IOL calculation in complex

corneal cases
Ahmed S. Bardan MSc MD PhD FRCOphth FRCSEd
Lecturer of Ophthalmology at Faculty of Medicine Alexandria University Egypt
Cornea, refractive surgery consultant, St James University Hospital, Leeds, UK
Acknowledgemnt
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• Professor Dr Alaa Al zawawy MD PhD, Professor of Ophthalmology, phth Faculty of
Medicine, Alexandria University, Egypt RC O
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Ph
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• Professor Dr Ahmed Shama MD PhD, ProfessorMof Ophthalmology, Faculty of
Medicine, Alexandria University, Egypt n MSc
rda
• Dr Ahmed Elsawy MD, Associate y B a
professor of Ophthalmology, Cairo University
a la b
• Dr Yasmin Hegazy MSc, d S h
Ophthalmologist at I-care hospital, Alexandria, Egypt
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• Dr Nancy ALtoRakkadh FRCS, Cornea and refractive surgery consultant, Chief of
cornea ig ht
specialty, Royal medical services, Jordan
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• Dr Eslam Ramadan Ophthalmology consultant, Maghrabi Hospitals, KSA
• Dr Ashraf M. Zeid MSc, Anterior segment surgeon, Eyecare center, Cairo, Egypt
Terms and conditions
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• This is a guide to assist surgeons choose the appropriate phthIOL power
RCO
for their patients with complex corneal conditions D F
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• Data is derived from literature searchSand c M our own experience
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• Surgeons must arrive at their B a rd independent determination
own
a
regarding the properhtreatment
l by for their patients and are solely
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responsible for m d
e refractive outcome
the
A h
t to
r igh
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 Post PRK/ LASIK cases

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FNo preop
Preop data Pre laser Ks
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available Surgical induced refractive correction (SIRC)
FRC data available
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an M 1- Haigis L available on IOL Master,
1- Clinical history method rd
by
(was the gold standard but not any more) Ba use IOL master K readings

Kpost = Kpre –SIRC (Myopic) Sha la

d 2- Shammas available on LENSTAR
e
hm
Kpost = Kpre +SIRC (Hyperopic)
A
t to 3- Barrett true K (ASCRS)
igh
r true K formula (Available through ASCRS)
y
2- Barrett
p
DroHill.com website tool
3- C If not matching, You can use average

Experts’ advice:
SHAMMAS Don’t aim for myopia
Barrett True K aim for slight myopia
Post RK
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• There is Diurnal variation so try to repeat biometry more pthan h t
• Always do Corneal Tomography (Pentacam or Galilei) RCO
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P hD
• Compare K readings of topography to IOL Master M D or LENSTAR to make sure
they are reliable S c
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• Don’t rely upon simK due to high B a rdradius error, use central 2.5 or 3 mm Ks
la by
• Consider toric IOLs if regular
ha Astigmatism
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• Expect postop hhypermetropia
m so experts advise target -1.0 D
to A
• Counsel ghthe
t patient about post op refractive surprises after all
yr i
p
• CUse
o ASCRS calculator tool for post RK cases
• If postop refractive surprise, wait for the refraction to stabilize before any
other considerations as postop refraction can fluctuate
 Most tools overestimate corneal power,
underestimate IOL power --> resulting in
Keratoconus patients postop hyperopia

Always compare IOL master Ks to Topography

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Mild h F RC
Moderate
pht Advanced
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FRC
Mean k 48 or
Mean k 49-55 Mean k >55
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less
D P
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an M
rd
1- Use actual k readings
by but target more myopia Ba as mild cases
Same Left for the surgeon’s judgement
Target low myopia -0.5 or -1 D
h a la May need to use standard K 43.25
2- Choose formula according to AL
e d S e.g. -1.5 D Especially if scarred cornea, future DALK
SRK T good results A hm
t toare myopic long eyes
as most of these eyes
igh
Target more myopia e.g. -2 D

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Toric IOL to be considered only if regular astigmatism + improving BSCVA using spectacles preoperatively
NO toric IOLs if vison improves only with RGP, Scleral contact lenses

New Kane formula adjusted for keratoconic patients showed better results than other available formulae available online
(Reference to evidence)
Kane JX, Connell B, Yip H, McAlister JC, Beckingsale P, Snibson GR, Chan E. Accuracy of Intraocular Lens Power Formulas Modified for Patients with Keratoconus. Ophthalmology. 2020 Aug;127(8):1037-1042. doi: 10.1016/j.ophtha.2020.02.008. Epub 2020 Apr 9. PMID: 32279887.
PKP/ DALK
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• Use standard K e.g 43.25 D if planning triple procedure
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FRC
• If patient already had PKP or DALK PhD
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Wait 3 months after full suture removal S c
Do serial topography to confirm stability a n M
B a rd
a la by by scheimpflug devices e.g. pentacam
Use True net power of the cornea generated

dS h
m e toric IOLs
If regular astigmatism, h consider
Athat they will require postop glasses or rigid contact lenses depending on how
t o
ght their cornea is
Counsel the patients
regular yorriirregular
Cop
Consider other options available (to regularize the corneal surface), like topo guided ablation before
proceeding with cataract surgery (to be judged by the surgeon on individual case basis
 Refractive surprise management
• Identifying the cause of refractive surprise
1. A formal subjective refraction is essential
2. A thorough dilated examination is necessary to identify surgical causes such as tight corneal sutures SE d,
F
placement of the IOL in the sulcus or subluxation. Look for a distended capsular bag due to retained R C
viscoelastic that can cause a myopic shift. The presence of corneal pathology such as cornealh t h scarring or
oedema can influence the refractive outcome. Post-operative cystoid macular oedema
CO p can cause a hyperopic
shift.
D FR
3. Review the refractive history as well as the biometry, the IOL selection Phprocess and the surgical records.
Wrong patient biometry, transcription errors, incorrect A-constant M D
or incorrect formula can all lead to insertion
of the wrong IOL. S c
M
aPCIn may not have been possible prior to surgery due to a
4. Check the axial length by repeating the biometry.
a rd
dense cataract.
b y B
5. Check for abnormal keratometry. The
h a lapresence of high Ks or astigmatism can indicate pre-existing
undiagnosed keratoconus.
e d S
hm the refractive surprise can be attributed to effective lens position and a similar
6. If there has been noAerror,
to in the fellow eye.
error is likely to occur
t
r ighrefraction to stabilize, treat causes like CMO, capsular distension
• Wait for
o p y the
• CDoing nothing, correction by spectacle or a contact lens is always an option
• Laser refractive surgery correction of the error
• IOL exchange
• Addon sulcus IOL
Reference: Royal College of Ophthalmologists Focus article on Management of refractive surprises