An Overview of Intraocular Lens

Power Calculation Methods

32
Han Bor Fam

Cataract surgery is refractive surgery. Besides this has recently been more thoroughly updated
removing the dysfunctional cataract, cataract by Savini, Hoffer and Kohnen in a recent JCRS
surgery restores and corrects the refractive status Editorial [2].
of the eye. The success of modern-day cataract
surgery is dependent on the refractive outcome.
Postoperative refractive surprise is unnecessarily Historical Methods
disappointing and frustrating to everyone.
In prescribing the correct glasses, accurate Standard Lens Method
refraction is key to that outcome. In laser cor-
nea refractive surgery, again good preoperative Learning from the poor outcomes of the pio-
refraction, whether objectively, subjectively, or neering implantations, the dioptric power of the
wavefront-driven, is imperative to a happy result. early lens implants was adjusted to an improved
In cataract surgery, good biometry coupled with single-­lens power for all patients, depending on
good intraocular lens power calculation is crucial what type IOL was used (Prepupillary, Iris Plane
to ensure good eventuality. It is akin to accurate or Anterior Chamber). The initial gross refractive
refraction in cornea refractive surgery. errors were reduced. This lasted for almost two
In 1949, Harold Ridley implanted a plastic decades. This overly simplistic method is obso-
lens in a patient. Despite the less than favorable lete due to the inherently poor outcomes.
initial results, he had ushered in a new era of
intraocular lenses and indirectly lead to the sub-
sequent development of the science of intraocular The Refraction Method
lens power calculation.
In the past, IOL power calculation formulas are Among the first attempts at calculating IOL
categorized by generation. However, this can be power was a simple refraction-based method.
confusing as formulas evolved and newer meth- The power of the IOL was adjusted by a factor of
ods are being developed. As aptly described by the preoperative refraction.
Koch et al., it is opportune to adopt a newer clas-
sification based on methodology [1, 2]. However, IOL Power = 18.00 + 1.25∗ preoperative refraction.

The refraction method has poor outcomes as

H. B. Fam (*)
National Healthcare Group Eye Institute, Tan Tock preoperative refraction with a cataract present is
Seng Hospital, Singapore, Singapore an imprecise method of determining the power

© The Author(s) 2024 473

J. Aramberri et al. (eds.), Intraocular Lens Calculations, Essentials in Ophthalmology,
https://doi.org/10.1007/978-3-031-50666-6_32
474 H. B. Fam

of the lens. The cataract itself may induce index

refractive error that confounds the preoperative
refraction.

Theoretical Formulas

In 1967, Fyodorov and Kolonko [3] presented

their theoretical formula based on geometric
optics. The formula utilizesd keratometry and
axial length which was measured with A-scan
ultrasonography. That marked the nascency of
today’s geometrical optics or theoretical formu-
las.
The eye is essentially a 2-lens system. It con-
sists of the cornea as the first lens that contrib- Fig. 32.1 A schematic optical diagram of the eye depict-
utes about two-third of the refractive power of ing the 2-lens system of the eye. ELP effective lens posi-
the eye; and the crystalline lens that accounts for tion (commonly known as the predicted postoperative
anterior chamber depth), vl vitreous length (optical vitre-
the remaining one-third of the refracting power ous length), AL axial length (optical axial length)
of the eye (Fig. 32.1). Theoretical formulas using
vergence formulas are based on Gaussian optics. The early generation of theoretical for-
The geometric formulas of Fyodorov and mulas assumed fixed postoperative anterior
Kolonko [3] and the other early workers, notably chamber depths. A second generations of theo-
Colenbrander [4], Thijssen [5], Van der Heijde retical formulas was introduced by Hoffer in
[6], Hoffer [7] and R Binkhorst (Binkhorst, The 1982, which includes a sub-equation for ELP that
optical design of intraocular lens calculation [8]) mathematically predicts the postoperative effec-
are all applied to schematic eyes using theoretical tive lens position (ELP) as a function of axial
constants. Basically, these formulas use different length. The sub-equation (ELP=2.92*AL-2.93)
correction factors but utilize identical vergence was based on one IOL model and would be
concept of: best for that model. R. Binkhorst followed
n n with another iteration. (Binkhorst, Intraocular
P= − lens power calculation manual: A guide to the
AL − ACD n
− ACD Author’s TICC-40 Programs, Edition 3 [9], [10]
K
(Hoffer, The effect of axial length on posterior
Where P is the IOL power; n is aqueous and chamber lenses and posterior capsule position
vitreous refractive index; and ACD the estimated [11, 12]). The main difference between these
anterior chamber depth that is adjusted by the second-­generation formulas lies in its prediction
individual formulaic correction factors. of the postoperative effective lens position.
The early formulas were good with nor- The third generation of theoretical formulas
mal axial lengths of around 23.5 mm (22–24.5 utilizes both AL and keratometry as predictors
mm) but were less precise with short (<22 mm) or of preoperative anterior chamber depth (Olsen,
long (>2.5 mm) axial length eyes. Further devel- Prediction of intraocular lens position after cata-
opment on regression and theoretical formulas ract extraction [13]), hence the ELP [14, 15]. All
involved improvement in outcomes in eyes with these formulas are based on the Gullstrand eye
an expanded range of axial lengths. model.
32 An Overview of Intraocular Lens Power Calculation Methods 475

