulting, MD, PhD, Daniel H. Chang, MD

PURPOSE: To compare the accuracy of intraocular lens (IOL) power calculations using 4 formulas:
Hoffer Q, Holladay 1, Holladay 2, and SRK/T.
SETTING: Tertiary care center.
METHODS: This study was a retrospective comparative analysis. Immersion ultrasound biometry (axial
length, anterior chamber depth, and lens thickness), manual keratometry, and postoperative manifest
refraction were obtained in 643 eyes of consecutive patients who had routine uneventful cataract sur-
gery with implantation of 1 of 2 IOLs using the same operative technique by the same surgeon. Bio-
metric data were entered into each of the 4 IOL power calculation formulas, and the results were
compared to the final manifest refraction. An optimized lens constant was used for each formula.
Results were also stratified into groups of short, average, medium long, and very long axial length
<22.0 mm, 22.0 to <24.5 mm, 24.5 to 26.0 mm, and >26.0 mm, respectively).
RESULTS: No formula was more accurate than the others as measured by mean absolute error. The
formulas were also equally accurate when eyes were stratified by axial length.
CONCLUSION: The 4 IOL power formulas provided equivalent refractive results in the entire group of
eyes and in the subsets of axial lengths tested.
J Cataract Refract Surg 2006; 32:2050–2053 Q 2006 ASCRS and ESCRS

Cataract surgery is the most common intraocular surgical
procedure performed in the United States. With modern
techniques, complications are uncommon and increasing
emphasis is being placed on refractive outcomes.
Patients also have increasingly higher refractive expec-
tations. A medicolegal review of 168 cataract surgery cases
Accepted for publication July 31, 2006.
From the Department of Ophthalmology (Narváez) and School of
Allied Health Professions (Zimmerman), Loma Linda University,
Loma Linda, California, Emory University (Stulting), Atlanta, Geor-
gia, and a private practice (Chang), Scottsdale, Arizona, USA.
Presented at the XXIIIrd Congress of the European Society of
Cataract & Refractive Surgeons, Lisbon, Portugal, September
2005.
No author has a financial or proprietary interest in any material or
method mentioned.
Corresponding author: Julio Narváez, MD, Loma Linda University,
Department of Ophthalmology, FMO, 11370 Anderson Street, Suite
1800, Loma Linda, California 92350, USA. E-mail: narvaezjd@verizon.
net.
resulting in litigation revealed that the most common rea-
sons for litigation were related to the intraocular lens
(IOL) and that among those reasons, incorrect choice of
power was the most common.1
To achieve optimum outcomes, preoperative biometry
must be accurate and an accurate IOL power formula must
be used. Although reports suggest there is a difference in
the predictive accuracy of older formulas for IOL power
calculations,2,3 relatively few studies have compared
third-generation IOL power formulas. Hoffer3 found the
Hoffer Q formula to be significantly more accurate than
the SRK and SRK II (P!.0001 and P!.004, respectively)
and equal to the Holladay 1 and SRK/T formulas. He also
reported mean absolute error in 317 eyes with 4 commonly
used formulas (Hoffer Q, Holladay 1, Holladay 2, and SRK/T)
in subjects stratified by axial length but did not perform
statistical analysis.4
We compared the refractive outcomes in 643 eyes with
the Hoffer Q, Holladay 1, Holladay 2, and SRK/T IOL power
formulas after routine cataract surgery by a single surgeon
using 1 of 2 similar IOLs.

