ADVANCED IOL POWER CALCULATIONS. Jack T. Holladay, MD, MSEE, FACS
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1 Jack T. Holladay, M.D., M.S.E.E., F.A.C.S. ADVANCED IOL POWER CALCULATIONS Jack T. Holladay, MD, MSEE, FACS I. Formulas and Measurements A. Variables Used to Predict ACD 1. Binkhorst AL 2. Holladay AL, K 3. SRK/T AL, K 4. Hoffer Q AL, K 5. Olsen AL, K, ACD 6. Clarke AL, K1, K2 ACD, LT 7. Holladay AL, K, HWTW, REF, ACD, LT, AGE B. Normal Values for required Measurements 1. Axial Length: mean = 23.5 mm, SD = 1.25 mm 2. Keratometry: mean = D, SD = 1.6 D 3. Horizontal White-to-White (Corneal diameter): mean = 11.7 mm, SD = 0.46 mm 4. Preoperative Refraction: mean = plano 5. Anterior Chamber Depth (ultrasonic): mean = 3.1 mm, SD = 0.30 mm 6. Crystalline Lens Thickness (ultrasonic): mean = 4.7 mm, SD = 0.41 mm 7. Age: mean = 72, SD = 12 years II. Axial length Measurements in Aphakic and Pseudophakic eyes A. Aphakia M/sec B. Pseudophakia 1. PMMA M/sec 2. Silicone M/sec 3. Acrylic M/sec III. Determination of corneal power following Keratorefrative Sx (PRK, LASIK, RK) A. Manual Keratometry B. Automated Keratometry C. Corneal Topography D. Calculation from pre- keratorefractive surgery K s E. Determination from hard contact lens trial IV. Data Screening Techniques on Preoperative Measurements A. Probability of unusual measurements (one eye only) B. Probability of asymmetrical measurements (both eyes) V. IOL Calculations requiring Axial Length Measurements A. Standard Cataract Removal with IOL 1. Piggy-Back IOL s: Use 34 D IOL posterior in bag 2. Multifocal IOL s: Target distance plano, near for D. 3. Toric IOL s: IOL Cylinder to Corneal Cylinder ~ 1.46, but not exact for low (1.75) and high (1.20) power IOLs a. Optimization of Cataract Incision Location: Normal 4 locations for zero residual astigmatism b. Back calculation for surprise: 1) P.O. Refraction &, 2) P.O. Ks OR Current IOL axis B. Cataract Removal with IOL and Silicone in Vitreous: use convexplano ~ 3 D more, for biconvex ~ from 5-6 D more in IOL. Page 1 of 2
2 Jack T. Holladay, M.D., M.S.E.E., F.A.C.S. VI. IOL Calculations not requiring Axial Length A. Secondary Implant for Aphakia: in sulcus or anterior chamber angle B. AC IOL in phakic patient: High myopia ( - IOL) & High hyperopia ( + IOL) C. Secondary Piggy-Back IOL for high hyperopia (or myopia within 1 year) VII. Pediatric IOL calculations A. Ideal Postoperative Target Refraction: plano to D. B. Expected Myopic Shift with age: 4 D from age 2 to age 21. VIII. Minimizing Prediction Error A. Personalizing Formula Constants (A-const, ACD or Surgeon Factor) B. Prediction Error vs. IOL Power C. Creating personalized constants for subgroups 1. Axial Length (< 22 mm or > 26 mm) 2. Keratometry (< 40 D or > 48 D) 3. Preoperative Refraction (< -4 D or > +4 D) IX. Calculating SIRC (Surgically induced refractive change) A. From pre and post operative keratometry B. From pre and post operative refraction X. Outcomes Analysis A. Prediction Error Analysis: Mean absolute prediction error should be < 0.50 D. B. Formula Comparisons: more predictors, better results in unusual eyes C. SIRC Results: Astigmatic Analysis D. Visual Acuity Results 1. Best corrected 2. Uncorrected XI. Back-calculations A. For determining source of error with refractive surprise B. Comparison of back-calculated lens constant and actual lens constant Page 2 of 2