2-Variables Thin-Lens Vergence  olladay 1 and Holladay 2 Formulas

H
Formula: Third Generation Holladay’s first formula (Holladay 1) is a 3-part
Theoretical Formulas formulation [14]. The first part is a set of screen-
ing criteria for data. The purpose is to identify
For the last 3 decades, modern theoretical formu- the improbable axial length and keratometry
las were the commonly used formulas. These were measurements and to alert the users to validate
Hoffer Q, the Holladay, and the SRK/T formu- the measurements and the possibility of untoward
las. These 3 formulas make use of the radius of outcomes. He used the Hoffer AJO 1980 study
curvature of the anterior cornea and axial length of 7,500 eyes for normal differences in bilateral
to predict the ELP. Olsen first introduced the use eyes [21]. This set of useful checklists has per-
of more variable such as the ACD and LT. Later, sisted and is now part of most biometry systems
Holladay introduced his Holladay 2 (Holladay, but with some modifications with the changing
Holladay IOL Consultant User’s Guide and Refer- times. The second part is the formula proper;
ence Manual [16]) which uses up to 7 variables to this is a further modification of the second-gen-
predict the ELP. Besides corneal radius and axial eration theoretical formula to improve on the
length, these include preoperative ACD, phakic prediction of the ELP using Fyodorov's Corneal
lens thickness, the corneal diameter (CD), and the Height equation (using AL and K). Finally, a
patient’s age. Hoffer and Savini later introduced personalized “surgeon factor” (SF) (his lens con-
gender and race in their Hoffer H-5 formula. stant) compensates for any systematic bias in the
individual surgeon’s postoperative outcome.
 offer Q and Hoffer QST
H Holladay’s Data Screening Criteria [14] to
This formula was published by Kenneth J Hoffer in identify unusual measurement and require further
1993 (Hoffer KJ, The Hoffer Q formula: a compar- validation. Repeat measurement if:
ison of theoretic and regression formulas [17]). The
core vergence formula is the basic Hoffer formula 1. Axial length < 22.0 mm or > 25.0 mm
(a major modification of Colenbrander’s formula) 2. Average corneal power < 40.0 Diopters
but with a new ELP prediction equation he called or > 47.0 Diopters
the Q formula which predicted the ELP based on 3. Calculated emmetropic IOL power > 3.0
the AL and the Tangent of the K. Diopters of average power* for the specific
Thanks to the studies by Melles [18, 19], Hof- lens type
fer, Savini, and Taroni have further developed a 4. Between eyes, the difference in.
new formula, the Hoffer QST. This is an evolution (a) Average corneal power > 1.0 Diopter
of the 1993 Hoffer Q formula with the use of AI (b) Axial length > 0.3 mm
to enhance the prediction of ELP and algorithms (c) Emmetropic IOL power > 1.0 Diopter
to improve accuracy in the long eyes. There are
several studies now showing the Hoffer QST to The Holladay 2 formula is unpublished but is
be as good or better than all the modern formulas available for purchase as part of the Holladay IOL
depending on the criteria chosen (MAE, MedAE, Consultant program (Fig. 32.2). It requires inputs of,
SD, %+/-0.50 D, etc) [20]. It is freely available on besides AL and K, phakic preop ACD, LT, CD and
its website www.HofferQST.com with a Research patient’s age. Having more parameters enabled the
page allowing lens constant (pACD) optimization Holladay 2 to appreciate the nuances of dispropor-
and IOL power studies on your data. tionate eyes and render the calculation appropriately.

