BIOMETRY

 By Samuel T. (R2)
 Moderators :
Dr Dagmawi A. (Ass. Professor of Ophthalmology)
Dr Kasahun E. (R4)

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Outline
 Introduction
 Keratometry
 Axial length
 Estimated lens position
 IOL formulas
 Special circumstances

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 Introduction
 Biometry is the process of measuring the power of the cornea
(keratometry) and the length of the eye, and other variables to
determine the ideal intraocular lens power.

 The refractive power of the human eye depends on three factors: the
power of the cornea, the power of the lens, and the length of the eye.

 Following cataract surgery, only the power of the cornea and the
length of the eye are relevant.

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Biometric formula requirements
 In order to determine the power of the IOL several values
need to be known:

-Corneal power (K)

-Axial length (AL)
-Estimated lens position (ELP)
-Anterior chamber constant: A-constant or
another lens related constant

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Keratometry
 Keratometry measures the radius of curvature of the anterior
surface of the cornea and its respective refractive power based on
its reflective properties as a highly polished spherical convex mirror
.

 If we place an object in front of a convex mirror we get a virtual,

erect and minified image.

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Keratometry
 Different types of keratometer
- Manual
-Topography
-Autokeratometer
-IOL master/ Lenstar 900

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 Manual Keratometry

Bausch & Lomb model

 “constant object size variable

image size”

 It is a one-position, variable
doubling instrument

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Procedure
 Instrument adjustment
 Patient adjustment
 Focusing
 Measuring
 Recording

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Javal - Schiotz model
 This is on the principle of “variable
object size constant image size”

 It is a two-position, fixed-doubling
keratometer

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Procedures
 Instrument adjustment
 Patient adjustment
 Adjustment of mires
 Measurement and
 Recording

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How to do accurate manual keratometry:
 Calibrate and check the accuracy of the keratometer
 Don't touch the cornea before
 Ensure a good tear film
 Adjust the eyepiece to bring the central cross-hairs into focus
 Make sure that the patient's other eye is occluded
 Make sure that the cornea is centered
 In a scarred cornea take the result of the fellow eye.
 Repeat if..--<40D or >47D
-- difference > 2D

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Source of keratometry errors
 Unfocused eye piece
 Failure to calibrate
 Poor patient fixation
 Dry eye
 Drooping eye lids
 Irregular cornea
 Contact lens user

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 Automated keratometer
 Focuses reflected corneal image on to an electronic photosensitive
device, which instantly records the size and computes the radius of
curvature.

 Image doubling device is not required

Advantage
 simplicity, Joystick focusing
 Accurate and repeatable measurement
 Allow printing of result
 Very short time consuming
 Comparatively easy to operate

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Handheld Auto Refract Keratometer
 Allow measuring of patients in different postures
-children under general anesthesia
-Disabled patients
-mentally retarded patients

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 Axial Length
 Axial length - is the distance between the anterior surface of the
cornea and the fovea.
 AL is the most important factor in IOL power calculation.
 A 1-mm error in AL measurement results in a refractive error of
approximately
 2.35 D/mm in a 23.5-mm eye.
 3.75 D/mm in a 20-mm eye
 1.75 D/mm in a 30-mm eye

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Measurement methods

 A- scan ultrasonography.
 applanation(contact)
 immersion(noncontact)

 Optical Laser interferometry

 IOL Master (Carl Zeiss)
 Lenstar LS 900 (Haag-Streit)

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A- scan ultrasonography
 A- scans measure the time required for a sound pulse to travel
from the cornea to the retina and back again.

 In A-scan - thin, parallel sound beam is emitted from the

probe tip, with an echo bouncing back into the probe tip as the
sound beam strikes each interface

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A- scan ultrasonography
 The average velocity is
 1555 m/s phakic eye of normal length
 1560 m/s for a short (20-mm) eye
 1550 m/s for a long (30-mm) eye.
 1554 m/s for an aphakic eye of any length.

