AAO READING

T ACT L ENS, A ND LOW V ISION

REFRACTION, CON
W E R C A L CUL A T ION AF T E R
INTRAOC U L AR L E N S P O
IV E SUR G ER Y – NO N
CORNEAL REFRACT
SP H ER IC AL O PT I C S
Ahdini Zulfiana Abidin

Supervisor :
S
dr. Muh. Irfan, Sp.M, MAR
 INTRAOCULAR LENS POWER CALCULATION AFTER CORNEAL REFRACTIVE SURGERY
• Intraocular lens power calculation is a problem in eyes that have undergone radial keratotomy (RK) or laser corneal refractive procedures. The difficulty stems from 3 sources
of errors:
• (1) instrument error,
• (2) index of refraction error, and
• (3) formula error.
Instrument Error
• first described by Koch in 1989.
• to measure corneal power
• (keratometers and corneal topographers)
cannot obtain accurate measurements in
eyes with corneal refractive surgery.
• often miss the central, flatter zone of
effective corneal power
• placido disk topography is susceptible to
similar errors and overestimates the central
corneal power,  a postoperative
hyperopic refractive surprise in myopic
eyes
• emerging technologies based on direct
anatomical analysis of the cornea
(Scheimpflug and computer modeling
techniques) may offer a truer measure of
corneal central power
Index of Refraction Error
• based on the relationship between the
anterior and posterior corneal curvatures 
relationship changes in eyes with ablative
laser procedures.
• ophthalmologists believed that IR error did
not occur in eyes with RK  an
overestimation of the corneal power by +/-
1 D for every 7 D of correction  in
hyperopic refractive surprise.
• recent study showed that in eyes treated
with RK > flattening of posterior than
anterior curvature
• both manual keratometers and
computerized corneal topographers that
measure only the front surface curvature
convert the radius of curvature (r) obtained
to diopters (D), usually by using an IR
value of 1.3375
Formula Error
• except for the Haigis formula, all the
modern IOL power formulas (eg, Hoffer Q,
Holladay 1 and 2, and SRK/T) use the AL
values and K readings to predict the
postoperative position of the IOL (ELP-
effective lens position)
• flatter-than-normal K value for eyes with
myopic refractive surgery  an error in
this prediction because the anterior
chamber dimensions do not change in these
eyes commensurately with the much flatter
K.
• these ELP errors  result in hyperopic
refractive surprise.
POWER CALCULATION METHODS FOR THE POST–KERATOREFRACTIVE PROCEDURE EYE

The double-k method uses the pre-lasik corneal power (or, if unknown, 43.50 D) to calculate The ELP, and the post-
lasik (much flatter) corneal power to calculate the IOL power. These calculations can be performed automatically with
computer programs. The double-k method is only one of more than 20 methods proposed over the years to either calculate
the true corneal power or adjust the calculated IOL power to account for the. Some methods require knowledge of pre–
refractive surgery values such as refractive error and K reading.

Many of these methods have come in and out of favor based on studies investigating their accuracy. More recent
theoretical or ray tracing formulas (olsen, barrett) may offer a more accurate alternative in abnormally sized eyes in which
previous refractive procedures have been performed, especially corneal refractive surgery. It is up to the surgeon to keep
abreast of the most accurate available methods.

Perhaps in the future there will be a more satisfactory method of measuring true corneal Power by use of topography
and advanced measuring techniques. At present, the ideal method For use with post–refractive surgery patients has yet to be
determined.
SPECIAL CONSIDERATION: POSTOPERATIVE REFRACTIVE SURPRISE IN PATIENTS WHO
HAVE UNDERGONE MYOPIC KERATOREFRACTIVE CORRECTION

• Keratometers fail to measure the flattest portion of the cornea. This overestimation of corneal power
will result in a hyperopic refractive surprise.

• Keratometers and computerized corneal topographers underestimate the relative contribution of the
posterior cornea and therefore overestimate the net corneal refractive index and overall corneal
refractive power. This overestimation of corneal power will result in a hyperopic refractive surprise.

• Standard IOL formulas estimate the ELP to be too anterior and therefore overestimate the refractive
contribution of the IOL. This overestimation of IOL refractive contribution will result in a
hyperopic refractive surprise.
INTRAOCULAR LENS POWER IN CORNEAL TRANSPLANT EYES
• It is very difficult to predict the ultimate power of the cornea after the eye has undergone penetrating
keratoplasty. Thus, in 1987 hoffer recommended that the surgeon wait for the corneal transplant to
heal completely before implanting an IOL. The current safety of intraocular surgery allows for such
a double-procedure approach in all but the rarest cases. Geggel has proven the validity of this
approach by showing that post transplant eyes have better uncorrected visual acuity (68% with 20/40
or better) and that the range of IOL power error decreases from 0 D to 5 D (95% within ±2.00 d).

• If simultaneous IOL implantation and corneal transplant are necessary, surgeons may use either the
K reading of the fellow eye or the average postoperative K value of a previous series of transplants,
but these approaches are fraught with error. When there is corneal scarring in an eye but no need for
a corneal graft, it might be best to use the corneal power of the other eye or even a power that is
commensurate with the eye’s AL and refractive error.
SILICONE OIL EYES
• Ophthalmologists considering IOL implantation in eyes filled with silicone oil encounter 2 major
problems.
• The first is obtaining an accurate AL measurement with the ultrasonic biometer. Recall that this instrument
measures the transit time of the ultrasound pulse and, using estimated ultrasound velocities through the
various ocular media, calculates the distance. This concept must be taken into consideration when velocities
differ from the norm, for example, when silicone oil fills the posterior segment (980 m/s for silicone oil vs
1532 m/s for vitreous).
• Use of optical biometry to measure AL solves this problem somewhat. It is recommended that retinal surgeons
perform an optical or immersion AL measurement before silicone oil placement, but doing so is not common practice.