Short Normal Long

Small Nanophthalmia(1.8%) Microcornea(1.5%) Microcornea + Axial Myopia (0%)
Normal Axial Hyperopia(6.9%) Normal(73.4%) Axial Myopia(13.5%)
Large Megalocornea + Axial Hyperopia (0%) Megalocornea(1.5%) Buphthalmia(1.5%)
476 H. B. Fam

Fig. 32.2 Holladay JT MD. has categorized human eyes in unusual eyes. Fortunately, most of the eyes are normal.
into nine categories (Fig. 32.2). This illustrates that the Modern IOL power calculation formulas factored in the
human is not necessarily proportional. This disparity above into their algorithms
poses a challenge to IOL power calculation, particularly

SRK/T The second adjustment, OAL2, was converting

Using the Holladay 1 formula as a base but modi- ‘actual optical axial length’ to ‘true optical path
fying so it will use the A constant of the SRK length’ using the mean refractive index proposed
formula, Retzlaff published the SRK/T formula by Olsen [24]. The smaller annulus keratometry
[15] in 1990. The SRK/T is a theoretical formula measurement with the PCI biometer was also
based on Fyodorov’s Corneal Height formula [1] calibrated to the slightly larger mire of auto-­
for the postoperative ELP prediction. The retinal keratometry. With these adjustments, the perfor-
thickness correction factor and the corneal refrac- mance of the third-generation formulas on longer
tive index are likewise optimized. eyes improved (Fig. 32.4).

Wang-Koch Adjustment
 elationship Between the Third-­
R Wang et al., in 2011 [25], proposed a set of
Generation Formulas and Axial adjustment equations to optimize the outcomes in
Length eyes longer than 25 mm. The adjustments were
shown to reduce the risk of hyperopic outcomes
While most third-generation formulas perform in patients with long eyes. It has been modified
well in normal eyes with axial lengths between since then.
22.0 mm to 25.0 mm, these formulas perform
less favorably beyond these confines. These for- The T2 Formula
mulas tend to have a higher percentage of hyper- The T2 formula was described by Sheard, in
opic prediction errors in longer axial lengths and 2010 [26]. Using a larger and more up-to-date
conversely, myopic outcomes in shorter axial database, Sheard was able to correct the non-­
lengths (Fig. 32.3). physiological behavior of the quadratic function
of the corneal height prediction of SRK/T first
Fam Adjusted pointed out by Hoffer and then Haigis [27].
In 2009, Fam et al. [22] published a paper to
optimize the relationship between the pre- Haigis Formula
dicted refractive outcomes and axial lengths as Haigis realized the importance of lens geometry
measured by PCI biometry. The concept was on the ELP [28]. Thin lens formulas, by having
based on 2 readjustments. The first readjust- just a single constant, neglect the effect of chang-
ment, OAL1, was to reverse the initial calibra- ing lens geometry with different IOL power, cur-
tion by Haigis [23] of the PCI against ultrasound vatures, thickness, and styles. In unusual eyes
biometry and thereby using the ‘actual’ optical where the almost linear relationship between the
axial length as measured by the PCI biometer. ELP and axial length starts to deviate, the perfor-
32 An Overview of Intraocular Lens Power Calculation Methods 477