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 A- scan ultrasonography
 Sources of error - Indenting the globe with probe , Misalignment of
the probe with the eye ,Silicone filled eyes

 In eyes with AL values >25 mm, staphyloma should be suspected

 To obtain the true measurement to the fovea, the clinician must use
- B-scan technique
- Optical methods ( IOL Master, Lenstar ) are very useful

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 A- scan ultrasonography
 Always measure both eyes in every patient
 Repeat measurement in both eyes if
- There is >0.3 mm difference between eyes
- AL is <22 mm or >25 mm in either eye
- AL does not correlate well with patient’s spectacle refraction
- Perform a B-scan to document the difference

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 Applanation A-scan Biometry
 An ultrasound probe is placed directly on the cornea, with attached
slit lamp or by holding the probe by hand.

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Applanation A-scan Biometry
 If pressure is applied on the cornea, the axial length
measurement may be falsely too short.

 It can be monitored by observing the anterior chamber depth,

read out by an instrument.

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Applanation A-scan Biometry

a: Initial spike (probe tip and

cornea)
b: Anterior lens capsule
c: Posterior lens capsule
d: Retina
e: Sclera
f: Orbital fat

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Applanation A-scan Biometry

 Advantage
-Simple to perform

 Disadvantages
- Inconsistent and unpredictable
- Variable corneal compression.
- Artificially shortened AL measurement
- Limited resolution

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Immersion A-scan Biometry
 Done by placing a small scleral shell between the patient's
lids, filling it with saline, and immersing the probe into the
fluid, being careful to avoid contact with the cornea.

 More accurate than contact method because corneal

compression is avoided.

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Immersion A-scan Biometry
a: Probe tip. Echo from tip of
probe, now moved away from the
cornea and has become visible.
b: Cornea. Double-peaked echo
will show both the anterior and
posterior surfaces.
c: Anterior lens capsule.
d: Posterior lens capsule.
e: Retina. This echo needs to have
sharp 90 degree take-off from the
baseline.
f: Sclera.
g: Orbital fat.

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Immersion A-scan Biometry

• Advantages
- The more accurate
- Eliminates corneal indentation

• Disadvantages
- Expensive
- Time-consuming
- As less control over alignment
- Requires the patient to be supine

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Optical Biometry

 The Zeiss IOL Master - non- contact optical device that

measures the distance from corneal vertex to the RPE by dual
beam partial coherence laser interferometry .

It Uses 780 nm infrared light to measure AC depth

- Keratometry
- Axial Length
- White to white distance
- IOL power calculation .

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 Advantages of IOL Master

 Easy & technician independent

 Noncontact
 No water bath is needed
 Can measure through glasses
 Accurate for silicone oil filled eyes and posterior staphyloma.
 Accurate (Holladay II)
 Haigis L formula incorporated.

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LENSTAR LS900

 The LENSTAR LS900 measures all optical interfaces

from anterior cornea to retinal pigment epithelium by
means of Optical Low Coherence Reflectometry (OLCR)

 It uses an 820-nm laser diode to measure CCT, ACD, Lens

thickness, Retinal thickness, AL, Keratometry, White to white
distance, Pupillometry & eccentricity of optical axis.

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Estimated lens position
 ELP - Is defined as the distance from the anterior surface
(vertex) of the cornea to the effective principle plane of the
IOL in the visual axis.

 In the original theoretical formula, the ELP was a constant

value of 3.5 mm for every lens in every patient

 Better results are obtained by relating expected ELP to the AL

and corneal curvature
-Decreases in the shorter eyes and flat corneas
-Increases in the longer eyes and steeper corneas

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 Estimated lens position
ELP is required for all formulas, but is used in different forms
 In Binkhorst and Hoffer formulas - It is used directly and called the
ACD .

 In Hoffer Q formula - Is referred to as pACD (personal ACD) .

 In Holladay 1 formula - It is calculated using a surgeon factor (SF)

specific to each IOL style .

 In SRK I, II and SRK/ T - It is incorporated into the A constant

specific to each IOL style.

