COMPARISON OF REFRACTIVE OUTCOME BETWEEN BIOMETRY

WITH APPLANATION ULTRASOUND AND PARTIAL COHERENCE

INTERFEROMETRY ( IOL MASTER ) IN EYES UNDERGOING
PHACOEMULSIFICATION

Dissertation submitted to

THE TAMILNADU Dr. M.G.R. MEDICAL UNIVERSITY

CHENNAI, INDIA

M.S. DEGREE

BRANCH III, OPHTHALMOLOGY

MARCH 2011
 ACKNOWLEDGEMENT

I would like to thank my Almighty God for leading me all throughout my endeavours. I
would like to express my profound gratitude to professor and director Dr. C.A. Nelson
Jesudasan, M.S, D.O. M.S, FRCS (Edin & Glas) for having assigned me this very
interesting topic and for providing me all the necessary facilities and guidance to enable
me to complete my study.

I extend my heartfelt thanks to my guide Prof. Dr. C.M.Kalavathy, M.S. for her support
& guidance.

I would like to thank Prof. Dr. Amjad Salman, M.S, Registrar, who was the co-guide for
the study. I am greatly indebted to him for the enormous patience with which he dealt
with me in clarifying my doubts, encouraging me in tough times & guiding me in an
awesome way throughout this study.

I would like to thank Prof. Philip Thomas, M.D, Ph.D., MAMS, FABMS, FIMSA for
his wise counsel and guidance & helping me in this study.

I would also like to thank Dr. Ashok Balagopal, D.O. M.S. for his timely help & support.

I would like to thank my husband Dr. Praveen Antharaj D.O. M.S., M.S. who was a
constant source of encouragement & my sons Kevin Enoch and Ezra Kenneth for their
prayer support.

I would like to thank my parents Mr. K. Jeevarathinam and Mrs. K. Santha for their
moral support & prayers.

I would to thank Mr. Rajendran & Mr. Emmanuel & Mr. R. Venkatraman, and the
librarians Mr. Rajkumar & Mr. Daniel for their support.

I would also like to thank all my friends and students who helped me in this study.
 TABLE OF CONTENTS

SL No Contents Page No

1. Introduction 1

2. Aim 5

3. Review of Literature 6

4. Materials and Methods 26

5. Results 30

6. Discussion 36

7. Conclusion 47

8. Summary 48

9. Bibliography 52
Introduction
 INTRODUCTION

In modern day ophthalmic practice everybody wants precision. Achieving

perfection is one of the greatest challenges and this quest for perfection is the

restoration of normal or near normal vision after cataract surgery which is possible with

accurate intraocular lens (IOL) power calculation.

Harold Ridley was the first to successfully implant an intraocular lens on

November 29, 1949, at St.Thomas Hospital at London 1. That first intraocular lens was

in manufactured by the Rayner company of Brighton, East Sussex, England from

Perspex CQ polymethylmethacrylate (PMMA) made by ICI (Imperial Chemical

Industries). It is said the idea of implanting an intraocular lens came to him after an

intern asked him why he was not replacing the lens he had removed during cataract

surgery with a new one 2 . As an Air Force Ophthalmologist he observed that retained

foreign bodies of aeroplane canopies made of polymethyl methacrylate(PMMA) were

tolerated well by the eyes of the pilots of World War II.

The intraocular lens did not find widespread acceptance in cataract surgery

until the 1970s, when further developments in lens design and surgical techniques had

come about. From Ridley’s first lens implantation to the present day, the evolution of

IOLs are divided into five generations.

1
 Advances in technology have brought about the use of silicone and acrylic,

both of which are soft foldable inert materials. This allows the lens to be folded and

inserted into the eye through a smaller incision. PMMA and acrylic lenses can also be

used with small incisions.

With further advances the following designs have come up.

 Bifocal or multifocal lens.

 Foldable lens which may be implanted through a 3 mm incision after

 Phacoemulsification. Foldable IOLs are made of silicones, acrylics and

hydrogels.

 Injectable lens by introducing a liquid biomaterial into the intact lens

capsule.this lens have accommodative capability.

In the past (before the1980s), IOL power calculations were based primarily on

the patient’s previous refractive status before cataractous changes occurred. If the

patient was an emmetrope, he received an ideal emmetropic lens(IDEM) with IOL

power restored to emmetropic status after cataract surgery. The power of the lens was

mathematically deduced to be +17.0 D for an AC lens, +19.0 D for an iris fixated lens

and +21.0 D for a posterior chamber lens.3

The “standard lens”, was implanted in the past by making the patient myopic of

-1.0 D in order to strike a balance between distance & near vision. This lens had

+1.25D sph added to IDEM lens power for adjusting 1.0 D of myopia from the

spectacle to the IOL plane.

2
 The IOL power prediction formulae; to achieve greater levels of accuracy in

predicting the IOL power that resulted in desired post operative spherical outcomes. 4

generations of IOL formulae were enumerated.4

Broadly speaking, these formulae could either be Theoretical formulae, which

are based on mathematical principles revolving around the schematic eye, or they could

be regression formulae, which were derived from post operative outcomes & working
5
backwards (regression analysis) in order to arrive at the IOL power These include

Fyodorov, Colenbrander and Binkhorst formulae 6,7

The second generation regression derived lens power formula, like the SRK II
8
formula have been developed, providing higher accuracy for IOL power
9
determination. The SRK II formula became universal because it is simpler to derive

and manipulate than are theoretical formulae. In the past several years,a total of 71% of

cataract surgeons exclusively used SRK or SRK II formulas.10 In addition to the

validity of IOL power calculation formulae and the precision of IOL manufacturing,

preoperative biometry is a major factor in a favourable post operative refraction. The

most important step for an accurate calculation of the IOL power is the preoperative

measurement of the ocular axial length (AL).

Optical biometry based on coherence interferometry was developed in the 1990s

and is a non-contact method ; an alternative to ultrasound applanation, optical biometry

has been proved to be superior in terms of precision,resolution and accuracy of axial

11
length measurements

3
 The IOLMaster (Carl Zeiss, Germany), which is based on the principle of dual

beam partial coherence interferometry PCI was produced recently. It uses infrared light

(λ = 780 nm) of short coherence for the measurement of the optical AL, which is

converted to geometric AL by using a group refractive index. Furthermore, it measures

the corneal curvature, the anterior chamber depth, and the corneal diameter and it

calculates the optimum IOL power by the acquired biometry data, employing several

IOL power calculation formulae built into its computer software. The high precision,

resolution, accuracy, and reproducibility of the AL measurements of the IOLMaster

12-15.
have been demonstrated It is a non-contact technique, which does not require use

of topical anesthesia, thus providing comfort to the patient and preventing corneal

abrasions and the transmission of infections.

A-scan ultrasonography, with a reported longitudinal resolution of

approximately 200 μm and an accuracy of approximately 100–150 μm, is routinely

16,17
employed in the measurement of the ocular AL. Ultrasound biometry however

requires physical contact of a transducer with the eye either directly (contact or

applanation) or through an immersion bath of normal saline(immersion).

Optical biometry based on coherence interferometry is a non- contact method.

An alternative to ultrasound applanation, it has been proved to be superior in terms of

18
precision, resolution and accuracy of axial length measurements .

In this study the post operative refractive outcome obtained by the IOLMaster

was compared with that of applanation ultrasonography.

4
Aim
 AIM

To compare the Post-operative refractive outcome employing IOL Master

biometry and Applanation ultrasonography in eyes undergoing Phacoemulsification

with intraocular lens implantation.

5
Review of Literature
 REVIEW OF LITERATURE

The refractive power of the human eye depends on the power of the cornea and

the lens, the position of the lens, and the length of the eye. Accurate assessment of

these variables is essential in achieving optimal postoperative refractive results. For

patients who desire optimal refractive outcomes after cataract surgery, proper pre

calculation of IOL power is essential.

Accurate biometry is crucial in decreasing errors in IOL power calculation.

Other than using accurate formulas, the most critical step in accurate IOL power
19
calculation is axial length measurement .An error in axial length measurement of

100um can result in a postoperative refractive error of 0.28D.20

Studies conducted by Olsen showed that imprecision in measurements of

anterior chamber depth, axial length and corneal power contribute to 42%, 36% and

22%, respectively of the error in predicted refraction after implantation of IOL 21

Axial length measurement.

Currently the axial length can be obtained by using either the A-scan ultrasound

biometry, or the partial coherence laser interferometer IOLMaster.

An error of 1mm affects the postoperative refraction by 2.5D approximately.

In Ascan ultrasound biometry, a crystal oscillates to generate a high-frequency

sound wave that penetrates into the eye. When the sound encounters a media interface,

6
part of the sound wave is reflected at the internal limiting membrane back toward the

probe. These echoes allow us to calculate the distance between the probe and the

various structures in the eye.

An alternative technique to measure the axial length is by the non contact laser

interferometer(IOL Master; Carl Zeiss Meditee,Jena Germany) it measures the delay

and the intensity of infrared light reflected back from media interfaces in order to

determine the distance from the cornea to the retinal pigment epithelium.

Ultrasound biometry.

Two types of A-scan ultrasound biometry are currently in use. In applanation

biometry an ultrasound probe is placed on the central cornea, and errors in

measurement result from probe indenting the cornea and shallowing the anterior

chamber. The IOL power calculations using these measurements will lead to an

overestimation of the IOL power.

In immersion A-scan biometry a saline filled scleral shell is placed between the

probe and the eye and it doesn’t exert pressure on the cornea and compression of the

anterior chamber is avoided.

In general, immersion biometry has been shown to be more accurate than

22-25.
contact applanation biometry in several studies Hitzenberger et al found that axial

lengths measured by optical biometry were 0.18 mm longer than those measured by the

7
immersion technique and 0.47mm longer than those measured by the applanation

technique.26-27

IOL DEVELOPMENT

After Harold Ridley inserted the first posterior chamber IOL in 1949,there has

been evolution of several generation of IOLs.

FIRST GENERATION IOLs

The first generation lenses experimented by Ridley in 1948 were posterior

28-29
chamber IOLS. The drawbacks of severe postoperative reactions, high incidence

of dislocation, glaucoma and iris atrophy led to abandonment of these lenses.

SECOND GENERATION (ANTERIOR CHAMBER LENSES)

These lenses were anterior chamber angle fixated lenses. The two major

complications were; corneal decompensation and glaucoma. In most of the cases the

lens had to be removed.