3 9/10/2014 JTH 1 Advanced IOL Power Calculations Jack T. Holladay, MD, MSEE, FACS Clinical Professor of Ophthalmology Baylor College of Medicine Houston, Texas, USA Financial Disclosure I have the following financial interests or relationships to disclose: Acufocus Consultant Alcon Consultant AMO Consultant Oculus Consultant Visiometrics Consultant Wavetec Consultant Zeiss Consultant Jack T. Holladay, MD, MSEE, FACS Clinical Professor of Ophthalmology Baylor College of Medicine Houston, Texas 9/10/2014 JTH 4 9/10/2014 JTH 5 7 Vergence Formula 9/10/2014 JTH 6 9/10/2014 JTH Theoretical Formula has not changed in 173 years Physiologic Assumptions may be slightly different Retinal thickness Corneal Index of Refraction JACK T. HOLLADAY, MD, MSEE, FACS Page 1 of 23
4 Vergence Formula IOL ALELP 1336 ELP 1000 K 1000 DPostRx V 9/10/2014 JTH 8 9/10/2014 JTH 9 E L P Effective Lens Position Distance from corneal vertex to principal plane of thin IOL (no thickness) Same as ACD, but avoids confusion with anatomy Prediction of E L P <1980 Constant (0) Binkhorst 2 (1) AL 1988 Holladay 1 (2) AL, K 1995 Olsen (4) AL, K, ACD, LT 9/10/2014 JTH 10 9/10/2014 JTH 11 Prediction of E L P 1996 Holladay 2 (7) AL, K, 9/10/2014 JTH 12 ACD, LT, HWTW, REF, AGE Investigation International Study /10/2014 JTH investigators (15 U.S.) Additional measurements are taken 35 eyes < 21 mm 35 eyes > 26 mm 35 eyes = normal JACK T. HOLLADAY, MD, MSEE, FACS Page 2 of 23
5 9/10/2014 JTH 16 Measurements taken for Predictors of ELP Axial Length Average K Horizontal WTW ACD LT Pre-opRefraction Age HWTW Gauge Horizontal Corneal Diameter 9/10/2014 JTH 17 ASICO # AE 9/10/2014 JTH 18 9/10/2014 JTH 19 ASICO # AE Normal Eyes Short Eyes ( < 21 mm) # of Cases N = % 2% 2% Small Normal Large Anterior Segment Size # of Cases % 20% 0% Small Normal Large Anterior Segment Size 9/10/2014 JTH 21 9/10/2014 JTH 22 JACK T. HOLLADAY, MD, MSEE, FACS Page 3 of 23
6 Long Eyes ( > 27 mm) Normal Physiologic Values # of Cases % 0% 10% Small Normal Large Anterior Segment Size Al: 23.5 mm mm K: D D Hwtw: 11.7 mm mm Ref: D D 9/10/2014 JTH 23 9/10/2014 JTH 24 Normal Physiologic Values ACD: 3.1 mm mm LT: 4.7 mm mm Age: 72 years years Critical Data Corneal Power Optical Axial Length Horizontal White-to-White (11.7) AC angle = WTW (12.7) Sulcus = WTW (13.2) Bag = WTW 1.0 (10.7) 9/10/2014 JTH 25 9/10/2014 JTH 26 9/10/2014 JTH 27 CONCLUSION Eye Model must include NINE types of eyes not only THREE Anterior Segment Size Large Normal Small 9/10/2014 JTH 28 CONCLUSION: 9 EYES Megalocornea Large Eye + axial Megalocornea Buphthalmos hyperopia Megalocornea + axial myopia (0%) (2%) (10%) axial hyperopia normal axial myopia (80%) (96%) (90%) Small eye Microcornea Nanophthalmia Microcornea + axial opia (20%) (2%) (0%) Short Normal Long Axial Length JACK T. HOLLADAY, MD, MSEE, FACS Page 4 of 23
