The Role of

Corneal
Imaging for
IOL Planning
Cornea and Refractive: Back to the Basics
By Liz Hillman
December 2022

Elmer Luigi B. Lozada Jr., M.D.

Ospital ng Makati
 Introduction
 Corneal imaging is vital
 What instruments to use?
 What measurements inform varies.
 Dr. Douglas Koch of Collen Eye Institute and Dr. Kevin Miller of Kolokotrones
Ophthalmology
 What do they use? (Dr. Koch)
 Galilei (Ziemer) image
 Placido Topography
 Scheimpflug Tomography
 If for cataract surgery
 preservative-free tears,
 warm compresses,
 lid scrub
 What do they use? (Dr. Koch)
 Biometry:
 Lenstar (Haag-Streit)
 IOLMaster
 Get at least two measurements, preferably with two
different instruments and on separate days
 What do they use? (Dr. Miller)
 Getting the spherical power of the lens:
  standard biometer (the Lenstar LS900 or IOLMaster)
 Astigmatism management:
 Topographer or Tomographer
 Pentacam AXL Wave (Oculus)
Considerations for Quality
Images and Analysis
 1. Head Positioning
 “If the patient is too low or too high to
the measurement axis or too far to the
left or right, the technician is going to be
centering its measurements on a
different part of the cornea rather than
the actual center of the cornea.”
 Tilt of the patient’s head should also be
assessed
 Make sure that they are looking at the
right direction.
2. Flag abnormalities and reimage, if
necessary.
 Surface abnormalities (especially dry eye), contact
lenses, or debris in the tear film can “trip up
measurements”
  Look for consistency (and inconsistency)
 3. Know when reimaging won’t
improve results

  some corneas are irregular and will

not improve with repeat imaging
 The surgeon needs to know when
repeat imaging won’t make a
difference unless prior intervention
is taken
 4. Get multiple measurements
 Allows to look for consistency and inconsistencies
 The best and ideal practice.
 5. Look at the total cornea
 consider the total cornea in the IOL planning and not just
the anterior surface
 a lot of ophthalmologists still use a biometer, an IOLMaster
or Lenstar, to do their astigmatism planning
 only see a small portion of the anterior surface of the
cornea
 6. Look for LASIK and PRK 
 some of the patients don’t include these procedures in
their medical history
 Topography, tomography, or OCT
 A biometry measurement is unlikely to reveal prior
refractive surgery
 7. Onboarding new equipment
 every time you bring in new equipment, you need to
evaluate it before abandoning the old one
 ‘Garbage in, garbage out’
 “There is a famous computer saying: Garbage in, garbage out. If you
have a person not looking in the right direction, their eyes are dry, their
head is tilted 30 degrees, guess what? You’re going to get terrible
information by which to operate on,” Dr. Miller said.
 Key Points
 Lens power formulas are looking for inputs and values: the most
important ones are corneal curvature and axial length.
 Axial length is the most important to nail, with small errors in
measurement resulting in large errors in lens power.
 Corneal power:  Scheimpflug and OCT devices that look at the front
and back surface of the cornea are best for calculating a toric lens than
using a simple biometer
Thank you!
Elmer Luigi B. Lozada Jr., M.D.
Ospital ng Makati