Fig. 32.3 The effect of axial lengths on the prediction long axial lengths. Conversely, the same 3 formulas
errors of 4 theoretical formulas on 4 different IOLs. 3 of showed myopic tendency with shorter axial lengths with 3
the 4 formulas showed hyperopic prediction errors with IOLs

mances of these formulas start to falter. The Hai- and integrity of the database. In theoretical for-
gis formula, without resorting to the complexity mulas, regression with real-world postoperative
of thick lens formulas, uses 3 lens constants (a0, results is utilized to refine its predictability. This
a1 a2) instead of one; and using the preopertive is notably so in predicting the effective lens posi-
measured ACD instead of K as a variable which tion and is embedded in the constants and cor-
overcomes some of the problems of thin lens ver- rection factors of the formulas. Pure regression
gence formulas with short and long eyes. formulas (SRK and SRK II) are no longer recom-
In the Haigis formula, there are 2 types of con- mended or used today.
stant optimization:

1. Classical optimization where one constant a0 is Thin Lens Formula

optimized but not the other two. In this case,
the formula performs as good, if not better than The popular 3rd generation formulas for IOL
the other popular thin lens vergence formulas. power calculation like the Hoffer Q, Holladay 1,
2. Full optimization where all three constants are and the SRK/T are based on thin lens optics. A
optimized. This is when the full potential of normal lens has a thickness and two refracting
the formula for wider ALs and lens types is surfaces. In thin lens optics, the thickness of the
achieved. lens is ignored, and its two refracting surfaces are
reduced to a single plane thin lens. It is assumed
that all refractions of light occur in that single
Regression Versus Theoretical Models plane. The advantage of the thin lens formula
is that it simplifies the calculation and circum-
Regression formulas are entirely based on regres- vents the difficulty of measuring certain param-
sion with a large database of postoperative out- eters often not obtainable.
comes. The larger the database, the better their The popular formulas of Hoffer Q [17], Hol-
predictability. More importantly, are the quality laday 1 [14], and SRK/T [15] are based on thin
478 H. B. Fam

a SRK-T(Errors vs Axial Length)

1.50

1.00 y=0.0613x-1.5272
2
R =0.0576
SRK-T
0.50

0.00
20 21 22 23 24 25 26 27 28 29 30

-0.50 Linear
[SRK-T]

-1.00

-1.50

b c
SRK-T(Errors vs Axial Length) SRK-T(Errors vs Axial Length)
1.50 1.50
y=0.079x+0.2107 y=0.0088x-0.2061
2 2
R =0.0009 R =0.0012
1.00 1.00

SRK-T SRK-T
0.50 0.50

0.00 0.00
20 21 22 23 24 25 26 27 28 29 30 20 21 22 23 24 25 26 27 28 29 30

-0.50 Linear Linear

-0.50
[SRK-T] [SRK-T]

-1.00 -1.00

-1.50 -1.50

Fig. 32.4 (a) SRK/T outcomes with inputs from PCI. (b) SRK/T outcomes with OAL1-K readjustment and (c) SRK/T
outcomes with OAL2-K readjustment. The abscissas are axial length in mm and the ordinates the prediction error

lens optics. Haigis [28] subsequently developed reduced from an SD of ±0.11 mm to ±0.03 mm
an improved thin lens formula by using a thick [31]. Despite the improvement in AL measure-
lens algorithm and regressing the ELP with pre- ment, this precision is not reflected in reducing
operative data. Unlike the other 3 formulas, Hai- prediction error according to Olsen [30]. This
gis’ ELP is derived ELP from the measured axial less than encouraging improvement was prob-
length and the preoperative anterior chamber ably overshadowed and supplanted by the ACD
depth. prediction error, a function of IOL power calcula-
tion formulas [31].
Newer formulas can leverage the ever improv-
The Impact of Optical Biometry ing accuracy of biometric measurement and the
quantum leap improvement in computational
In ultrasound biometry, axial length measurement power to improve the precision and sophistica-
error alone accounted for 54% to 68% of the total tion toward better outcomes and predictability.
prediction error according to Olsen [29]. With In the last decade, many new and better formu-
the availability of optical biometry, the source of las have emerged, making use of the heightened
error from axial length measurement decreased accuracy of the newer biometers and increas-
substantially from 0.65 D to 0.43 D or 30 to 40% ing computational power. It is not feasible to go
of the total prediction error according to Olsen through all the formulas and this article does not
[30]. The repeatability of optical biometry was claim to be exhaustive.
32 An Overview of Intraocular Lens Power Calculation Methods 479