THIRD GENERATION IOLs (IRIS SUPPORTED, IRIS CLIP LENSES)

Binkhorst in 1957 developed iris clip lenses which were clipped to the iris with

two anterior loops and two posterior loops extending behind the iris through the pupil.

Disadvantages were pupillary block glaucoma and iris atrophy. The lens was far in

front of the nodal point of the eye. 30-34

8
FOURTH GENERATION IOLs

Choyce’s anterior chamber one piece lens emerged in 1956.These lenses were

easy to insert and had stable fixation. There were as many as nine modifications of this

lens 35

FIFTH GENERATION IOLs

Fifth Generation IOLs are posterior chamber lenses initially modified by

removing the posterior two loops of Binkhorst’s four loop iris clip lens. Subsequently

posterior chamber IOLs for placement in the capsular bag have been designed 36-37

Advantages are;

 The lens lies close to the nodal point of the eye thereby reducing image

magnification and aniseikonia.

 Glare is eliminated because the lens is covered by the iris.

 Pupil mobility is good.

 Fundus view is good.

 There is no damage to the corneal endothelium, trabecular meshwork or iris

erosion and chances of late dislocation are nil.

Types of IOLs

Basically there are 2 types;

Three piece lens- optic and haptic made of different or same material.

One piece lens –optic and haptic made of the same material.

9
IOL POWER CALCULATION

Two methods may be used to calculate the power of the IOL to be implanted in

a particular eye;

1. Emperical,

2. Theoretical

Emperical Formula or regression formulae are derived from empirical data and

based on retrospective analysis of postoperative refraction after IOL imlplantation. The

results of a large number of IOL implantations are plotted with respect to the corneal

power, axial length of the eye, and emmetropic IOL power. In the early days of IOL

implant surgery a standard lens of plus 19.0 D was used in all cases. Calculation of IOL

Power by Biometry; three basic parameters are necessary to calculate the power by

using various formulae;

Anterior chamber depth (by A- scan ultrasonography).

Axial length of the eye (by A-scan ultrasonography).

Keratometry reading in terms of dioptric power of the eye or in terms of radius

of curvature with keratometer. The values of the above parameters are inserted to the

computer which is programmed in most of the A-scan machines for calculating power

by using different formulae.

Theoretical formulae

These formulae are based on an optical model of the eye. An optical model is

solved to determine the IOL power needed to focus light from a distant object onto the

10
retina. In the different formulae, different assumptions are made about the refractive

index of the cornea, the distance of the cornea to the IOL, the distance of the cornea to

the IOL, the distance of the IOL to the retina as well as other factors.These are called
10.
theoretical because they are based on a theoretical optical model of the eye All the

theoretical formulae can be algebraically transformed into the following;

P=[N/(L-C)]-[N K/ (N-K C)]

Where

P=Diopteric power of the lens for emmetropia

N=Aqueous and vitreous refractive index

L=Axial length (mm)

C=Estimated postoperative anterior chamber depth (mm)

K=Corneal curvature (D)

Fyodorov,Colenbrander and Binkhorst are the theoretical formulae and the most

popular one is the Binkhorst formula.

Holladay Formulae; it is said to be a second generation of theoretical formulae.

The number of parameters include retinal thickness factor, anterior chamber diameter

from angle to angle, surgeon factor, refractive index of cornea and aqueous, and many

more.

38
It is considered as the most accurate formula for power calculation The

formula is easy to optimize and works well across a wide range of axial lengths.

11
The modern formulas

These include formulas of Holladay I and II, Hoffer Q, SRK/T formula Haigis

d- formula and Lin’s formula.

Sanders- Retzlaff- Kraff (SRK) Formula

The most popular regression formula is the SRK formula which was developed

by Sanders, Retzlaff and Kraff in 1980. This is given by;

P=A-2.5L-0.9K

Where,

P=Implant power to produce emmetropia,

L=Axial length (mm),

K=Average keratometer reading, and

A=Specific constant for each lens type and manufacture.

The SRK formula calculates the IOL power by linearly regressing the results of

previous implants and it will overestimate the power of low powered lenses and under

estimate the power of high powered lenses compared to theoretical calculation.

SRK II Formula; In this formula, the A constant is adjusted to different axial length

ranges. It is given by; P=A1-0.9K-2.5L

A1=new constant

A1=A+3 if, axial length L< 20 mm

12
A1=A+2 if, L is 20 to 21 mm

A1=A+1 if, L is 21 to 22 mm

A1=A if, L is 22 to 24.5 mm

A1=A-0.5 if, L > 24.5

Factors affecting accuracy of IOL power calculation

Many factors can affect the accuracy of the power of the IOL calculated.

Keratometry

Keratometers only measure the radius of curvature of the anterior surface. This

measurement must be converted to an estimate of the refracting power of the cornea in

diopters using a fictitious refractive index. The variability can alter calculated corneal

dioptric power by 0.7 D.A 0.25D error in Keratometry corresponds to about 0.25D

error in postoperative refraction.

Axial length measurement

Indentation of the cornea by the Ascan instrument tip can alter the axial length

affecting the accuracy of the IOL power and lower the axial length reading.A 0.1 mm

error in axial length measurement results in about 0.25 error in postoperative refraction.

Axial length correction factor

The distance from the vitreoretinal interface to the photoreceptor layer has been

estimated to be 0.15 to 0.5mm.This distance can affect the accuracy of the IOL power

calculated.

13
Site of loop implantation

Positioning the posterior chamber IOLs in the capsular bag places the implant

further back in the eye and decreases the effective power of the lens. There is usually a

0.5 to 1.5 D loss of effectivity by placing the implant in the capsular bag as opposed to

the ciliary sulcus. A high power lens should therefore be used when the implant is

placed in the capsular bag.

A-Constant error

A-Constant error in SRK formula may also be a source of error in IOL power

calculation.

A-Constant represent averages of A-Constants for a particular design of IOL

determined by a group of surgeons which are dependent on the surgical technique

adopted by those particular surgeons. These values may not be accurate for another

surgeon using the same IOL design.

Orientation of planoconvex implants

Flipping of the implant with the plano surface of the lenses forward decreases

the effective power of the lens by 0.75 D even if the lens is unchanged. This leads to a

loss of 0.5 D loss of effectivity because the principal plane of the lens is further

displaced back into the eye.

14
Postoperative change in corneal curvature

Suturing of a cataract incision tends to steepen the vertical meridian and affects

the post operative refraction of the patient.

Density of the cataract

In a dense cataract the ultrasonic waves travel faster whereas in an early cataract

the ultrasonic waves travel slower.

IOL tilt and decentration

When a lens is tilted, its effective power increases and plus cylinder

astigmatism is induced about the of the lens tilt. The tilting of the lens occurs if one

loop is in the capsular bag and the other is in the sulcus. Alternatively, residual cortex

can cause an inflammatory response which causes contraction and pulling unequally on

parts of the loops and the optic.

A-scan biometry

A-scan ultrasound probes use a frequency of approximately 10 million Hz. In

A-scan biometry, the sound travels through the solid cornea, the liquid aqueous, the

solid lens, the liquid vitreous, the solid retina, choroid, sclera, and then orbital tissue;

therefore, it continually changes velocity. The known sound velocity through the

cornea and the lens (average lens velocity for the cataract age group ie, approximately

50-65 y) is 1641 meters/second (m/s), and the velocity through the aqueous and

vitreous is 1532 m/s. The average sound velocity through the phakic eye is 1550 m/s 39.

The sound velocity through the aphakic eye is 1532 m/s, and the velocity through the

15
pseudophakic eye is 1532 m/s plus the correction factor for the intraocular lens (IOL)

material.40-44

In A-scan biometry, one thin, parallel sound beam is emitted from the probe tip

at its given frequency of approximately 10 MHz, with an echo bouncing back into the

probe tip as the sound beam strikes each interface the contact (or applanation method)

of biometry was accomplished by gently placing the probe on the corneal vertex and

directing the sound beam through the visual axis. This handheld method was most

easily and accurately performed with the patient in a reclined position with the patient's

head placed in front of the display screen of the biometer. The patient was instructed to

look at a target affixed to the ceiling. Using a gentle on-and-off technique allowed for

less corneal compression since the examiner's hand was braced more firmly.

When the sound beam incidence is perpendicular to the visual axis (upper

image), most returning echoes are received back into the probe tip to be interpreted on

the display as high-amplitude spikes. When the sound beam incidence is non

perpendicular to the visual axis (lower image), part of the returning echo is reflected

away from the probe tip, with only a portion received by the probe. As a result, the

spikes will be compromised.

The echoes received back into the probe from each of these interfaces are

converted by the biometer to spikes arising from baseline. In the case of a cataractous

lens, multiple spikes occur within the central lens area as the sound beam strikes the

16
differing densities within the lens nucleus. This spike height, or amplitude, is therefore

what gives the information on which to base the quality of the measurements.

Zeiss IOLMaster

The Zeiss IOLMaster was approved by the United States Food and Drug

Administration in March of 2000. A non-contact optical device that measures the

distance from the corneal vertex to the retinal pigment epithelium by partial coherence

interferometry, the IOL Master is consistently accurate to within ±0.02 mm or better

45.
The IOL Master is the first such device to be widely used in clinical ophthalmology.

Calibrated against the ultra-high resolution 40-MHz Grieshaber Biometric System, an

internal algorithm approximates the distance to the vitreoretinal interface, for the

equivalent of an immersion A-scan ultrasonic axial length.45

The IOLMaster is based on the principle of dual beam PCI and uses incident

light of 780 nm wavelength emitted from a semiconductor diode laser in a Michelson

interferometer set-up. This light is split by a beam splitting prism into two parallel

beams of different optical paths and directed at the eye. The light is reflected by the

optical surfaces of the eye and interference is produced if the optical path length of the

two beams is equal. The interferometer mirror is moved longitudinally across the

measuring range to locate constructive interference by a photo detector and therefore

the position corresponding to the axial length.