7 9/10/2014 JTH 29 Relative Importance of Predictors for ELP Axial Length 100 Average K 76 Horizontal WTW 24 Refraction 18 ACD 8 LT 7 Age 1 9/10/2014 JTH 30 IOL Power (D) EMMETROPIC IOL POWER Axial Length (mm) Large Ant. Seg. Normal Ant. Seg. Small Ant. Seg. THE HOLLADAY 2 FORMULA More Measurements More Accuracy 9/10/2014 JTH 31 9/10/2014 JTH 32 RESULTS New Holladay 2: Normal eye: 50% D Unusual eye: 50% D Previous results: Normal eye: 50% D Unusual eye: 50% D FORMULA PERFORMANCE CONCLUSIONS Mean Absolute Error (D) N = Axial Length (mm) Holladay 1 Hoffer Q SRK/T Holladay 2 Prediction Errors in Short Eyes: significantly improved by more measurements Prediction Errors in Long Eyes: due to bad Axial Lengths, B-Scan 9/10/2014 JTH 33 9/10/2014 JTH 34 JACK T. HOLLADAY, MD, MSEE, FACS Page 5 of 23
8 Myopic Staphyloma 9/10/2014 JTH 35 9/10/2014 JTH 36 Subtract from Ascan measured Axial Length ~ 0.8 mm J Cataract Refract Surg 2011; 37: Zaldivar-Holladay JCRS May 2000 Zeiss 9/10/2014 JTH 37 - IOL Master /10/2014 JTH 38 Measured mm Linear Regression to compensate for AVERAGE Index of Refraction in Long Eyes 9/10/2014 JTH 39 Zeiss-Humphrey IOL Master LenStar Difficult Cases Asteroid Hyalosis (vit. debris) Extreme Length (26.5 mm) Uses Average Index Too Long Extreme Short (< 21 mm) Pseudophakic Eyes Silicone in Vitreous 9/10/2014 JTH 40 JACK T. HOLLADAY, MD, MSEE, FACS Page 6 of 23
9 Data Screening Monocular and Binocular Using Mean and St. Dev. an exact p-value for each measurement can be calculated Any measurement beyond two Std. Dev. from the mean should be double checked (p<0.05) Data Screening Monocular and Binocular Monocular: AL = mm p = Binocular: K right - K left = 1.5 D p = /10/2014 JTH 41 9/10/2014 JTH 42 Cataract Surgery IOL Power Calculations Following Refractive Surgery Preoperative Assessment Endothelial Cell Count Pachymetry Direct 16 Corneal Topography Determining Corneal Power IOL Calculation 9/10/2014 JTH 43 9/10/2014 JTH 44 9/10/2014 JTH 45 9/10/2014 JTH 46 JACK T. HOLLADAY, MD, MSEE, FACS Page 7 of 23
10 9/10/2014 JTH 47 Corneal Power after LASIK, PRK, RK Ideally, Calculation from both surfaces Calculation from Prior Data Trial Hard Contact Lens Corneal Topography Automated Keratometry Manual Keratometry 9/10/2014 JTH 48 Corneal Power after LASIK, PRK, RK Methods listed in order of reliability Methods 3, 4 and 5 almost always exceed true power & result in hyperopic error Use lowest reliable value 9/10/2014 JTH 49 9/10/2014 JTH 50 4 mm OZ with 6 cuts ~~ D 9/10/2014 JTH 52 9/10/2014 JTH 53 JACK T. HOLLADAY, MD, MSEE, FACS Page 8 of 23
11 3 mm pinhole Rigid Contact Lens Trial Frame 9/10/2014 JTH 54 9/10/2014 JTH Calculation from Prior Data (Pre K & Δ MR known) Pre KR Mean K = D Change in SEQ Ref = D Calc Mean K = D 9/10/2014 JTH 56 9/10/2014 JTH Calculation from Prior Data (Post Std. K s & Δ MR only) Post Mean K = D Change in SEQ Ref = D STD K s: * SEQ = Calculation from Prior Data (Post Ctr Top Power & Δ MR only) Post Mean K = D Change in SEQ Ref = D Ctr Top: * SEQ = Calc Mean K = D Calc Mean K = D 9/10/2014 JTH 58 9/10/2014 JTH 59 JACK T. HOLLADAY, MD, MSEE, FACS Page 9 of 23
12 4. Trial Hard Contact Lens (Rigid Contact lens only) 9/10/2014 JTH 60 9/10/2014 JTH 61 Plano HCL Base Curve = D SEQ Ref without CL = D SEQ Ref with CL = D Front K = = D D 10% (4.50) = D Mean K = D Post-operative Initial Hyperopic Shift Long Term Hyperopic Drift ATR Astigmatism Drift 9/10/2014 JTH 62 9/10/2014 JTH 63 9/10/2014 JTH 64 9/10/2014 JTH 65 JACK T. HOLLADAY, MD, MSEE, FACS Page 10 of 23