 adas Super Formula (LSF) 1.0

L Castrop
The Hoffer Q, Holladay 1, and SRK/T formu- Castrop is a hybrid thin and thick lens formula
las have different optimal ranges for better out- [40]. It considers the cornea as a thick lens. It
comes, first proven and published by Hoffer uses a constant like the Olsen C constant and
in 1993. The Ladas Super Formula blends the readjusts the axial length based on Cooke’s sum-­
proven popular formulas of Hoffer Q, Holladay of-­segments approach. Finally, besides the IOL
1 (with and without Wang-Koch adjustment [25], constant that is integral to the equation, it uses
Haigis and SRK/T using a 3-dimensional model a second constant, offset R to the final dioptric
to determine the best power for each eye [32] power. The formula requires mandatory AL,
based on its 2 to 3 variables inputs. This formula ACD, and K inputs, with CCT and Post K being
was originally developed by Ladas and subse- optional.
quently included Siddiqui, Devgan, and Jun. The
method has now been enhanced with artificial
intelligence. www.iolcalc.com. Thick Lens Formula

Kane Formula The third-generation formulas are simple thin

Developed by Jack X Kane, [33–35] the Kane lens formulas that do not require complex calcu-
formula is an unpublished formula based on lations. A simple calculator would be sufficient
theoretical optics with refinements through both for the formula to be executed. Thin lens formu-
regression and artificial intelligence. It was devel-las are based on the Gullstrand eye model that
oped using approximately 30,000 eyes from vari- assumed a fixed ratio of anterior to posterior cor-
ous cataract practices. The required parameters neal curvature and a keratometric index of refrac-
are AL, K, ACD, and gender with LT and CCT tion of 1.3375. The systematic deviations of these
being optional. Various studies have reported thin lens assumptions are compensated by the
excellent outcomes with this formula. The for- IOL constants. A thin lens formula assumed all
mula is available on www.iolfomula.com. the IOL powers of the same IOL model to have
the same lens constant. This works reasonably
Panacea well for the average eye requiring the average
This is a thin lens vergence formula developed by IOL power. Despite being the same IOL model,
David Flikier. It is a 5-variable calculator using as the IOL power changes: its two curvatures,
AL, K, ACD, LT; and to date the only formula the ratio of its curvatures, and the lens thickness
that can utilize the asphericity Q value of the change. These changes will shift the ELP of the
anterior corneal curvature and the anterior-to-­ IOL.
posterior corneal curvature ratio [36]. It uses a Similarly, as the measuring devices become
demographic to statistically data screen the qual- more accurate and comprehensive, more param-
ity of the various inputs. This formula is available eters can be measured accurately and be included
only for downloading at www.panaceaiolan- in the computation of IOL power, without the
dtoriccalculator.com. risk of increasing the errors of propagation.
Barrett Universal II and EVO are thick lens
VRF-G formulas. In simpler terms, these formulas, like
The VRF is a published vergence-based thin lens the third-generation formulas, predict the ACD
formula by Voytsekivskyy [37]. The VRF-G is a of the IOL in the eye. After determining the
newer improved unpublished formula [38, 39]. initial ACD for the eye, the formulas iterate to
The latter formula is based on theoretical optics determine the final ELP and thence the final IOL
with ray-tracing components; further refined power for the eye. These iterative calculations
through regression. This is an 8-variables for- are far more complex and require the power of
mula. modern-­day computers.
480 H. B. Fam