Considering the fact that axial length measurements by A-scan ultrasonography

(using a standard 10-MHz transducer) have a typical resolution of 0.10 mm to 0.12

17
mm, The IOLMaster uses infrared light source and has a fivefold increased accuracy in

axial length measurements. The IOL Master allows fast, accurate measurements of eye

length and surface curvature, necessary for cataract surgery. The IOL Master is more

efficient because it allows measurements to be taken with complete confidence in the

accuracy of the results. Also, because the IOL Master is non-contact (nothing touches

the eye itself), there is no need for anesthesia and there is no potential for spread of

contamination from the IOLMaster.45

Optical Biometry (PCI), Technology is based on laser interferometry with

partial coherent light, often termed partial coherence interferometry (PCI). Resolution

of axial length measurements is 0.01 mm. light of the IOL Master is reflected at the

level of retinal pigment epithelium. 45

TECHNIQUE

Patient is seated on a chair with chin resting on the chin rest. The overview

mode is used for course alignment. The patient looks at a small yellow fixation light.

The patient then looks at the small red fixation light so that accurate axial length

measurements are done. The examiner selects a best area and takes measurement of the

axial length. An ideal axial length display is far more important than high signal noise

ratio (SNR).

Ideal Axial Length Recording

The characteristics are ;

1. SN ratio greater than 2.0.

2. Tall narrow primary maxima, with a thin well center termination and

one set of secondary maxima.

18
 3. At least 4 out of 20 measurements should be within 0.02mm of each

other.

Pros/Cons of Optical Biometry

Pros

• Non-contact patient friendly, no risk of infection from patient to patient

• Speed of measurement (< 1 minute)

• Operator independent high reproducibility of results.

• Machines (i.e. IOL Master) also calculate corneal curvature (K’s), anterior chamber

depth, and IOL power.

Non dependent on media (silicon filled eyes) and also useful in high myopes or

hypermetropes. It is an examiner- independent tool providing reproducible and

accurate values thereby decreasing deviation from the post operative target refraction.

Can be performed easily in children.

Cons

IOLMaster being optical device, any media opacities in axial region will cause

problem in measurement

• Poor signal reflected at the retina with:

• Dense cataracts –mature or dark brown/ black cataracts

• Epiretinal membranes

• Corneal scars or vitreous haemorrhage.

• Difficult to obtain measurements if patient is poor fixator.

IOLMaster measures the central power by Automated Keratometry. The

instrument takes five Keratometry readings within 0.5 seconds and takes the average.

19
 IOLMaster also measures anterior chamber depth using lateral slit illumination

at approximately 300 to optical axis.

The various formulae put in IOLMaster are Holladay, SRK/T, Haigis, SRKII

and Hoffer Q.

Thus with the introduction of IOLMaster, there is new era of high resolution

lens power calculation which is highly accurate.

Points to be remembered while doing biometry are ;

IOLpower calculation should ideally be done for both the eyes though the

operation is planned for one eye.

Measurement should be repeated if –

 Axial length is less than 22mm or more than 25mm.

 Difference between the 2 eyes is: mean corneal power more than 1D and axial

length more than 0.3mm.

46
The study by Bhatt et al (2008) was done to ascertain whether IOL Master

or ultrasound biometry provides a more accurate prediction of refractive outcomes in

cataract surgery. The mean (SD) of the difference between predicted refraction and

final spherical equivalent was -0.43(0.84) diopters (D) for the IOLMaster and -0.60

(0.87)D for ultrasound biometry,indicating that, on average, the IOLMaster was a

closer predictor than ultrasound biometry of the final spherical equivalent (p<.001).

20
The IOLMaster had a 5% higher likelihood of predicting a spherical equivalent within

0.25 D than did ultrasound biometry (P=.06), an 8% higher likelihood of predicting a

spherical equivalent within 0.50 D (P<.001), and an 8% higher likelihood of

predicting a spherical equivalent within 1.00 D (P<.001).These authors concluded that

the IOL Master is a better predictor of postoperative refraction than ultrasound

biometry, particularly within close ranges

Rajan et al (2002) 47 compared optical biometry based on the partial coherence

laser interferometry principle to conventional ultrasound biometry in the accuracy of

intraocular lens power calculations. The role of partial coherence laser interferometry in

pseudophakic axial length measurement was analysed in the study. One hundred

patients were included in this prospective randomised trial, of whom 50 patients

underwent optical biometry by the partial coherence laser interferometry (PCLI) and 50

patients had biometry by applanation ultrasound. Eighty-seven percent of patients were

within +/- 1 D in the PCLI group as compared to 80% in the ultrasound group (P =

0.24). The mean absolute error(MAE) of axial length difference with optical biometry

was 0.13 mm +/- 0.13 SD (range -0.42 to 0.78 mm) in the PCLI group and 0.19 +/-

0.13 mm in the ultrasound group. These authors concluded that non contact optical

biometry using the PCLI principle improves the predictive value for postoperative

refraction and is a reliable tool in the measurement of intraocular distances in

pseudophakic eye.

21
 48
Findl et al (2001) evaluated the feasibility of using a new optical biometry

technique,namely, dual-beam partial coherence interferometry, to improve intraocular

lens power prediction in cataract surgery. Preoperative axial length data obtained with

PCI biometry and applanation ultrasound biometry in 77 eyes of 51 patients was

applied to 4 commonly used IOL power formulas. The refractive outcome and the mean

absolute error (MAE) were calculated for each formula using both biometry methods.

Using PCI instead of ultrasound biometry significantly improved the refractive

outcome with all 4 IOL power formulas. Partial coherence interferometry biometry

applied to several widely used IOL power formulas yielded significantly better IOL

power prediction and therefore refractive outcome in cataract surgery than ultrasound

biometry.

Kiss et al (2002)49 evaluated the refractive outcome of cataract patients 3

months postoperatively using optical biometry obtained with a prototype version (axial

length measurement, ALM, Carl Zeiss Jena) of the commercial partial coherence

interferometry instrument (IOLMaster). Forty five patients with age-related cataract in

both eyes were scheduled for bilateral cataract surgery. Axial length was measured

preoperatively with a prototype (ALM) of the commercial PCI instrument as well as

with immersion ultrasound.Interestingly, refractive outcomes with the 2 techniques did

not differ significantly (P =.28).

22
 Eleftheriadis et al (2003) 50 studied the refractive outcome of cataract surgery

employing IOLMaster biometry data and compared it with that of applanation

ultrasonography in a prospective study of 100 eyes that underwent phacoemulsification

with intraocular lens implantation. The Holladay formula using IOLMaster data was

employed for the prediction of implanted IOLs. One month after cataract surgery the

refractive outcome was determined. Preoperative applanation ultrasonography data

were used retrospectively to calculate the IOL prediction error. Then the two different

biometry methods were compared. The optical axial length obtained by the IOLMaster

was significantly longer (p<0.001, Student's t test) than the axial length by applanation

ultrasound,((23.36 (SD 0.85) mm v 22.89 (0.83) mm)). The mean postoperative

spherical equivalent was 0.00 (0.40) D and the mean prediction error -0.15 (0.38) D.

This author concluded that IOLMaster optical biometry improves the refractive results

of selected cataract surgery patients and is more accurate than applanation ultrasound

biometry.

51
Gokhan et al (2007) Compared the refractive outcomes of Optical

Coherence Biometry and Applanation Ultrasound Biometry in 17 High-Myopic eyes

with Posterior Pole Staphyloma. The optical coherence biometry provided more

accurate IOL power calculations than did applanation ultrasound biometry in patients

with high myopia and posterior pole staphyloma

23
 Rose et al (2003) 52 conducted a study of comparison of axial length estimates

using applanation A-scan ultrasound and the Zeiss IOL Master. The accuracy in

predicting postoperative refraction determined by each method was also compared. On

average the axial lengths measured by the IOL Master were longer by 0.15 mm

compared to ultrasound biometry (P < 0.01). Using the IOL Master over applanation

ultrasound biometry significantly improved the postoperative refractive outcome from

0.65 D to 0.42 D (P = 0.011).These authors concluded that IOL Master provides an

accurate axial length measurement and results in accurate intraocular lens power

calculation based on the SRK/T formula. Furthermore they feel that this is quick and

easy to use and provides a non-contact technique with no risk of infection or corneal

abrasion

Vashist et al (2008) 53 studied the prevalence of lens opacities in older people

in 2 study centres in north and south India. Digital images of lens opacities were

graded by type and severity using the lens opacity classification System lll (LOCS).

The prevalence of any cataract was 73.6% and similar in the two centres(p=0.2)Type of

cataract differed in prevalence between the centres; nuclear 60.0%in north India,48.0%

in south India; cortical 9.6%in north India and 12.8%in south India. prevalence of any

cataract rose with age and similar patterns with age and gender were observed for each

type of cataract.

24
 54
Ueda et al (2010) evaluated the relationship between cataract density and

the deviation from the predicted refraction. Axial length (AL) was measured in eyes

mainly nuclear cataract using partial coherence interferometry (IOLMaster).The post

operative AL was measured in pseudophakic mode. The AL difference was calculated

by subtracting the postoperative AL from the preoperative AL.Cataract density was

measured with the pupil dilated using anterior segment Scheimpflug imaging. The

predicted postoperative refraction was calculated using the SRK/T formula. The mean

absolute prediction error (MAE) was calculated and correlated with cataract density

(r=0.37, P=.001) and the AL difference (r=0.34, P=.003) but not with other parameters.

The AL difference was correlated with cataract density (r=0.53, P<.0001). The

postoperative refractive outcome was affected by cataract density.

25
Materials & Methods
 MATERIALS AND METHODS

This study entitiled “Comparison of refractive outcome between biometry

with Applanation ultrasound and IOLMaster in eyes undergoing Phacoemulsification”

was a prospective study on 100 eyes of 100 patients who attended Joseph Eye

Hospital, Trichy, between January 2010 and April 2010. This study was approved by

the Institutional Ethics Committee.

Selection criteria -Patients with age related cataracts with no other ocular pathology

or history of ocular surgery were included in the study.

Exclusion criteria - Age related macular degeneration

- Diabetic retinopathy

- Glaucoma

- Macular disorder

-corneal disorders

-Dense cataracts

Data collection and demographic details included; age, sex, pre-operative

refractive error, type of cataract, type of IOL implantation, post operative visual acuity

and post operative refractive value by the Autorefractometer at 6 weeks follow up

visit.

26
• Procedure - The clinical history of each patient was first elicited for systemic
illnesses such as Diabetes mellitus and Hypertension. Visual acuity was checked for

the patients at 6 metres distance with Snellen’s chart. A detailed slit lamp

examination of the anterior segment was done and the type of cataract was recorded.