13 9/10/2014 JTH 66 9/10/2014 JTH 67 Accuracy of EKR Prior Sx STD 4.5 (D) LASIK 0.56 RK /10/2014 JTH 68 9/10/2014 JTH 73 Holladay JT, Hill WE, Steinmueller A. Corneal Power Measurements Using Scheimpfl ug Imaging in Eyes With Prior Corneal Refractive Surgery. J Refractive Surgery 2009:25: (October 2009 Issue of J Refr Surgery) 9/10/2014 JTH 78 9/10/2014 JTH 79 Holladay Report Equivalent Keratometric Power JACK T. HOLLADAY, MD, MSEE, FACS Page 11 of 23
14 9/10/2014 JTH 80 9/10/2014 JTH 81 9/10/2014 JTH 82 9/10/2014 JTH 83 Normal LASIK RK 41 to 44 D 3 D Range 36 to 41 D 5 D Range 32 to 45 D 13 D Range Summary Optimal Zone LASIK: 4.5 mm RK: 5.0 mm Customize for small/large pupils Accuracy LASIK: 0.56 D RK: 0.94 D Error on MYOPIC side 9/10/2014 JTH 85 JACK T. HOLLADAY, MD, MSEE, FACS Page 12 of 23
15 IOL CALCS in Keratoconus Keratoconus #1 Corneal is Bifocal Patient does not look through cone for distance (may use at 10 cm as magnifier Look at Power Distribution Use Paracentral Power 9/10/2014 JTH 86 (65% Mean Power) 9/10/2014 JTH 87 Keratoconus #1 Keratoconus #1 #1 9/10/2014 JTH 88 9/10/2014 JTH 89 Keratoconus #1 ` Keratoconus Calculation #1 OS Used Km = 46.5 D => D Should have used 65% Mean 45.5 D => plano should have targeted D (-0.50 always better than +0.50) 9/10/2014 JTH 90 9/10/2014 JTH 91 JACK T. HOLLADAY, MD, MSEE, FACS Page 13 of 23
16 9/10/2014 JTH 92 Keratoconus Calculation #2 Dear Dr. Holladay, > Will you please review this case and give me some insight. A KKC with Intacs patient undewent ECCE/IOL the doc targeted -4.OO so as to not make him anisometropic. I used the Pentacam 3.0mm zone EKR and the Holladay ll formula. The patient came out Pl -0.75x 135= 20/30! UCVA = 20/40. Patient is very very happy. But, this was an unintended outcome. How does one measure the central corneal power in an Intacs pt?. Can you determine the cause of this outcome?. It appears that the cornea must be flatter than what the instruments measured? Is that a correct assumption. The suggested IOL power was 26.0D. for a target 0f When I click the keratoconous box (after the fact) for the same target the suggested IOL power was ?????? What should I have done differently! > > Please Advise! THANK YOU 1000x > Yvonne 9/10/2014 JTH 93 Keratoconus #2 Keratoconus #2 Keratoconus Calculation #2 Used Km = D => Plano, but targeted for D Should have used 65% Mean 37.7 D => D If had KKC => D (not will use steeper K to size eye) 9/10/2014 JTH 94 9/10/2014 JTH 95 Keratoconus Case #3 Dear Dr. Holladay, I am so pleased and excited to tell you about a very successful outcome involving IOL calcs on KCN patient and the assistance Holladay distribution scale on the Pentacam. I thought you might find this case interesting and gratifying at the least. Pre Op Refraction: x 075= 20/40 IOLM ks 47/54.17 x 91 1wk Post-Op Refraction : X65 = 20/50 The surgeon placed a temporal suture. Will this 1 suture significantly impact the astigmatism? I ran IOL calcs based on instructions you gave me on a similar case,previously. You instructed me to use the Ks from a paracentral region derived from the EKR Distribution