IOL Intraocular Lens Calculations

Prior Keratorefractive Surgery 2-variable Formulas Another Source of Errors.

OKay, Mrs. Smith had LASIK several years ago for -8.00 D of myopia and is now scheduled to undergo cataract surgery. You have carefully gathered together all of the historical information needed and have even measured the corneal power its exact center with one of the newer, very sophisticated topographers. The measured and historical numbers all line up and you are confident that your estimation of central corneal power is as accurate as possible. Using the SRK/T formula, you calculate for an IOL power that seems appropriate. Her surgery goes well, but to your great surprise, the first post-operative week Mrs. Smith has a spherical equivalent of +2.00 D. You go back and re-calculate everything, confirm the axial length and still arrive at the same IOL power. What happened? Until recently, our attention for the post-keratorefractive eye has mainly been focused on accurately determining the central corneal power. It is now becoming more widely understood that a flattened central cornea not only renders keratometry inaccurate, but also causes problems with many IOL power calculation formulas that were previously old and trusted friends. Third generation, 2-variable formulas such as SRK/T, assume that the anterior and posterior segments of the eye are mostly proportional and use a combination of axial length, and keratometric corneal power, to estimate the postoperative location of the IOL, known as the effective lens position (ELPo). If the central corneal power is very low, as we see following keratorefractive surgery, the formula assumes that the anterior chamber is shallow. Why is this important? It turns out that in a two lens system such as the eye (cornea and lens) the power of the intraocular lens can be thought of as something of a relative figure. For example, if a +21.00 D IOL placed within the capsular bag produces emmetropia, with only a 0.50 mm posterior displacement, that same lens has an effective power of +20.00 D. If that same lens is moved anterior by only 0.50 mm, it then would have an effective power of +22.00 D. Try holding your fingers 0.50 mm apart and the it's easy to see why even a small miscalculation can lead to problems. With a low central corneal power the formula makes the assumption that the IOL following cataract surgery will end up sitting closer to the cornea than normal and call for less power. And the flatter the cornea, the bigger a problem this becomes. Where the IOL power calculation formula thinks the lens will sit inside the eye can have a profound effect on the power that it recommends. Unless a correction is made for this situation, the artifact of centrally flattened Ks following keratorefractive surgery will have these formulas incorrectly assume a falsely shallow post-operative ELPo. The end result is that without a special correction, 2-variable formulas following LASIK, PRK and RK will recommend less IOL power than is actually required. This is a second, and little recognized, source of unanticipated post-operative hyperopia following keratorefractive surgery for myopia. So, what do we do? IOL power calculations following any form of keratorefractive surgery are best carried out using the Holladay 2 formula (contained within the Holladay IOL Consultant). If your office does not have this software package, a trial version can be downloaded from the Internet at: http://docholladay.com/iolprogram.html   Lacking the Holladay 2 formula, instead you can use the "double K method" in conjunction with the SRK/T, Hoffer Q or Holladay 1 formulas as described in: Aramberri J. Intraocular lens power calculation after corneal refractive surgery: Double K method. J Cataract Refract Surg 2003; 29(11): 2063-2068. View this article at: http://ascrs.org/publications/jcrs/absnov03.html along with the companion editorial piece, which has a very nice "double K method" nomogram for the Hoffer Q, SRK/T and Holladay 1 formulas: Koch, D., Wang I. Calculating IOL power in eyes that have had refractive surgery. J Cataract Refract Surg 2003 29(11) 2039-2042. This article, and its Hoffer Q, SRK/T and Holladay 1 formula correction tables can be viewed at: http://ascrs.org/publications/jcrs/editnov03.html. Both are excellent articles and well worth the time it takes to go through them. A basic correction table for the Aramberri "double K method" can be viewed for each of the following formulas based on the above article By Drs. Koch & Wang.   SRK/T Hoffer Q Holladay 1   By making this additional correction, the accuracy of your refractive outcomes in the setting of cataract surgery following keratorefractive surgery should be significantly improved.

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