• The second problem is that, as the refractive index of silicone oil is greater than that of the vitreous humor, the
oil filling the vitreous cavity reduces the optical power of the posterior surface of the IOL in the eye when a
biconvex IOL is implanted. This problem must be counteracted by an increase in IOL power of 3–5 D.
PEDIATRIC EYES
• Several issues make IOL power selection for children much more complex than that for adults.
• The first challenge is obtaining accurate AL and corneal measurements, which is usually performed when the child is
under general anesthesia.
• The second issue is that, because shorter AL causes greater IOL power errors, the small size of a child’s eye
compounds power calculation errors, particularly if the child is very young.
• The third problem is selecting an appropriate target IOL power, one that will not only provide adequate visual acuity
to prevent amblyopia but also allow adequate vision with the expected growth of the eye after the IOL implantation.

• A possible solution to the third problem is to implant 2 (or more) IOLs simultaneously: one IOL with the
predicted adult emmetropic power placed posteriorly and the other (or others) with the power that provides
childhood emmetropia placed anterior to the first lens. When the patient reaches adulthood, the obsolete
IOL(s) can be removed (sequentially). Alternatively, corneal refractive surgery may be used to treat myopia
that develops in adulthood. Most recent studies have shown that the best modern formulas do not perform as
accurately for children’s eyes as they do for adults’ eyes.
IMAGE MAGNIFICATION
• Image magnification of as much as 20%–35% is the major disadvantage of aphakic spectacles. Contact lenses
magnify images by only 7%–12%, whereas IOLs magnify images by 4% or less. An IOL implanted in the
posterior chamber produces less image magnification than does an IOL in the anterior chamber. The issue of
magnification is further complicated by the correction of residual postsurgical refractive errors. A galilean
telescope effect is created when spectacles are worn over pseudophakic eyes. Clinically, each diopter of
spectacle overcorrection at a vertex of 12 mm causes a 2% magnification or minification (for plus or minus
lenses, respectively). Thus, a pseudophakic patient with a posterior chamber IOL and a residual refractive
error of −1 D would have 2% magnification from the IOL and 2% minification from the spectacle lens,
resulting in little change in image size.

• Aniseikonia is defined as a difference in image size between the 2 eyes and can cause disturbances in
stereopsis. Generally, a person can tolerate spherical aniseikonia of 5%–8%. In clinical practice, aniseikonia
is rarely a significant problem; however, it should be considered in patients with unexplained vision
symptoms.
LENS-RELATED VISION DISTURBANCES
• The presence of IOLs may cause numerous optical phenomena. Various light-related visual
phenomena encountered by pseudophakic (and phakic) patients are termed dysphotopsias. These
phenomena are divided into positive and negative dysphotopsias.
• Positive dysphotopsias are characterized by brightness, streaks, and rays emanating from a central point
source of light, sometimes with a diffuse, hazy glare.
• Negative dysphotopsias are characterized by subjective darkness or shadowing. Such optical phenomena
may be related to light reflection and refraction along the edges of the IOL.

• High-index acrylic lenses with square or truncated edges produce a more intense edge glare (fig 6-
11A). These phenomena may also be due to internal re-reflection. Within the IOL itself; such re-
reflection is more likely to occur with materials that have a higher refractive index, such as acrylic (fig
6-11B). With a less steeply curved anterior surface, the lens may be more likely to have internal
reflections that are directed toward the fovea and are therefore more distracting (fig 6-11C, D).
NONSPHERICAL OPTICS
• IOLs with more complex optical designs are now available. It may be possible to offset the positive spherical aberration of the cornea in
pseudophakic patients by implanting an IOL with the appropriate negative asphericity on its anterior surface. IOLs with a toric surface may be
used to correct astigmatism. Rotational stability may be of greater concern when plate-haptic toric lenses are implanted in the vertical axis
than when they are implanted in the horizontal axis. As a toric lens rotates from the optimal desired angular orientation, the benefit of the toric
correction diminishes.
• Misalignment of a toric lens may occur because of excyclotorsion or incyclotorsion of the eye as the patient moves from a vertical position to a
recumbent position during surgery. Therefore, it is important to mark the eye for purposes of orientation while the patient is standing or sitting up. For the
same reason, optical registration systems obtain their orientation data while the patient is sitting up.
• A misalignment of a properly powered toric IOL of only 10° reduces its efficacy by 30% and a misalignment of more than 30° off-axis increases the
residual astigmatism of an eye; if it is 90° off-axis, the residual astigmatism doubles. Fortunately, some benefit remains even with lesser degrees of axis
error, although the axis of residual cylinder changes. Newer designs are more stable than earlier ones.

• Toric iols do not correct lenticular astigmatism and correct only that portion of corneal astigmatism that is regular. Although toric iols may
hold benefit for patients with irregular, nonorthogonal, asymmetric, or unstable astigmatism, as may occur with keratoconus, caution should
be exercised with the degree of astigmatic correction to be attempted.

• Investigators have developed an IOL in which the optical power can be altered by laser after lens implantation. Similarly, a laser system in
development may alter the optical power of a conventional acrylic lens after implantation. These technologies would be useful for correcting
both IOL power calculation errors and residual astigmatism.
THANK YOU