Q 2006 ASCRS and ESCRS 0886-3350/06/$-see front matter

Published by Elsevier Inc. doi:10.1016/j.jcrs.2006.09.009

2050
 IOL POWER PREDICTION ACCURACY WITH 4 FORMULAS

PATIENTS AND METHODS
A retrospective review was conducted of 643 consecutive
eyes that had cataract extraction with IOL implantation under
topical anesthesia by one surgeon (R.D.S.) using the same tech-
nique. A CC4204BF Collamer plate-haptic IOL (Staar Surgical)
was implanted in 338 eyes, and an AA4203VF silicone plate-hap-
tic IOL (Staar Surgical) was implanted in 305 eyes. Inclusion cri-
teria were age 18 and older and 20/40 or better postoperative
visual acuity. Exclusion criteria were incomplete postoperative
data or perioperative complications.
All eyes had ocular biometry with immersion ultrasound by
experienced ultrasonographers. Manual keratometry was ob-
tained in all cases. The Holladay 2 formula with a customized sur-
geon factor was routinely used with both lenses to calculate the
actual IOL used.
Data were entered into the Holladay IOL Consultant software
program, which calculated results for 4 formulas: Hoffer Q, Holla-
day 1, Holladay 2, and SRK/T. The software compared the pre-
dicted final spherical equivalent (SE) refractive error in each eye
with each formula with the actual postoperative manifest refrac-
tion SE and calculated the difference as the error. The program
also calculated and used a personalized lens constant for each for-
mula. Final refraction was performed 2 weeks after surgery or
later, by which time refractive stability has been reached in
small-incision, clear corneal cataract surgery.5,6
Predictive refractive accuracy for each formula was analyzed
in all eyes. For further analysis, eyes were stratified into groups
of short, average, medium long, and very long axial length
(!22.0 mm, 22.0 to !24.5 mm, 24.5 to 26.0 mm, and O26.0 mm,
respectively).
Statistical Analysis
To determine the significance of the mean absolute differ-
ences between the 4 formulas, repeated-measures analysis of var-
iance testing was performed using SPSS statistical software
(version 12.0, SPSS, Inc.). The total experimental level of signifi-
cance was set at 0.05; however, because of multiple testing, indi-
vidual tests were done (using the Bonferroni correction) with
a significance level of 0.01. A sample size of 643 subjects has
a power of over 99% to detect a mean absolute difference of
0.25 diopter (D) among the formulas tested. For the subsets of pa-
tients with axial lengths less than 22.0 mm (n Z 25), 22.0 to less
than 24.5 mm (n Z 437), 24.5 to 26.0 mm (n Z 137), and greater
than 26.0 mm (n Z 44), the power to detect a 0.25 D difference
would be 85%, 99%, 99%, and 99%, respectively, for a Z 0.01.
RESULTS
There was no significant difference in the accuracy of
the 4 formulas in the prediction of postoperative SE refrac-
tive error measured by the mean absolute error and no dif-
ference when the eyes were stratified according to axial
length (Table 1). Although not the primary focus of the
study, the descriptive statistics in Table 2 and Table 3 sug-
gest the 2 IOLs did not act the same in the smallest axial
length group. The sample size in these subsets is small, so
no conclusions could be reached.
DISCUSSION
Since the first theoretical formula for IOL power calcu-
lation was described by Fedorov et al.7 in 1967, others (eg,
Binkhorst, Holladay, Hoffer, Sanders) have aimed to create
formulas to improve refractive outcomes. First-generation
formulas depended on a single constant to predict the post-
operative position of the IOL. Third-generation formulas
(Holladay 1, SRK/T, and Hoffer Q) aimed to predict the po-
sition of the IOL more accurately, incorporating the effect
of corneal curvature. Fourth-generation formulas such as

Table 1. Mean absolute error for all eyes by formula.

Mean Absolute Difference, Predicted Vs Actual Postop SE Refraction (D) G SD

Axial Length, mm (Range) Eyes Holladay 1 Holladay 2 Hoffer Q SRK/T P Value*
!22.0 (21.12–21.98) 25 .38
Mean G SD 0.75 G 0.56 0.75 G 0.60 0.69 G 0.48 0.77 G 0.59
Range 0.03 to 1.82 0.02 to 2.17 0.09 to 1.62 0.06 to 1.89
22.0 to !24.5 (22.00–24.49) 437 .74
Mean G SD 0.52 G 0.43 0.52 G 0.43 0.53 G 0.44 0.52 G 0.43
Range 0.00 to 2.38 0.00 to 2.46 0.00 to 2.26 0.00 to 2.49
24.5 to 26.0 (24.50–25.96) 137 .53
Mean G SD 0.49 G 0.39 0.47 G 0.38 0.50 G 0.39 0.49 G 0.39
Range 0.01 to 2.43 0.00 to 2.63 0.01 to 2.81 0.00 to 2.26
O26.0 (26.03–29.50) 44 .19
Mean G SD 0.60 G 0.62 0.53 G 0.55 0.59 G 0.58 0.55 G 0.64
Range 0.01 to 3.21 0.01 to 3.19 0.02 to 3.03 0.04 to 3.48
All eyes (21.12–29.50) 643 .45
Mean G SD 0.53 G 0.44 0.52 G 0.44 0.53 G 0.44 0.53 G 0.45
Range 0.01 to 3.21 0.01 to 3.19 0.02 to 3.03 0.04 to 3.48
SE Z spherical equivalent
*Repeated-measures analysis of variance

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 IOL POWER PREDICTION ACCURACY WITH 4 FORMULAS

Table 2. Mean absolute error in eyes implanted with the CC4204 BF IOL.