scale on Holladay report. I used the Ks from the smaller peak which I approximated to be about 44D. With those Ks and Holladay consultant we obtained the above results. I think this case demonstrates the invaluable utility of the Holldaday report when calculating IOL power in pts with KCN. I attached the screenshots of Pentacam and IOL calcs. The technician who perfromed the IOL Master was unable to get ACD with IOLM and failed to get ACD with Immersion ultrasound- thats the reason that field is blank. Yvonne 9/10/2014 JTH 96 9/10/2014 JTH 97 JACK T. HOLLADAY, MD, MSEE, FACS Page 14 of 23
17 Keratoconus Calculation K mean = 48.8 D Used 44 D => SEQ = D ( X65 = 20/50) 65% mean = 46.2 D => D Always KKC Use 65% mean K 9/10/2014 JTH 98 9/10/2014 JTH 99 IOL Calcs Using Axial Length Axial Length Measurements Cataract or Clear Lens Removal Primary Piggy-Back IOL s Multifocal IOL s Toric IOL s Silicone in Vitreous Compartment Phakia AL 1555 Aphakia AL 1532 Pseudophakia PMMA AL Silicone AL Acrylic AL /10/2014 JTH 100 9/10/2014 JTH 101 Primary Piggy-Back IOL s Primary PIGGY-BACK INTRAOCULAR LENSES Current Formulas are very inaccurate ELP underestimated due to AL Back lens displaced posteriorly Severe hyperopic errors (+5 D) 9/10/2014 JTH 102 9/10/2014 JTH 103 JACK T. HOLLADAY, MD, MSEE, FACS Page 15 of 23
18 Polypseudophakia Up to 4 IOL s 9/10/2014 JTH 104 9/10/2014 JTH 105 PIGGY-BACK INTRAOCULAR LENSES J.T. Holladay Jane Leidlein James P. Gills Myra Cherchio Achieving Emmetropia In Extremely Short Eyes With Two Piggy-Back Posterior Chamber Intraocular Lenses. Ophthalmology Journal. Vol July 1996 Blue Journal 9/10/2014 JTH 106 9/10/2014 JTH 111 Primary Piggy-Back Complications Acrylic Interlenticular membrane 3 to 5 D hyperopic 3 yr Silicone Interlenticular membrane Flat Spot Minimizing Prediction Error Holladay 2 Formula Personalize Constant Prediction Error vs. IOL power Constants for Sub-groups Axial Length, K s and Refraction 9/10/2014 JTH 115 9/10/2014 JTH 120 JACK T. HOLLADAY, MD, MSEE, FACS Page 16 of 23
19 9/10/2014 JTH 125 Toric IOL s Current Formulas do not work because calculate different ELP for steep and flat meridian Predicted ELP must be the same for each meridian -- only one IOL position 9/10/2014 JTH 127 Toric IOL s Calculate IOL power for steep and flat meridian using same ELP Difference in IOL powers is the toricity necessary to completely correct corneal astigmatism Toric IOL s Always choose toricity to undercorrect corneal astigmatism WRONG! LEAVE MIN RESIDUAL CYL! Eg: Steep calc yields 24.0 D Flat calc yields 27.0 D Ideal Toricity is 3.0 D (Use 9/10/2014 JTH D with < 3.0 D of toricity) Ratio and Power of IOL Cylinder to Corneal Cylinder TABLE 1 Effective Lens Position (ELP) A-constant > Surgeon Factor > ELP > IOL POWER Resulting Ratio of IOL Toricity to 2 D of Corneal Astigmatism TABLE 2 Effective Lens Position (ELP) A-constant(D) > Surgeon Factor(mm) > ELP(mm) > IOL POWER Required IOL Toricity for 2 D of Corneal Astigmatism /10/2014 JTH 132 9/10/2014 JTH 133 JACK T. HOLLADAY, MD, MSEE, FACS Page 17 of 23