 arrett Universal II (BUII) Formula

B was developed by G. Debellemanière, D. Gatinel
The concept behind the Barrett Universal formula and A. Saad. The formula is accessible at iol-
was first described by Barrett himself in 1987 [41] solver.com.
and further elucidated in 1993 [42]. The Barrett
Universal II (BUII) is a further refinement of the
Barrett Universal formula and includes the use Ray Tracing
of more variables such as ACD, LT, and radius
of curvature of the posterior cornea. These latter Ray tracing is a method for calculating the path
additional parameters have reached a high level of individual rays through the various elements
of precision (with today’s optical biometers) to in an optical system. These various elements,
be used confidently. with their surfaces and refractive indices, bend
The BUII heralded in a new era of IOL power and change the passing light path. These indi-
calculation formulas, with improved and con- vidual rays are traced and calculated as they are
sistent performances [43]. AL and K inputs are refracted at each of these surfaces according to
mandatory with ACD, LT, and CD being optional. Snell’s law [46]. Ray tracing may be limited to
With the accessibility to corneal thickness (CCT) just the paraxial rays or cover any area on the
and posterior corneal curvature (PK) in newer pupil. The former neglects higher-order aberra-
biometers, these variables are now additional tion, while the latter takes account of them and
optional variables for the formula. allows predicting the IOL power that provides the
best visual quality.
Næser Formula
Conceptualized by Kristian Næser, this is a par- Olsen Formula
axial, step-along formula that considers the IOL First published by Olsen in 1987 [47], this for-
a thick lens. The difference between Næser 1 [44] mula has undergone many upgrades and refine-
and Næser 2 [45] are on the source of the IOL ment over the years [48, 49]. The latest is based
architecture. Næser 1 uses the available informa- on thick-lens ray-tracing optics. The uniqueness
tion on the IOL architecture from the manufac- of this formula is the C constant concept [50]
turers (Cutting Card), whereas Næser 2 derived that generates the ELP based on the preopera-
this information from open, commercial but non- tive measurements of ACD and LT but can be
proprietary sources. Also, the measured AL is additionally tweaked by AL and K, if desirable.
optimized for different axial lengths. The Olsen formula is available as an option in the
LenStar biometer or as a standalone PhacoOptics
 VO
E program for purchase (www.phacooptics.net).
Emmetropia Verifying Optical (EVO) formula is The Olsen formula (Olsen2P = Olsen 2 param-
a thick lens formula developed by TK Yeo. The eters) that is preinstalled in biometers uses 2
formula is based on the emmetropization con- parameters: ACD and LT to predict the C con-
cept of a normal eye and is constantly updated stant. The Olsen formula (Olsen4P) in the stand-
and improved. Presently, it requires mandatory alone PhacoOptics program uses 4 parameters,
AL and K inputs, with ACD, LT and CCT being besides ACD and LT, AL, and K as well.
optional, has recently been updated to include
posterior cornea curvature. Okulix
Okulix is a standalone computer program that
PEARL-DGS calculates IOL power based on ray-tracing the
This is a thick lens IOL formula that relies on optical path of single rays that pass through the
artificial intelligence of machine learning and ocular structure. It uses measured parameters that
modeling to predict ELP and fine-tuning of out- are fed directly via computer interfacing from the
puts for extreme biometric values. This formula biometers and corneal tomographers. Parameters
32 An Overview of Intraocular Lens Power Calculation Methods 481

can also be entered manually, where interfacing Artificial Intelligence (AI)