Fundus examination was done in detail with +90D lens on all the patients. The

refractive status of the patients was evaluated using an Autorefractometer (Topcon

8000B).

• The patients were randomised into 2 groups. Keratometry and A scan

ultrasonography by Ocuscan was done in 50 patients and ocular biometry was done

by IOL Master in 50 patients and the IOL power calculation was done based on

SRK II formula.

A Scan ultrasound by Ocuscan- Procedure-The patient’s cornea was

anaesthetised by instilling 2% xylocaine eye drops and the probe was placed on the

patients cornea. Probe is attached to a device that delivers adjustable sound waves. The

measurements are displaced as spikes in the screen of an oscilloscope (visual monitor).

The appearance of the spikes & the distance between them can be correlated to the

structures within the eye & the distance between them.

Keratometry was done with the Automated keratometer where the central 3mm

of the corneal curvature was measured.

27
 Intraocular tension was recorded with the non contact tonometer (NCT). The

type of IOL whether foldable or rigid IOL was selected according to the patients

choice.

All the patients underwent uncomplicated Phacoemulsification surgery through

a 3.2 mm superior temporal scleral incision with IOL implantation in the capsular bag

by a single surgeon.

Post operatively all the patients were reviewed at 6 weeks, and

Autorefractometry was done and the vision was recorded by Snellens chart. The

residual astigmatism was calculated for all the cases by subtracting from the

preoperative value.

The final spherical equivalent was evaluated and compared between the 2

groups.The results obtained are presented as mean (SD) values and measured range

indicating minimums and maximums.For comparison of the means, paired students t

test was used for statistical analysis.

• SRK II FORMULA - Was described by Donald Sanders, John Retzlaff and

Kraff 55-57 in the mid 1980’s. The formula attempted to predict the IOL power based

on the axial length and the average central corneal power.

• P= A-2.5L-0.9K.

P=Lens implant power to produce emmetropia(D)

28
• L=Axial length in millimeters.

• K=average central corneal power in Diopters.

• A=Specific constant for each lens type and/ or manufacturer

For each millimeter of change in axial length,a 2.5 D change in lens implant

power occurs in opposite direction. The implant power for emmetropia decreases by

2.5 D for each millimeter increase in axial length, and vice versa.

For each diopters change in K reading, a 0.9 D change in lens implant power

occurs in the opposite direction. The implant power for emmetropia decreases by 0.9 D

for every diopters increase in K readings and vice versa. The A constant is greater, the

closer the lens implant is to the retina the A constant for a given style of lens implant

from the same manufacturer can be determined.

29
Results
 RESULTS

In this prospective study performed at a tertiary eye care hospital in Tamilnadu

from January 2010 to June 2010 (six months), 100 eyes of 100 patients, who were

posted for phacoemulsification surgery, underwent preliminary testing of various

parameters of refraction by conventional Ascan ultrasonography (50 eyes) or by the

newer technique of partial coherence interferometry (PCI) using the IOLMaster TM.

1. AGE DISTRIBUTION

In the IOLMaster group five patients were 45-50 years of age,18 patients were

56 to 60 years of age and 27 patients were 61 to 75 years of age. In the Ascan

ultrasonography group, seven patients were in the age group 45-50 years, 14 patients in

the age group 56 to 60 years and 29 patients in the age group 61 to 75 years (Table 1).

The mean age was 60.82 ± 10.5 years in the IOLMaster group and 60.64 ±11.2

years in the Ascan ultrasonography group (Tables 2,3).This difference was not

statistically significant [unpaired ‘t’ test (degree of freedom (d. f.)=98) =0.0824; P(2-

tailed )=0.9341].

2. GENDER DISTRIBUTION

There were 31 males (62%) and 19 females (38%)in the IOLMaster group,

compared to 22 males (44%) and 28 females (56%) in the Ascan ultrasonography group

(Table 4);this difference was not statistically significant (Pearson’s chi –square (d.f=1)

=3.25;P=0.07).

30
3. LATERALITY OF THE TEST EYE

The right eye was the study eye in 31 patients and the left eye in 19 patients in

the IOLMaster group, compared to 33 patients and 17 patients respectively in the

Ascan ultrasonography group (Tables 2,3); this difference was not statistically

significant [Pearson’s chi-square (d.f=1)=0.492; P=0.48].

4. VISUAL ACUITY AT PRESENTATION

The preoperative visual acuity of the test eyes in the IOL Master group was as

follows; vision better than 6/24 in 22 (44%) eyes, vision between 6/36 and 6/60 in 13

(26%) eyes and vision worse than 6/60 in 15 (30%) eyes. In the Ascan

ultrasonography group, vision less than 6/24 occurred in 19 (38%) eyes, between

6/36 and 6/60 in 13 (26%) eyes and vision worse than 6/60 in 18 (36%)

patients.(Table 5) These differences were not statistically significant [Pearson’s chi-

square (d.f=2)=0.5; P>0.05]

5. INTRAOCULAR LENS (IOL) POWER

A total of seven (14%) eyes had IOL power in the range of 16-18D in the

IOLMaster group and four eyes (8%) in the Ascan ultrasonography group. In the 19-

21D range, there were 31(62%) eyes in the IOLMaster group and 22 (44%) eyes in

the Ascan ultrasonography group. In the 22-24D range there were 12 (24%) eyes in

the IOLMaster group and 24 (48%) eyes in the Ascan ultrasonography group (Table 6).

These differences were statistically significant [Pearson’s chi square (d.f=2)=6.34;

p<0.05].

31
6. AXIAL LENGTH

The pre-operative mean axial length (AL) was 23.27±0.98mm in the IOLMaster

group and 23.01±1.58mm in the Ascan ultrasonography group (Tables 2,3).This

difference was not statistically significant [unpaired ‘t’ test(d.f=98)=0.9888;

P(2-tailed)=0.3252]

7. POSTOPERATIVE REFRACTION

Six weeks following surgery, the mean spherical equivalent in the IOL Master

group was 0.5752± 0.3450 (Table 2), while the mean spherical equivalent in the Ascan

ultrasonography group was 0.6358 ±0.3918 (Table 3); this difference was not

statistically significant [unpaired ‘t’test (d.f=98)=0.9446;P(2-tailed)=0.3472].

In the IOLMaster group, nine (18%) of 50 eyes had a final refractive error of

<0.25D and in the Ascan ultrasonography group, it was 12 (24%) of 50 eyes (Table

7); this difference was not statistically significant [Pearson’s chi-square

(d.f.=1)=0.542; P (2-tailed)=0.46]

In the IOLMaster group, 23 (46%) of 50 eyes had a final refractive error of

<0.5D and in the Ascan ultrasonography group it was 21 (42%) of 50 eyes; (Table

7);this difference was not statiscally significant [Pearson’s chi-square(d.f=1),=0.162;

P(2-tailed)=0.69]

32
 When comparing the number of eyes with a postoperative spherical equivalent

≤ 1.0 D, it was 44(88%) of 50 eyes in the IOLMaster group and 44(88%) of 50 eyes

in the Ascan ultrasonography group (Table 7).

The number of eyes with >1.0 D of postoperative refractive error was six

(12%) of 50 eyes in the IOLMaster group and also six eyes (12%) in the Ascan

ultrasonography group (Table 7)

8. POSTOPERATIVE VISUAL ACUITY

The number of eyes with uncorrected visual acuity of 6/9 or better in the

IOLMaster group was 37(74%) whereas in the Ascan ultrasonography group it was 39

(78%) (Table 8); this difference was not statistically significant [Pearson’s chi square

(d.f=1)=0.219;P(2- tailed) =0.639575]

The number of eyes with uncorrected visual acuity of 6/12 or better in the

IOLMaster group was 46 eyes(92%) whereas the number of eyes with uncorrected

visual acuity of 6/12 or better in the Ascan group was 47 eyes (94%) (Table 8); this

difference was not statistically significant [Pearson’s chi-square (d.f.=1)] =0.154; P(2-

tailed=0.69109).

9. TYPES OF CATARACT

In the IOLMaster group, there were 36 (72%) eyes with nuclear cataract and 14

eyes (28%) with both nuclear and posterior subcapsular cataract, whereas in the Ascan

group there were 35 (70%) eyes with nuclear cataract and 15(30%) eyes with both

33
nuclear and posterior subcapsular cataract(Table 9); and this difference was not

statistically significant [Pearson’s chi-square (d.f. =1)=0.049; P(2-tailed=0.825575]

10. MISCELLANEOUS FACTORS POSSIBLY INFLUENCING OUTCOME

Factors reported to influence the accuracy of pre-operative biometric

measurements in relation to postoperative refractive outcomes include patient age and

gender and pre-operative measurements of axial length and visual acuity. Hence these

factors were evaluated by categorising patients according to the postoperative spherical

equivalent (SE) into three groups;≤0.5D, >0.5 to 1.0D and >1.0D.In the IOLMaster

group, 23 patients had post-operative spherical equivalent of ≤0.5D, 21 had an SE of

>0.5 to 1.0 D, and six had an SE >1.0D (Table 2);corresponding figures in the Ascan

ultrasonography group were 22,22 and six (Table 3).

With reference to age, in the IOLMaster group,the mean age(in years) in the

three categories (SE≤0.5D, >0.5D to1.0D, >1.0D) was 60.22±9.73, 60.62±10.7 and

63.83±13.8,respectively;the differences were not statistically significant [one –way

ANOVA,(d.f.=23)Fisher F-value=0.28, P=0.757] (Table 2).

In the Ascan ultrasonography group, the mean age (in years) in the three

categories of SE was 60.77 ± 9.58, 60.32 ± 11.65 and 61.33 ±16.49, respectively,

these differences were not statistically significant (one –way ANOVA [d.f=2] Fisher F-

value= 0.021; P=0.979) (Table 3).

With reference to gender, in the IOLMaster group,there were 15 males and 8

females in the SE≤0.5D category, 13 males and 8 females in the SE>0.5 D to 1.0 D

34
category, and three males and three females in the SE>1.0D category; these differences

were not statistically significant(Pearson’s chi-square [d.f.=13]=0.417;P=0.51(Table 2).