20 9/10/2014 JTH 134 Dioptric Error vs. Angular Error for a 1.00 D of astigmatism 9/10/2014 Jack T. Holladay, M.D. % Error Angle Error ( ) Dioptric Error (D) % % % % % % % Dioptric Error = 2 * Cyl * sin (angular error) 135 9/10/2014 JTH 139 9/10/2014 JTH 140 PREOP 6 D Toric IOL PREOP 6 D Toric IOL -- OD LEFT LEFT 9/10/2014 JTH 141 9/10/2014 JTH 142 JACK T. HOLLADAY, MD, MSEE, FACS Page 18 of 23
21 PREOP 6 D Toric IOL -- OS LEFT Mean Dev = D 9/10/2014 JTH 143 9/10/2014 JTH 145 9/10/2014 JTH 146 Silicone in Vitreous Cavity Use Convexo-Plano IOL to minimize effect of Silicone (add 3 D to calculated IOL) If Biconvex IOL (add 6 D to calculated IOL) When Silicone removed -- 2 to 5 D of induced myopia IOL Calculations using a Refractive Formula (ignore axial length) 9/10/2014 JTH 147 IOL Calculation without AL REFRACTION FORMULA Secondary AC or PC IOL for Aphakia Secondary Piggy-Back AC or PC IOL for Pseudophakia Primary AC IOL in Phakia IOL ELP 1000 K 1000 PreRx V ELP 1000 K 1000 DPostRx V 9/10/2014 JTH 148 9/10/2014 JTH 149 JACK T. HOLLADAY, MD, MSEE, FACS Page 19 of 23
22 Secondary Piggy-Back IOL s Indications Intolerable Pseudophakic Refractive Error Refractive Surprises Previous RK, PRK, LASIK Bad axial length - short/long Mislabeled IOL Axially displaced Misc. 9/10/2014 JTH 150 9/10/2014 JTH 151 Secondary Piggy-Back Calc Advantages over Exchange Mislabeled IOL irrelevant Less risk to capsule or zonules Mismeasured AL irrelevant No AP shift of existing IOL Fewer unknown variables 9/10/2014 JTH 152 9/10/2014 JTH 153 9/10/2014 JTH 154 9/10/2014 JTH 167 JACK T. HOLLADAY, MD, MSEE, FACS Page 20 of 23
23 IOL Power Calcs for Phakic IOLs (2º Piggy-Back & IOL Exchange after Refractive Surprise) 9/10/2014 JTH 168 Jack T. Holladay, MD, MSEE, FACS Clinical Professor of Ophthalmology Baylor College of Medicine 9/10/2014 JTH 169 Houston, Tx Phakic IOL s Compete with corneal refractive procedures for high myopia and med & high hyperopia ACL, ICL or Iris Clip? Phakic IOL s (Secondary Piggy Back IOL s) Refraction Formula 9/10/2014 JTH 170 9/10/2014 JTH 171 9/10/2014 JTH 173 Phakic IOL Calculation Input Variables Refraction and Vertex Keratometry Desired Refraction Predict ELP (ACD) Effective Lens Position IOL 9/10/2014 JTH 174 REFRACTION FORMULA ELP 1000 K 1000 PreRx V ELP 1000 K 1000 DPostRx V Holladay, J.T.: "Refractive Power Calculations for Intraocular Lenses in the Phakic Eye." American Journal of Ophthalmology. Volume 116:63-66, July JACK T. HOLLADAY, MD, MSEE, FACS Page 21 of 23
24 Phakic IOL Calculation Input Variables Refraction and Vertex Soft Contact Vtx = 0 w Small Over-Refraction (< 2 D) is most accurate. Effective Lens Position (ELP) OLD ACD Verisye Avg ELP = 4.27 mm AACD (20 y/o) = 3.60 mm AACD mm = ELPx 9/10/2014 JTH 175 9/10/2014 JTH 176 Effective Lens Position (ELP) OLD ACD Visian ICL Avg ELP = 4.00 mm Effective Lens Position (ELP) OLD ACD Visian ICL Avg ELP = 4.00 mm AACD (20 y/o) = 3.60 mm AACD mm = ELPx 9/10/2014 JTH 177 9/10/2014 JTH 178 Phakic IOL Calculations + IOL s to Specs ~ 1.5 to 1 - IOL s to Specs ~ 1.0 to 1 Approximation only 9/10/2014 JTH 179 9/10/2014 JTH 184 JACK T. HOLLADAY, MD, MSEE, FACS Page 22 of 23
25 Thank you! Sydney 9/10/2014 JTH 186 The International Society of Refractive Surgery April 23,2002 JACK T. HOLLADAY, MD, MSEE, FACS Page 23 of 23
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