is not available. The program includes a compila-
tion of IOL geometry of commonly used IOLs. AI examines huge data efficiently and differently
from how we humans do; it identifies relationships,
CSO Method patterns, and trends that escape us. AI has been
Two corneal tomographers (developed by the used in medicine, but these are mainly for image
Italian company CSO) include a software module classification and object recognition. IOL power
that performs IOL power calculations based on calculation is now benefiting from AI as well.
exact ray tracing: Sirius is a Scheimpfug-Placido Critical to the success of AI is a large and
device, and MS 39 is an OCT-Placido instrument. sound “training” dataset. AI learns from its
Corneal surfaces as well as actual IOL data are dataset through interpreting and unraveling, to
raytraced to calculate the optical performance of achieve the desired goal. An accurate and con-
the eye and select the IOL power that will pro- sistent dataset is indispensable to good machine
duce the targeted refraction or the best visual learning. With a large and accurate dataset, AI
quality. can figure out the complex relationships between
the many biometric parameters that may not fit
traditional eye models or Gaussian optics.
Regression Methods Datasets from different devices may have to
be interpreted differently, or at the very least
To improve the accuracy of the early 2nd gen- adjusted and optimized to the device. Newer
eration (R Binkhorst, regression formulas were IOLs with novel optical structures that have yet
born). The regression formulas are derived empir- to attain a sufficient sizable dataset may pose
ically from analyzing the relationship between a challenge for AI. As AI learning capabilities
the preoperative biometric measurements and the improve, it may be able to adapt to parameters
postoperative refractive outcomes. Using a large from different devices and bridge newer IOLs.
outcomes database, the relationship below was Despite these challenges, the future of AI is
established. bright. It has already markedly improved out-
comes as shown by some formulas such as
P ∝ A + bK + cAL
RBF 3.0, Hoffer QST and PEARL-DGS. As the
Where P is the IOL power, A is the A constant; b datasets get larger, these formulas improve fur-
and c are constants; K is the keratometry power ther as typified by the version numbers. More and
and AL is the axial length. more parameters are being utilized as the neuro-
It was first introduced by Thomas Lloyd (a nal circuits are refined and expanded.
technician with James Gills) [51] and followed
first by John Retzlaff [52, 53] and then by Donald
Sanders [54] & Manus Kraff. After the latter 3 Radial Basis Function (RBF)
combined forces, the SRK formula by Sanders,
Retzlaff, and Kraff became the most established Developed by Hill and his team, this formula is
regression formula. It underwent subsequent based on radial basis function (RBF), a machine-­
revision (SRK II by Sanders) to compensate for learning form of artificial intelligence. RBF with
the non-linear relationship between the intraocu- its multidimensions pattern recognition and
lar lens power and the axial length. The SRK II adaptive neural learning process is appropriate to
was popular during the 1980s. It was superseded these real-world challenges of IOL power calcu-
by the later more accurate 3rd generation theo- lation. The formula is constantly being updated
retical formulas. as more and more data is available to refine
482 H. B. Fam

the process. At last look, the formula has been etry measures the ocular wavefront aberrations
updated to version 3.0 with an expanded domain. after removal of the crystalline lens in surgery.
RBF is available as an option on some devices The captured real-time wavefront information is
as well as online at www.rbfcalculator.com. The used to determine the aphakic spherical equiva-
required variables are AL, K, and ACD with LT, lent of the eye and thence calculate the proper
CCT, and CD as options. desired IOL power. The system is independent of
AL and K.

BART
Conclusion
This update on the development of Bayesian Addi-
tive Regression Trees (BART) [55] was described Today, there is an explosion of new IOL power
by Clarke et al. in 2020. This is an AI method using calculation formulas and methods. This is a
a machine-learned algorithm that sums decision welcome development, as today patients are
trees. It gauges its accuracy using Monte Carlo expecting better refractive outcomes. The newer
simulations and generates intervals of possible lens formulas have shown to be more accurate than
powers with a probability density. Over a fivefold the once eminently popular third-generation for-
cross-validation process, the result of BART was mulas. As the hardware and computational power
an SD of 0.242 D compared to 0.416 (Holladay improve, we can expect even better formulas [1].
1), 0.569 D (RBF 1.0), 0.575 D (SRK/T), 0.936 D
(Hoffer Q), and 1.48 D (Haigis). The results were
without optimizing the constants (which might References
be unfair to some of the formulas). MedAE was
0.204 D (BART), 0.416 D (Holladay 1), 0.676 D 1. Koch D, Hill W, Abulafia A, Wang L. Pursuing per-
(RBF 1.0), 0.714 D (SRK/T), 0.936 D for Hof- fection in intraocular lens calculations: 1. Logical
approach for classifying IOL calculation formulas. J
fer Q, and 1.204 D for Haigis. BART prediction Cataract Refract Surg. 2017;43:717–8.
achieved 89.5% within +/-0.50 D of prediction 2. Savini G, Hoffer KJ, Kohnen T. IOL power formula
error, RBF 1.0 was 61.4%, and SRK/T with 52.0%. classifications (Guest Editorial). J Cataract Refract
Surg. 2024;50(2):105. https://doi.org/10.1097/j.
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