In the Ascan ultrasonography group, there were 11 males and 11 females in the SE

≤0.5D category, seven males and 15 females in the SE>0.5 to 1.0D category, and four

males and two females in the SE>0.1 D category ; these differences were not

statistically significant (Pearson’s chi-square test [d.f=1]=1.422, P=0.233) (Table 3).

Another factor considered was the pre-operative axial length (AL). In the

IOLMaster group, the mean AL(mm) was 23.24±1.0,23.21±1.06 and 23.19±0.67 in the

SE ≤0.5D, SE>0.5 to 1.0 D and SE>1.0 D categories, respectively (Table 2) ;these

differences were not statistically significant (one way ANOVA [d.f.=2] Fisher F

value=0.114;P=0.893). Corresponding values in the Ascan ultrasonography group

were 23.23 ± 2.13, 22.93 ± 0.95 and 22.37± 0.72mm respectively (Table 3); these

differences were not statistically significant [one way ANOVA(d.f.=2)Fisher F value

=0.735; P=0.485.

The pre-operative visual acuity was also considered as a possible influencing

factor (Table 10). In the IOLMaster group, four (17%) of 23 patients in SE≤0.5 D

category, four (19%) of 21 patients in the SE>0.5 to 1.0D category and one(17%) of six

patients in the SE >1.0 D category had pre-operative visual acuity of 6/12 or better

;these differences were not statistically significant (chi-square

[d.f=1]=0.004;P=0.9465). In the Ascan ultrasonography group, corresponding figures

were four (18%) of 22, five (23%) of 22 and one(17%) of six; these differences were

not statistically significant (chi-square [d.f.=1]=0.047;P=0.8277).

35
 Table – 1
Age distribution of patients in the study groups

Age( in yrs) Study groups

IOL Master* A – Scan**
45 to 50 5 7
51 to 60 18 14
61 to 75 27 29

*Patients underwent pre-operative biometry with IOLMaster .

** Patients underwent pre-operative biometry with Ascan ultrasonography.

Age Distribution

29
30 27
25
20 18
No of eyes

14
15
IOL Master
10 7
5 A - Scan
5
0
45 - 50 51 - 60 61 -75

Age in yrs
 Table - 2

Salient characteristics of Patients / Eyes in the IOLMaster group

(underwent pre-operative biometry with IOLMaster)

Parameter Overall Categories based on Spherical Equivalent (SE)

≤0.5D >0.5 TO 1.0D >1.0D
Mean Age(yrs) 60.82 + 10.5 60.22 + 9.73 60.62 + 10.7 63.83 +13.8
Gender M=31 F=19 M=15 F=8 M=13 F=8 M=3 F=3
Affected eye R=31 L=19 R=15 L=8 R=11 L=10 R=5 L=1
Mean axial 23.27 +0.98 23.34 +1.0 23.21 +1.06 23.19 +0.67
length (AL)
(mm)
Mean spherical 0.57 + 0.35 D ------ ----- -----
equivalent (SE)

Abbreviations: M=males; F=females; R=right eye; L = left eye d.f. = degrees of

freedom

Statistical Analysis
a) Age: IOL Master vs. AScan Unpaired ‘t’ test (d.f.=98)=0.0824; P(2-
tailed)=0.9341
b) Gender IOL Master vs. AScan Pearson’s chi-square (d.f.=1) = 3.25; P(2-
tailed)=0.07
c) Pre-operative Axial Length: IOL Master vs AScan
Unpaired ‘t’ test (df.=98) = 0.9888; P (2-tailed)=0.3252
d) Post-operative Spherical Equivalent(SE) : IOL Master vs. AScan
Unpaired ‘t’ test (d.f.=98)=0.9446;P(2-tailed)=0.3472
e) IOL Master group: Age vs. SE category:
One-Way Analysis of Variance (ANOVA) (d.f=2) Fisher F value=0.28;
P=0.757
f) IOL Master group : Gender vs SE category: Pearson’s chi-square (d.f.=1) =
0.417;P(2-tailed)=0.51
g) IOL Master group: Axial Length vs SE category:
One-Way Analysis of Variance (ANOVA) (d.f=2) Fisher F value=-0.114;
P=0.893
 Table - 3
Salient Characteristics of Patients/Eyes in the A Scan
Ultrasonography group
(underwent Pre-operative Biometry with A Scan Ultrasonography)

Categories based on Spherical Equivalent

Parameter Overall (S.E)
< 0.5 D >0.5 to 1.0 D > 1.0 D
Men Age (Yrs.) 60.64 + 11.2 60.77 + 9.58 60.32 + 11.65 61.33 + 16.49
Gender M=22 F=28 M=11 F=11 M=7 F=15 M=4 F=2
Affected eye R=33 L=17 R=15 L=7 R=15 L=7 R=3 L=3
Mean axial length 23.01 +1.58 23.23 +2.13 22.93 +0.95 22.37 +0.72
(AL) (mm.)
Mean spherical 0.64 +0.39 D ------- ------ -------
equivalent (SE)

Abbreviations: M=males; F=females; R=right eye; L = left eye

Statistical Analysis
a) Age.: AScan vs IOL Master Unpaired ‘t’ test (d.f.=98)=0.0824;
P(2-tailed)=0.9341
b) Gender AScan vs IOL Master Pearson’s chi-square (d.f.=1) = 3.25;
P(2-tailed)=0.07
c) Pre-operative Axial Length: AScan vs IOL Master
Unpaired ‘t’ test (d.f.=98) = 0.9888; P (2-tailed)=0.3252
d) Post-operative Spherical Equivalent(SE) : AScan vs IOL Master
Unpaired ‘t’ test (d.f.=98)=0.9446;P(2-tailed)=0.3472
e) A Scan Ultrasonography group: Age vs. SE category:
One-Way Analysis of Variance (ANOVA) (d.f=2) Fisher F value=0.021;
P=0.979
f) A Scan Ultrasonography group : Gender vs SE category: Pearson’s chi-square
(d.f.=1) = 1.422; P(2-tailed)=0.233
g) A Scan Ultrasonography group: Axial Length vs SE category:
One-Way Analysis of Variance (ANOVA) (d.f=2) Fisher F value=-0.735;
P=0.485
 Table – 4

Gender Distribution of Patients in the study groups

Gender Study Groups

IOL Master* A – Scan**

Male 31 22

Female 19 28

*Underwent Pre-operative Biometry with IOL Master

**Underwent Pre-operative Biometry with A Scan Ultrasonography

Gender Distribution - (IOL Master)

Female, 19 Male
Female
Male, 31

Statiscal Analysis ;

Percentage of males in IOLMaster group vs percentage of males in Ascan group.

Pearson’s chi-square (d.f.=1)=3.25; P=0.07

 Gender Distribution - (A - Scan)

Male, 22
Male
Female, 28
Female
 Table 5

Pre-operative Visual Acuity of Study Eyes

Pre operative vision Study Eyes

Visual acuity IOLMaster* Ascan**

<6/24 22 19

6/36-6/60 13 13

>6/60 15 18

*Underwent Pre-operative Biometry with IOL Master

**Underwent Pre-operative Biometry with A Scan Ultrasonography

Statistical Analysis : IOL Master vs A Scan Groups; Pearson’s chi square

(d.f.2)=0.5;P(2 tailed)=>0.05
 Table – 6

Pre-operative Intraocular Lens Power calculation in the Study Eyes

Pre-operative IOL Study Eyes

Power Calculation
Dioptres IOL Master* A- Scan**

16 - 18 D 7 4

19 - 21D 31 22

22 - 24 D 12 24

*Underwent Pre-operative Biometry with IOL Master

**Underwent Pre-operative Biometry with A Scan Ultrasonography

Statistical Analysis :

IOL Master vs A Scan Groups; Pearson’s chi square (d.f.2)=6.34 ;P(2 tailed)=<0.05
 Table - 7
Post-Operative (Phacoemulsification) Refraction in the Study Eyes

Post-Operative IOL Master* A scan**

Spherical Equivalent (cumulative) (cumulative)
≤0.25 D 9 12
≤0.5D 23 21
≤1.0D 44 44
>1.0D 6 6

*Underwent Pre-operative Biometry with IOL Master

**Underwent Pre-operative Biometry with A Scan Ultrasonography

Statistical Analysis :

a) <0.25 D, IOL Master vs A Scan; chi-square=0.542;P=0.46

b)<0.5 D, IOLMaster VS Ascan;chi-square =0.162;P=0.69

Post - operative Refraction

50
44 44
40
30 POST OPERATIVE
No. of Eyes

23 21
20 REFRACTION IOL Master
12
10 9
6 6 POST OPERATIVE
0 REFRACTION A scan
≤0.25 D ≤0.5D ≤1D >1D

Dioptres
 Table -8
Post-Operative (Phacoemulsification) Visual Acuity in the Study Eyes

Post – operative Study Eyes

Visual Acuity IOL Master* (cumulative) A – Scan**
(cumulative)
6/6. 22 27
6/9. 37 39
6/12 . 46 47
6/18 . 50 50

*Underwent Pre-operative Biometry with IOL Master

**Underwent Pre-operative Biometry with A Scan Ultrasonography

Statistical Analysis :

a)V.A. of 6/9 or better, IOLMaster vs Ascan; Pearson’s chi-square (d.f.=1)=0.219; P=0.64

b) V.A. of 6/12 or better, IOLMaster vs Ascan ; Pearson’s chi-square

(d.f.=1)=0.154;P=0.69

Post - operative Vision

50 47 50
39 50
No of Eyes

40 46
27 37
30
20 22
IOL Master
10
A - Scan
0 A - Scan
6/6. IOL Master
6/9.
6/12 .
6/18 .

