IOL power calculation

Introduction
 The aim of an accurate intraocular lens power
calculation is to provide an intraocular lens (IOL)
that fits the specific needs and desires of the
individual patient.
 The development of better instrumentation for
measuring the eye's axial length (AL) and the use
of more precise mathematical formulas to perform
the appropriate calculations have significantly
improved the accuracy with which the surgeon
determines the IOL power.
 In order to determine the power of intraocular
lens several values need to be known:
• Eye's axial length (AL)
• Corneal power (K)
• Postoperative IOL position within the eye
known as estimated lens position (ELP)
• The anterior chamber constant: A-constant or
another lens related constant
 First two are measured before the implantation,
the third parameter, the ELP, need to be
estimated mathematically before the
implantation and the last parameter is provided
by the manufacturer of the intraocular lens.
 Axial Length
 The axial length (AL) is the distance between the
anterior surface of the cornea and the fovea and
usually measured by A-scan ultrasonography or
optical coherence biometry.
 The AL is the most important factor in IOL
calculation: A 1-mm error in AL measurement
results in a refractive error of approximately 2.88
D or about 3.0-3.5 D error of IOL power in an
average eye.
 A mean shortening of 0.25–0.33mm can translate
into an error of IOL power by approximately 1 D
A high-quality A-scan should have five
spikes clearly defined and of
approximately the same amplitude.
Techniques to measure the AL
1: A-scan ultrasonography
2: Optical coherence biometry.
 Ultrasonography
 In A-scan ultrasound biometry, a crystal oscillates to
generate a high-frequency sound wave that
penetrates into the eye.
 When the sound wave encounters a media interface,
part of the sound wave is reflected back toward the
probe.
 These echoes allow us to calculate the distance
between the probe and various structures in the eye.
 Ultrasonography does not measure the distance but rather
the time required for a sound pulse to travel from the
cornea to the retina. The speed of sound varies in different
parts of the eye.
 The eye is divided ultrasonographically into four
components:Cornea, Anterior chamber, Lens thickness
and Vitreous cavity.
 The velocity of sound in these compartments are 1620,
1532, 1641, 1532 m/s respectively. Through normal eyes
an average velocity of 1555 m/s is accepted for
calculation.
A-scan ultrasound biometry
Techniques.
a) Contact applanation biometry.
b) Immersion A-scan biometry
 Contact applanation biometry.
 This technique requires placing an ultrasound
probe on the central cornea with attached slit lamp
 Since the compression error is variable, it cannot
be compensated for by a constant. IOL power
calculations using these measurements will lead
to an overestimation of the
IOL power.
 Error chances
 IOL power calculations using these measurements
will lead to an overestimation of the IOL power. In
shorter eyes, this effect is amplified.
 Probe indenting the cornea results the shallowing
of the anterior chamber. This will lead to an
overestimation of the IOL power.
 Mean shortening of 0.25–0.33 mm in axial length can
cause an error of IOL power by approximately 1 D.
 Disadvantage: Poor image resolution due to the
use of a relatively long, low-resolution wavelength
(10 MHz)
 Procedure
 Explain the procedure
 Use topical anesthesia
 clean the probe
 Probe is placed on the cornea
 The probe is attached with the device that deliver the
adjustable sound waves
 The measurements are displayed as spikes on screen of a
visual monitor
 The appearance of the spikes and the distance between
them can be corelated to the within the eye and the distance
between them
 Probe position
 The probe lightly touches the cornea and is
positioned, such that the barrel of the probe is
aligned with the optical axis of the visual axis
of the eye. The aim is the probe towards the
macula
 Alignment with the optical
axis is indicated by high lens
spikes and a high retina
spike on the scan graph.
Immersion A-scan biometry

 Which requires placing a saline filled scleral

shell between the probe and the eye.
 Since the probe does not exert direct pressure
on the cornea, compression of the anterior
chamber is avoided.
 Eyes measured with this technique are
average 0.1 to 0.3 mm more longer
 Partial coherence interferometry
In A-scan ultrasound biometry, a crystal oscillates to
generate a high-frequency sound wave that
penetrates into the eye.
When the sound wave encounters a media interface,
part of the sound wave is reflected back toward the
probe.
These echoes allow us to calculate the distance
between the probe and various structures in the eye.
Ultrasonography does not measure the distance
but rather the time required for a sound pulse to
travel from the cornea to the retina.
 The axial length obtained from PCI may be
slightly longer than that obtained from
ultrasound. This is due to PCI measuring the
distance from the corneal surface to the RPE
while ultrasound measures to the anterior
retinal surface.
Advantages
 Does not require contact with the globe, so corneal
compression artifacts are eliminated
 More accurate, reproducible AL measurement.
 PCI is also superior to ultrasound in the measurement
of pseudophakic and silicone oil-filled eyes.
Disadvantage:
 Difficult to obtain a measurement in the presence of a
dense cataract or other media opacities, which limits
the use of this technique.
IOL power calculation formulas
 Two catagories , regression formulas and
theoretical formulas. Regression formulas are
now obsolete and modern theoretic formulas
are used instead.
 The most common regression formulas are the
SRK (Sanders- Retzlaff-Kraff) and SRK II.
 P=A-0.9K-2.5L
SRKI

 P=A-(2.5L-0.9K)
 P=IOL power
 A= constant specific for each lens
 L= axial length
 K= average keratometry in diopters
SRKII
 P=A-(2.5L-0.9K)
But A is modified on the basis of the axial length
If L is < 20 mm then A +3.0
If L is 20-20.99 mm then A +2.0
If L is 21-21.99 mm then A +1.0
If L is 22-24 mm then A
If L is >24 mm then A-0.50
 Where P =IOL power
 A =IOL specific constant
 K =average corneal refractive power in diopter
 L= length of the eye in mm
The SRK II formula adjusts the A constant utilized
depending on the axial length: increasing the A constant
for short eyes and decreasing the A constant for long
eyes.
Remember

 Normal axial length is 23.06 mm

 Majority 22.0 to 24.5 mm
 Error of 0.4 mm in measurement of AL may
result in a 1 D change in IOL power
 Difference in AL measurement b/w both eyes
+/- 0.3 mm
 What is “A” constant
 The A-constant was originally designed for the SRK
equation and depends on multiple variables including IOL
manufacturer, refraction index, style and placement within
the eye.
 A-constants are used directly in SRK II and SRK/T
formulas. The constant is a theoretical value that
relates the lens power to AL and keratometry, it is not
expressed in units and is specific to the design of the
IOL and its intended location and orientation within the
eye.
 Power of the lens varies in a 1:1 relationship with the A-
constants: if A decreases by 1 diopter, IOL power
decreases by 1 diopter also.
Thank you