Mean Absolute Difference, Predicted Vs Actual Postop SE Refraction (D) G SD

Axial Length (mm) Eyes Holladay 1 Holladay 2 Hoffer Q SRK/T
!22.0 14 0.85 G 0.58 0.90 G 0.67 0.72 G 0.48 0.91 G 0.58
22.0 to !24.50 236 0.57 G 0.45 0.56 G 0.44 0.58 G 0.46 0.56 G 0.45
24.5 to 26.00 72 0.50 G 0.38 0.46 G 0.36 0.51 G 0.36 0.49 G 0.38
O26.00 16 0.78 G 0.73 0.65 G 0.76 0.75 G 0.70 0.65 G 0.83
All eyes (CC4204BF) 338 0.58 G 0.46 0.56 G 0.46 0.58 G 0.46 0.57 G 0.47
SE Z spherical equivalent

the Holladay 2 use other factors, such as corneal diameter
and lens thickness, in an attempt to better predict the final
position of the IOL.
Earlier IOL power calculation formulas can differ in
their predictive accuracy.2,3 Also, differences in the accu-
racy of power calculation formulas may differ for different
IOL types.8
Donoso et al.9 examined 212 eyes with the SRK II,
Binkhorst II, Hoffer Q, Holladay 2, and SRK-T formulas
and inferred that the Binkhorst II and Hoffer Q formulas
may provide the best predictive results in small eyes
(!22.0 mm) while the SRK/T may be the most accurate
for long eyes (O28.0 mm). However, the number of eyes
in the small and long axial length groups was small. A study
of Chinese patients with long axial lengths (O25.0 mm)
found the Hoffer Q formula provided the best predictive re-
sult, while the Holladay 1 and SRK/T gave comparable re-
sults.10 In that study, however, approximately half the
patients had large-incision extracapsular surgery and ap-
planation biometry was used. Both factors could affect
the variability of refractive results.
Hoffer4 examined the mean absolute error in 317 eyes
using 4 formulas. The mean absolute error tended to
be lower in average length eyes (22.0 to 24.5 mm) with
the Holladay 1 and Hoffer Q formulas. In short eyes
(!22.0 mm), the Hoffer Q and Holladay 2 had a lower
mean absolute error. The SRK/T showed a trend toward
the lowest mean absolute error in medium long (24.5 to
26.0 mm) and very long (O26.0 mm) eyes. The Holladay
2 formula trended toward the least accurate mean absolute
error of the 4 formulas in all ranges of axial length except
the shortest and very longest. However, no statistical anal-
ysis was performed.
Our relatively large study using optimized lens con-
stants, immersion ultrasound biometry, and a single sur-
geon performing surgery with modern techniques
statistically compared the refractive outcomes in 643 con-
secutive eyes with the Hoffer Q, Holladay 1, Holladay 2,
and SRK/T IOL power formulas in 4 subgroups of axial
length. The 4 commonly used modern formulas were sim-
ilar in accuracy in all subsets of axial length.
Although not the primary focus of the study, descrip-
tive statistics suggest that the 2 IOL types did not act the
same in the group with the shortest axial length. The sam-
ple size in each IOL subset was small, so no conclusions
could be reached. However, this difference indicates that
looking at these or other IOLs separately may be useful in
further research. As the formulas performed similarly, other
factors might be used to select an IOL power formula in
clinical use. These include the availability of proprietary
software and the need for additional measurements such
as IOL thickness, which would increase the preoperative
workload.
In conclusion, we found no difference in the accuracy
of IOL power prediction with the Hoffer Q, Holladay 1,
Holladay 2, and SRK/T formulas in all eyes and in 4 subsets
of axial lengths. The 4 formulas were equally accurate at all
axial lengths.

Table 3. Mean absolute error in eyes implanted with the AA4203 IOL.

Mean Absolute Difference, Predicted Vs Actual Postop SE Refraction (D) G SD

Axial Length (mm) Eyes Holladay 1 Holladay 2 Hoffer Q SRK/T
!22.0 11 0.63 G 0.54 0.56 G 0.45 0.64 G 0.50 0.60 G 0.57
22.0 to !24.50 201 0.46 G 0.39 0.46 G 0.41 0.46 G 0.40 0.47 G 0.40
24.5 to 26.00 65 0.48 G 0.40 0.49 G 0.40 0.48 G 0.43 0.49 G 0.41
O26.00 28 0.50 G 0.53 0.46 G 0.39 0.50 G 0.49 0.50 G 0.50
All eyes (AA4203) 305 0.47 G 0.41 0.47 G 0.41 0.48 G 0.42 0.48 G 0.42
SE Z spherical equivalent

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 IOL POWER PREDICTION ACCURACY WITH 4 FORMULAS

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