Visual acuity
 Table 9
Types of Cataract in the Study Eyes

Study Eyes
Types of Cataract
IOL Master* A – scan**

Nuclear 36 35

Nuclear + Posterior 14 15
subcapsular

*Underwent Pre-operative Biometry with IOL Master

**Underwent Pre-operative Biometry with A Scan Ultrasonography

Statistical Analysis :

Nuclear cataract only, IOLMaster vs Ascan; Pearson’s chi-square(d.f.=1) =0.049;

P=0.0825575].
 Table 10

Pre-operative Visual Acuity versus Post-operative Spherical

Equivalent in Operated Eyes

Pre- SE (D) in IOL Master SE (D) In A Scan

Operative group Ultrasonograph group
visual
acuity < 0.5 >0.5 to > 1.0 < 0.5 >0.5 to > 1.0
1.0 1.0

< 6/12 4 4 1 4 5 1

>6/18 19 17 5 18 17 5

Total 23 21 6 22 22 6

Abbreviation : SE = Post –operative spherical equivalent

Statistical Analysis

a) IOL Master group : Pre-operative visual acuity vs SE category:

Pearson’s chi-square (d.f=1) = 0.004; P(2-tailed) = 0.9465

b) A Scan ultrasonography group: Pre-Operative visual acuity vs SE category:

Pearson’s chi-square (d.f.=1) = 0.047; P (2-tailed) = 0.8277

PHOTO 2 – IOL MASTER
PHOTO 1 – AUTOKERATOMETER ( NIDEK )
PHOTO 3 – A- SCAN ( ALCON )
PHOTO 4 - TOPCON AUTO-REFRACTOMETER
Discussion
 DISCUSSION

Today, most patients expect to have excellent quality of vision after cataract

surgery. To meet these expectations, there have been improvements in intraocular lens

(IOL) calculation formulas (Narvaez et al., 2006)58, IOL design, and devices to measure

axial length (Ueda et al. 2010) 54.

In modern cataract surgery, the use of biometry allows surgeons to aim for a
59
specific postoperative refraction (Kugelberg and Lundstrom 2008) , which is usually

between 0.0 diopter (D) and 0.5 D. With newer formulas, personalization of IOL

constants and improvements in surgical technique, at least 90% of patients should have

a spherical equivalent (SE) refraction within + 1.00 D of the target refraction (Holladay

et al., 1986; Olsen, 2007) 60,61.

Recent publications on routine cataract surgery have reported that between

75% and 90% of surgeries result in a final refraction within + 1.00 D of the target

refraction (Lundstrom et al., 2001, 2002; Murphy et al., 2002; Daniel et al. 2003;

Olsen, 2007) 62-65.

However, in spite of all the advances made, measurement errors in

keratometry, axial length and precision of the IOL power may occur, therein rendering

it difficult to achieve an SE refraction within + 1.00 D of the target refraction in routine

cataract surgery, posing problems for patients (Kugelberg and Lundstrom, 2008) 59.

36
 Ultrasound was introduced in the 1970s for axial length biometry (Kraff et al.
66
1978) and was considered for more than two decades to be the `gold standard’ for

this indication. One reason why the ultrasonic biometry technique has been found so

useful is possibly because it is able to penetrate a dense cataract (Weinstein and Baum,
67
1966) However, with refinements in cataract surgery, many cataracts are being

removed before dense opacity develops, and this has allowed optical biometry to

emerge as a viable alternative to conventional A scan ultrasonography for preoperative

biometry.

The infrared optical biometry system that is based on the principle of partial

coherence interferometry (PCI) has found tangible expression in the form of the

commercially-available PCI optical biometer, the IOLMasterTM. This instrument, the

PCI optical biometer, performs biometry by a non-contact method, which does not

require the use of topical anaesthesia, thus providing comfort to the patient and

preventing corneal abrasions and the transmission of infections.

The device also offers the ease of obtaining keratometry values, anterior chamber

depth and axial length measurements in a single sitting. These are significant

advantages in comparison to conventional ultrasound biometry, which is time-

consuming and which requires topical anaesthesia for corneal applanation.

Since its inception, the IOLMaster and its PCI prototypes have been

extensively studied for IOL power calculation from axial length measurement (Drexler
68-69
et al. 1998; Findl et al. 1998; Kiss et al. 2002) , since axial length is the most

influential parameter in calculation of the IOL power.

37
 Furthermore, PCI optical biometry measures the ocular axial length in addition

to the visual axis, as the patient fixates at the measurement beam, which ensures

accurate measurement ; during ultrasound biometry, a misalignment between the

measured axis and the visual axis may result in erroneously longer axial length

measurements.

Employing optical biometry instead of ultrasound biometry has improved

significantly the refractive results of cataract surgery. PCI optical biometry is reported

to exhibit excellent intra- and interobserver reliability (Vogel et al. 2001 70; Tehrani et
71
al. 2003a) and several authors (Drexler et al. 1998; Tehrani et al. 2003, among

others) have reported that its performance is superior to applanation ultrasound

biometry.

In the study by Bhatt et al46, the IOL Master was 0.17 D more accurate than

ultrasound biometry in predicting the final spherical equivalent (a statistically

significant result), and offered a slightly better prediction of the postoperative refraction

than ultrasound biometry within the 0.25 D, 0.5 D and 1.00 D ranges.

Eleftheriadas50 compared the refractive outcomes after cataract surgery

between PCI optical biometry and ultrasound biometry, and found that the former gave

better postoperative results. The precision of optical biometry in pseudophakic eyes is

reported to be better by a factor of more than 20 than that achieved with ultrasound71

(the disadvantages of using A-scan ultrasonography in pseudophakic eyes have been

reported in earlier studies49 ).

38
 Although the PCI optical biometer has simplified considerably the process of

ocular biometry, and can yield rapid measurements with a precision 8 to 10 times that

of ultrasound, doing so requires patience and cooperation on the part of both the patient

and the technician operating the device. More importantly, pathological conditions,

such as nystagmus, maculopathy and dense cataracts, may render the instrument

useless.

Some studies have shown that 8-20% of patients cannot be measured with
72.
optical biometry due to poor fixation, dense cataract or corneal pathology Ueda et

al.73 reported that axial length measurements taken with the IOLMaster were slightly

affected by the cataract density (although to a lesser extent than ultrasound biometry).

Freeman and Pesudovs74 reported that posterior subcapsular cataracts with a

Lens Opacities Classification System III score of greater than 3.5 and mature cataracts

accounted for 16% of measurement failures with the IOLMaster75.

In India, there is a high prevalence rate of nuclear and posterior subcapsular

cataracts, possibly due to excessive exposure to ultraviolet radition, especially in the

older rural population in which childhood and adult exposures to outdoor activities are

high76-77; use of indoor biomass cooking fuels78-79 and poor nutrition80-81 may be other

risk factors in this population.

In view of this important factor that potentially affects the results obtained with

the PCI optical biometer, and because few such comparative studies have been done in

39
India, the present study was undertaken to compare the post-phacoemulsification

refractive outcomes in eyes that had undergone preoperative conventional contact

biometry (using A scan ultrasonography) and those that had undergone optical

biometry (using PCI optical biometry[the IOLMaster]).

Patients with mature cataracts and dense nuclear cataracts were not included in

the present study because in the PCI optical biometer (IOLMaster), light is strongly

attenuated by opaque ocular media, making it more difficult to obtain reliable

measurements.

In the present study, patients undergoing preoperative biometry were randomly

assigned to undergo either A scan ultrasonography (50 eyes) or PCI optical biometry

(50 eyes). There were no significant differences between these groups in the mean

age(60.82 + 10.5 years in the IOL master group, 60.64 + 11.2 years in the A scan

ultrasonography group), and also no significant differences in age distribution (Tables

1,2,3) and gender distribution (Tables 2,3,4); that is, the patients in the groups were age

and gender (sex)- matched.

Similarly, the eyes in the groups were matched (no statistically significant

differences) with respect to laterality (Tables 2,3), preoperative visual acuity (Table 5),

preoperative axial length measurements (Tables 2,3) and types of cataract present

(Table 9).

40
 In the present study, the mean post-operative spherical equivalent was 0.57 +

0.34 D in the PCI optical biometer (IOLMaster) group and 0.63 + 0.39 D in the A scan

ultrasonography group; this difference was not statistically significant (Tables 2,3). In a

similar study done by Rajan et al.47, the post-operative mean absolute error (MAE) was

0.6 + 0.4 D in patients who underwent ultrasound biometry, which was not

significantly different from the value obtained (0.52 + 0.35 D) in the IOLMaster group.

In the present study, 88% of the patients in the PCI optical biometer

(IOLMaster) group achieved postoperative refraction of + 1 D as compared to 86% in

the A scan ultrasonography group (Table 7). These results are similar to those obtained

in an earlier study47, where 87 percent of the eyes in the IOLMaster group and 80

percent of the eyes in the ultrasound group achieved a postoperative refraction of + 1 D

spherical equivalent postoperatively. Interestingly, in the present study, preoperative

IOL power calculations had yielded significant differences between the groups (Table

6); the significance of this observation is uncertain

In the present study, there were no significant differences between the groups in

post-operative visual acuity (Table 8); 74% of eyes in the PCI optical biometer

(IOLMaster group) and 78 % of eyes in the A scan ultrasonography group attained a

visual acuity of 6/9 or better.

Thus, the results of the present study suggest that contact biometry (A scan

ultrasonography) and optical biometry (using PCI optical biometer [IOLMaster) are

similar in their predictive capabilities.

41
 In a postoperative study of 140 consecutive eyes undergoing cataract surgery,

Kutschan and Wiegand82 found that both contact ultrasound biometry and the

IOLMaster were similar in their predictive capabilities, and concluded that the

IOLMaster was easier to use. Similarly, Moieni et al83, who compared the refractive

outcomes after phacoemulsification by ultrasound and optical biometry methods, found

no significant difference between them.

In contrast, Rajan et al.47 found that the use of optical biometry offered a better

predictive value than the use of applanation axial biometry measurement. Interestingly,

in a propective study of 162 consecutive eyes undergoing cataract surgery, Gatenbein

84
and Ruprecht concluded that contact axial biometry offered a better prediction of

final refraction than did IOLMaster, but that the IOLMaster was an easier and faster

tool to use.

Verhulst 85 and Vrijghem and Skorkovska et al. 86 also found that in eyes with

significant nuclear sclerotic cataract, axial biometry was still needed for accurate axial

length measurement.

In the present study, it was found that found that a decrease in visual acuity

decreased the probability of successful measurements with the PCI optical biometer
87
(IOL Master). This observation is similar to that made by Mana Tehrani , who

correlated lenticular opacity and visual acuity with the probability of successful

measurements, and found that 80% of eyes with an uncorrected visual acuity worse

42
than 20/200 and 65% with worse than 20/400, and 45% with worse than 20/800, could

be measured.

Several factors, namely age and gender of the patient, and preoperative axial

length and visual acuity of the eye involved, have been reported to influence the

accuracy of pre-operative biometric measurements in relation to postoperative

refractive outcomes (Kugelberg and Lundsrom, 2008). Hence, in the present study, an

attempt was made to look at the possible influence of these variables.

One research group found older age to be a risk factor for deviation from
88.
emmetropia in pseudophakia (Nuzzi et al., 2001) In the study by Kugelberg and

Lundstrom (2008), when preoperative visual acuity was excluded from the analysis,

older age emerged as being associated with a larger post-operative refractive error.

However, in the present study, age did not appear to influence the accuracy of post-

operative refractive outcomes in either of the study groups (Tables 2,3).

Kugelberg and Lundstrom (2008), in their analysis, found that it was

significantly more difficult to achieve the target refraction in female patients than in

male patients; they found this to be surprising and hard to explain. Some studies have

shown that women have a worse visual outcome than men after cataract surgery, but

none of these studies analysed the refractive outome (Murthy et al., 2001; Logan et al.,

2005) 89-90.

Although the findings reported by other workers are interesting, in the present

study, gender (sex) did not appear to influence the accuracy of post-operative refractive

outcomes in either of the study groups (Tables 2,3).

43
 It has been reported that an axial length difference of 0.1 mm corresponds to a

prediction error of 0.28 D (Olsen, 1992) 37. Ueda et al (2010) recently observed that the

mean absolute error (MAE) was significantly correlated with the axial length difference

and cataract density; they also observed that the MAE based on postoperative axial

length was smaller than that based on preoperative axial length, and the postoperative

axial length was thus considered to be closer to the true axial length than the

preoperative axial length (Ueda et al., 2010).

In the present study, only the preoperative axial length was measured. Although

the findings reported by other workers are interesting, in the present study,

preoperative axial length values did not appear to influence the accuracy of post-

operative refractive outcomes in either of the study groups (Tables 2,3).

Kugelberg and Lundstrom (2008) reported that one important factor that

affected the MAE was preoperative visual acuity; the lower preoperative visual acuity,

the larger the mean absolute prediction error. They speculated that since a low

preoperative vision is an indicator of dense cataract, it may hide posterior eye problems

that could not be seen during the preoperative examination.

Biometry measurements are less reliable in eyes with a dense nuclear cataract

(Eleftheriadis, 2003). In the present study, however, preoperative visual acuity readings

did not appear to influence the accuracy of post-operative refractive outcomes in either

of the study groups (Table 10).

44
 The initial promising results obtained with the PCI optical biometer

(IOLMaster) suggested its potential to supercede applanation ultrasound as the most

utilized axial length measurement procedure. However, to supercede ultrasound, an

alternative technique should be able to measure reliably across the same breadth of the

clinical population. This is not the case with the PCI optical biometer (IOLMaster) as it

exists now. The biggest problem is with the type of cataract that is being measured.

Cataracts, especially posterior subcapsular and mature cataracts, commonly

cause acquisition failure of 20% when the PCI optical biometer (IOLMaster) is used.

Since 100% of mature cataracts and posterior subcapsular cataracts with lens

opacification classification (LOCS) III grade > 3.5 cannot be measured, this provides a

convenient clinical cut-off for the use of the IOLMaster66.

According to Chylack et al.91, measurement failure with IOLMaster may occur

at even lower levels of posterior subcapsular cataract (3.5>p2.5), which may be related

to the location of the cataracts. Measurement with the IOLMaster relies upon two rays

of light; perhaps lower levels of posterior subcapsular cataracts might be located such

that at least one of these rays is scattered, so that measurement acquisition is

prevented.

In addition, it may not be possible to acquire measurements using the

IOLMaster due to practical reasons, such as the inability to position the patient at the

machine or due to tremor of the head, and also due to fixation problems, such as

45
macular degeneration or dense amblyopia (Connors et al. [2002] 92 and also Tehrani et

al. 93.

Two small recent case series have examined the effect of macular disease on the

two techniques and suggested that the IOLMaster may be more accurate in these

cases94-95. Schreker and Strobel and Hagis 96 concluded that eyes with normal cataracts

and visual acuity worse than 20/200 without additional pathology were ideal candidates

for preoperative biometry with the IOLMaster..

Similarly, in cases of moderate cataract without other pathology, in eyes filled

with silicon oil, and in children, the IOLMaster provides accurate readings74. However,

in cases of poor visual acuity, dense cataract and other pathology, creating poor clarity

of media, A scan ultrasonography would probably be indicated73.

46
Conclusion
 CONCLUSION

Cataract extraction with the implantation of IOL is the most frequently

performed ophthalmic surgical procedure. Accurate preoperative calculation of IOL

power is necessary to attain the desired postoperative refraction; several factors

(keratometry, anterior chamber depth, lens formulas) contribute to the calculation, but

the preoperative axial length is the most critical variable of all.

Partial laser coherence interferometry (IOLMaster) has proven more accurate than

ultrasound biometry in predicting the refractive outcome in patients in the west.

However, most cataracts in Indian patients are dense nuclear and posterior subcapsular

types, in which the IOL Master may fail to calculate the IOL power; in such instances,

A scan ultrasonography may work better. The present study aimed to compare the

outcomes of the two procedures in Indian patients.

The present study revealed that there was no significant difference between the

two techniques in predicting post-operative refractive outcomes in this population of

Indian patients undergoing phacoemulsification. There was also no significant

difference in post-operative visual acuity between the two groups. Thus, although

partial laser coherence interferometry (IOLMaster), being a non-contact procedure,

offers the practicing ophthalmologist a slight advantage over ultrasound biometry

because of increasing patient expectation and for precise post-operative refraction, A

scan ultrasonography still holds the pride of place when dense nuclear, posterior

subcapsular and mature cataracts are encountered.

47
Summary
 SUMMARY

Cataract extraction with the implantation of IOL is the most frequently

performed ophthalmic surgical procedure. Accurate preoperative calculation of IOL

power is necessary to attain the desired postoperative refraction; several factors

(keratometry, anterior chamber depth, lens formulas) contribute to the calculation, but

the preoperative axial length is the most critical variable of all.

Partial laser coherence interferometry (IOLMaster) has proven more accurate

than ultrasound biometry in predicting the refractive outcome in patients in some

studies.

However, most cataracts in Indian patients are dense nuclear and posterior

subcapsular types, in which the IOL Master may fail to calculate the IOL power; in

such instances, A scan ultrasonography may be the only option for IOL power

calculation.

The present study aimed to compare the outcomes of the two procedures in

Indian patients. One hundred eyes of 100 patients undergoing phacoemulsification were

randomized to undergo biometry using the conventional Ascan (50 eyes) or by the

newer technique of partial coherence interferometry (PCI) using the IOLMaster TM (50

eyes).

48
 The mean age was 60.82 ± 10.5 years in the IOLMaster group and 60.64 ±11.2

years in the Ascan ultrasonography group .This difference was not statistically

significant.

There were 31 males (62%) and 19 females (38%) in the IOLMaster group,

compared to 22 males (44%) and 28 females (56%) in the Ascan ultrasonography

group; this difference was not statistically significant.

The preoperative visual acuity of the test eyes in the IOL Master group was as

follows; vision better than 6/24 in 22 (44%) eyes, vision between 6/36 and 6/60 in 13

(26%) eyes and vision worse than 6/60 in 15 (30%) eyes.

In the Ascan ultrasonography group, vision less than 6/24 occurred in 19

(38%) eyes, between 6/36 and 6/60 in 13 (26%) eyes and vision worse than 6/60 in 18

(36%) patients. These differences were not statistically significant.

A total of seven (14%) eyes had IOL power in the range of 16-18D in the

IOLMaster group and four eyes (8%) in the Ascan ultrasonography group. In the 19-

21D range, there were 31(62%) eyes in the IOLMaster group and 22 (44%) eyes in the

Ascan ultrasonography group. In the 22-24D range there were 12 (24%) eyes in the

IOLMaster group and 24 (48%) eyes in the Ascan ultrasonography group. These

differences were statistically significant.

49
 The pre-operative mean axial length (AL) was 23.27±0.98mm in the IOLMaster

group and 23.01±1.58mm in the Ascan ultrasonography group.This difference was not

statistically significant.

Six weeks following surgery, the mean spherical equivalent in the IOL Master

group was 0.5752± 0.3450, while the mean spherical equivalent in the Ascan

ultrasonography group was 0.6358 ±0.3918; this difference was not statistically

significant.

The number of eyes with uncorrected visual acuity of 6/9 or better in the

IOLMaster group was 37(74%) whereas in the Ascan ultrasonography group it was

39(78%) ; this difference was not statistically significant.

In the IOLMaster group, there were 36 (72%) eyes with nuclear cataract and 14

eyes (28%) with both nuclear and posterior subcapsular cataract, whereas in the Ascan

group there were 35 (70%) eyes with nuclear cataract and 15(30%) eyes with both

nuclear and posterior subcapsular cataract; this difference was not statistically

significant.

The present study revealed that there was no significant difference between the

two techniques in predicting post-operative refractive outcomes in this population of

Indian patients undergoing phacoemulsification. There was also no significant

difference in post-operative visual acuity between the two groups.

50
 Thus, although partial laser coherence interferometry (IOLMaster), being a non-

contact procedure, offers the practicing ophthalmologist a slight advantage over

ultrasound biometry because of increasing patient expectation and for precise post-

operative refraction, A scan ultrasonography still holds a pride of place when dense

nuclear, posterior subcapsular and mature cataracts are encountered.

51
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60
Proforma
 Proforma

NAME -

AGE -

SEX -

HOSPITAL NO –

ADDRESS -

VISUAL ACUITY - RE - LE –

IOP - RE LE –

ANTERIOR SEGMENT –

CATARACT TYPE –

FUNDUS –

PRE OP EVALUATION –

ULTRASOUND – IOL MASTER –

AXIAL LENGTH – K1 –

K1 – K2 –

K2 – AXIAL LENGTH -

IOL POWER – IOLPOWER -

TYPE OF SURGERY –

TYPE OF TUNNEL –

TYPE OF IOL –

IN THE BAG – SULCUS FIXATED –

POST OP REFRACTION – 6 WEEKS - AR –

POST OP VISION -

61
Master Chart
 IOL Master
SL
NAME HOSP NO AGE SEX VN OP EYE OTHER EYE K1 K2 AXL mm IOL PO
NO
1 NATARAJAN 654637 73 M 6/12.RE 6/12. 44.29D / 7.62mm@ 96 45.30 / 7.45mm@ 6 23.25mm 20
2 RAJESHWARI 763804 32 F 6/24LE 5/60. 43.83D/7.70mm@171 45.12D/7.48mm@81 23.64mm 19
3 BHANUMATHY 711181 60 F 6/24RE 6/24. 42.03D/8.03mm@74 42.78D/7.89mm@164 23.34mm 2
4 JAINAMBU 638551 70 F 6/36RE 6/36. 45.24D/7.46mm@97 46.36D/7.28mm@7 21.63mm 2
5 ELANKODI 763968 53 F 5/60RE 6/18. 45.36D/7.44mm@126 46.17D/7.31mm@36 22.24mm 21
6 P.PALANISAMY 765603 71 M 5/60RE 6/60. 43.10D/7.83mm@86 44.29D/7.62mm@176 23.44mm 20
7 BOOPATHY 765515 42 M 5/60LE 5/60. 46.36D/7.28mm@90 47.74D/7.07mm@0 22.25mm 20
8 A.RANJITHAM 762902 75 F 6/60LE 6/60. 45.18D/7.47mm@93 45.86D/7.36mm@3 22.48mm 2
9 R.RAJAMANI 766150 72 F 5/60LE 5/60. 46.62D/7.24mm@80 47.14D/7.16mm@170 21.22mm 2
10 R.INDRA 764531 75 F 6/18RE 6/36. 44.06D/7.66mm@84 44.58D/7.57mm@174 22.93mm 2
11 RAIDURAI 767938 50 M 6/60LE 5/60. 43.66D/7.73mm@37 44.29D/7.62mm@127 23.81mm 1
12 KAMALAM 767895 78 F 6/24RE 6/18. 45.12D/7.48mm@72 46.73D/7.30mm@162 22.66mm 20
13 SR.GONZAGAMARY 673420 70 F 6/24LE 6/36. 45.35D/7.44mm@68 45.73D/7.38mm@158 22.64mm 2
14 T.M.Md.BASHEER 763232 53 M 5/60LE 5/60. 41.77D/8.08mm@89 42.67D/7.91mm@179 25.39mm 16
15 PUSHPADOSS 766706 71 M 6/26LE 6/36. 48.42D/6.97mm@128 49.13D/6.87mm@38 21.18mm 22
16 N.CHINNAPILLAI 744396 65 M 6/60RE. 5/60. 44.41D/7.60mm@103 45.61D/7.40mm@13 23.03mm 20
17 SUBBULAXMI 778981 67 F 5/60RE. 6/9. 42.78D/7.89mm@87 43.49D/7.76mm@177 24.68mm 1
18 IRUDAYAMARY 763901 69 F 6/36RE 6/24. 43.72D/7.72mm@109 44.47D/7.59mm@19 22.62mm 2
19 G.SEKAR 693270 44 M 6/9RE 6/9. 43.66D/7.7mm@4 44.47D/7.59mm@94 23.46mm 2
20 JEGANATHAN 762376 59 M 6/6RE 6/9. 45.42D/7.43mm@158 46.17D/7.31mm@68 22.82mm 20
21 YESUDAS 764073 54 M 6/60RE. 6/9. 45.00D/7.55mm@69 45.49D/7.42mm@159 23.13mm 19
22 CHINNASAMI 745273 70 M 6/9LE 6/9. 44.41D/7.60mm@111 45.24D/7.46mm@21 23.40mm 19
23 SOOSAIRAJ.S 732245 68 M 5/60RE 5/60. 43.44D/7.77mm@95 44.00D/7.67mm@5 22.79mm 2
24 CHRISTABEL.N 763146 58 F 6/6LE 6/60. 42.56D/7.93mm@133 42.99D/7.85mm@43 23.91mm 2
25 REV.ASHOK KUMAR 713825 65 M 6/24RE 6/24. 43.38D/7.78mm@157 44.06D/7.66mm@67 24.59mm 1
26 LEELAVATHY 754049 64 F 6/12RE 6/18. 46.75D/7.22mm@99 47.34D/7.13mm@9 22.07mm 2
27 SIVALINGAM 761183 56 M 4/60LE 6/9. 44.88D/7.52mm@117 45.18D/7.47mm@27 23.66mm 19
28 V.SHANMUGAM 616264 56 M 6/12RE 6/9. 45.86D/7.36mm@163 46.81D/7.21mm@73 22.30mm 2
29 V.KARUPPAN 768356 55 M 6/36RE 6/12. 43.16D/7.80mm@98 44.12D/7.65mm@8 23.74mm 19
30 KARUPPAMMAL 768922 60 F 5/60LE 5/60. 45.30D/7.45mm@91 46.42D/7.27mm@1 21.89mm 2
31 ANNAPORANI 769904 58 F 4/60LE 6/60. 44.53D/7.58mm@71 44.76D/7.54mm@161 22.57mm 2
32 THIRUGNANASAMBA 745179 63 M 6/18RE 6/24. 42.24D/7.99mm@100 42.67D/7.91mm@12 24.39mm 1
33 HASSAN NAINAR 728366 65 M 6/60RE. 6/60. 46.17D/7.31mm@164 46.87D/7.20mm@74 24.79mm 1
34 PANEERSELVAN 756275 54 M 5/60LE 6/6. 42.61D/7.92mm@1 42.94D/7.86mm@91 23.38mm 21
35 A.J.SOLOMON 768683 53 M 6/60LE 5/60. 41.77D/8.08mm@78 42.61D/7.92mm@168 23.76mm 2
36 SHEIK DAWOOD 768343 50 M 5/60LE 5/60. 46.23D/7.30mm@165 46.55D/7.25mm@75 24.65mm 1
37 VARADHARAJAN 767848 78 M 6/36LE 6/60. 45.06D/7.49mm@86 45.92D/7.35mm@176 22.07mm 2
 A Scan
1 VASANTHA.R.K 672656 61 F 6/9RE 6/12. 43.50D@153⁰ 44.00@153 22.73mm 2
2 CHELLAMAL 764780 55 F 6/12RE 6/9. 43.00D 43.00D 22.60mm 2
3 SEETHAI CHANDRAKAS 763609 59 F 1/60RE 5/60. 45.50D 46.25D@65 22.17mm 21
4 SEKAR .U 763463 51 M 6/12RE 6/12. 43.63D 43.63D 23.79mm 19
5 GOVINDARAJ 574115 68 M 6/12LE 6/24. 45.50D 45.50D 22.52mm 2
6 SR.ALOSIUS MARY 764534 73 F 5/60RE 6/60. 46.00D 46.00D 22.52mm 20
7 VASUKI 734487 46 F 3/60RE 3/60. 44.25D 44.50D@85 22.30mm 22
8 MOHAMED IBRAHIM 759445 62 M 6/36LE 6/36. 42.25D 43.75D 24.40mm 18
9 A.SIMON RAJ 750956 53 M 6/9RE 6/9. 42.25D 42.75D@160 23.18mm 2
10 JESSIE 7660665 63 F 5/60LE 5/60. 44.38D 44.38D 24.70mm 1
11 PUSHPAVALLI 761075 65 F 2/60RE Nil 45.75D 47.00D@28 24.60mm 14
12 THAHIRABANU 761022 32 F 6/12RE 6/9. 44.50D 46.50@172 21.40mm 25
13 RENGARAJ 761547 67 M HMRE 6/12. 45.50D 46.00@119 21.83mm 23
14 KULANDAIVELU 762190 71 M 5/60LE 6/12. 43.75D 44.25D 21.64mm 25
15 RANJITHAM 762902 75 F 6/60RE 6/60. 45.25D 45.25D 22.40mm 21
16 KALIFULLAH 713851 75 M 6/24LE 6/24. 43.50D 44.00D@105 22.9mm 21
17 AMSAVALLI 762537 50 F 6/18LE 6/18. 44.00D 44.50D@10 32.22mm 20
18 PREMA 730005 50 F 6/12RE 6/18. 44.12D 45.53D@99 22.12mm 2
19 P.VASANTHA 762907 52 F 6/60LE 6/18. 46.25D 46.25D 21.65mm 23
20 THIYAGARAJ 754652 56 M 6/60RE 6/60. 47.00D@90 47.25@90 21.58mm 2
21 PUSHPA SAMBADHAM 762533 67 F 1/60LE 6/60. 46.36D 46.55D 22.73mm 20
22 RAJAKUMARI 727383 57 F 6/24RE 6/12. 45.67D 46.17D 22.35mm 2
23 RAMAN .S 755535 62 M 6/24RE 6/36. 43.25D 44.00D@98 24.18mm 18
24 SUSHEELA 764222 60 F 5/60RE 6/9. 41.63D 41.63D 23.07mm 2
25 LOGISTHA NTHAN 766257 60 M 6/60LE 6/18. 40.38D 40.38D 24.35mm 2
26 VIJAYA 760976 55 F 6/9RE 6/12. 45.00D 45.50D@61 22.59mm 2
27 BASHA JAN 636335 62 M 6/18LE 6/18. 42.75D 42.75D 23.49mm 2
28 SELVARAJ 767604 45 M 6/60LE 6/36. 44.00D 44.75D@90 22.90mm 2
29 MUTHAIAN 764934 70 M HMLE 6/12. 44.50D 45.23D@64 23.12mm 2
30 MUNIAMMAL DHARM 764634 47 F 2/60LE 6/36. 44.00D 44.75@43 22.71mm 21
31 AROCKIAMARY 710766 73 F 6/36RE 6/12. 44.13D 44.13D 22.20mm 2
32 J.S.MARY VAZ 767995 78 F 5/60LE 5/60. 43.75D 45.00@72 22.50mm 2
33 R.CHANDRSEKAR 772244 64 M 1/60RE 6/36. 44.0D 44.0D 23.24mm 20
34 F.VINCY 774612 65 F 6/36RE 6/60. 45.00D 45.50@52 23.39mm 1
35 R.ROSALIND 752585 68 F 6/18RE 6/18. 44.00D 44.25D 22.80mm 21
36 SR.LILY 746190 72 F 6/12E 6/24. 44.17D 44.17D 22.57mm 2
37 PERIYANAYAGAM 764789 62 M 6/36RE 6/36. 44.00D 44.75@40 24.11mm 1