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 A-constant
 A unitless, theoretical value that relates the lens power to AL
and keratometry

 Originally designed for the SRK equation

 Depends on variables like IOL manufacturer, style and

placement within the eye

 power of the lens varies in a 1:1 relationship with the A-

constants:
- If A decreases by 1 diopter, IOL power decreases by 1 diopter
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 IOL formulas
Regression formulas (Empirical Formula)

generated
 by averaging large numbers of post-operative clinical results
(retrospective analysis).

Theoretical formula
 Derived from the geometric optics as applied to the schematic eyes
 The eye is considered a two lens system (i.e. IOL and cornea)
 These formulas is based on 3 variables - Axial length ,K reading and
Estimated postoperative ACD

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Generations of IOL formulas

IOL calculation formulas differ in the way they calculate ELP

First Second Third Fourth

generation generation generation generation

Binkhorst, SRK II Holladay-1 Holladay-2

SRK I Hoffer Q Haigis
SRK/T Olsen

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1st Generation
 All these formulas depended on a single constant for each lens
that represented the predicted IOL position (ACD/ELP).

Binkhorst
Earliest theoretical formulae
P= 1336 (4r-L) / (L-C) (4r-C)
P - power
r – corneal radius
L– AL
C– assumed post op ACD

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 1st Generation

SRK 1 (Sanders ,Retzlaff & Kraff) - regression formula

 They replaced ACD with A constant specific for each IOLs
 More accurate than many of the 1st generation formulas
 Suitable for eyes with AL range of 22.0-24.5mm

P = A – (2.5L -0.9K)
P- power of the IOL
A- A constant of the IOL
L- axial length
K- average Keratometry

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2nd Generation
 SRK II formula
Modification of SRK
The basic were same , A-constant is modified on the basis of AL
More accurate than first generation
 P = A1 – 2.5L – 0.9K
A1 = A + 3 AL < 20mm
A1 = A + 2 AL 20-21
A1 = A + 1 AL 21-22
A1 = A AL 22-24.5
A1 = A – 0.5 AL >24.5

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3rd Generation
 Third generation formulas - calculate the ELP based on the
axial length and the corneal curvature.

 Significantly more accurate than previous theoretic formulas

and the SRK II

- HofferQ - Short eyes<24.5 mm

- Holladay I - long eyes 24.5 -26 mm
- SRK/T - very long eyes >26mm

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 4th Generation

Calculate the ELP based on more than 2 variables

Haigis
 Eliminated the K as a prediction factor and replaced it with
the preoperative ACD measurement

 Proposed using three constants (a0, a1 & a2) based on The

characteristics of the eye and the IOL to predict the ELP .

 Applicable for all ranges of axial lengths

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4th Generation
ELP= a0 + (a1 * ACD) + (a2 * AL)
ELP = predicted IOL position.
a0 = an IOL specific constant
a1 = IOL specific constant to be effected by the measured
preoperative ACD
a2 = IOL specific constant to be effected by the measured
preoperative Axial length
ACD = distance from the cornea to the front surface of the lens
AL = Axial length

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 4th Generation

Holladay 2:
Holliday 2 formulae takes into account (Beside AL and K reading) :
A. Corneal white to white diameter
B. Preoperative AC depth
C. Phakic lens thickness
D. Patient age and preoperative refraction

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Special circumstances

 Post refractive surgery

 Post PK surgery
 Silicone oil filled eyes
 Pediatric patients

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Post refractive surgery
 Intraocular lens power calculation is a problem in eyes that
have under gone radial keratotomy (RK)or laser corneal
refractive procedures.

 The difficulty stems from 3 sources of errors:

1) instrument error
2) index of refraction error
3) formula error.

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 Post refractive surgery
 Instrument error
- keratometers cannot obtain accurate measurements in eyes that
have undergone corneal refractive surgery

-The flatter the cornea, the larger the zone of measurement, and
the greater is the error

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Post refractive surgery
Index of Refraction Error
 IR of the normal cornea is based on the relationship
between the anterior and posterior corneal curvatures.

Ophthalmologists long believed that IR error did not

occur in eyes that have under gone RK.

This situation leads to an overestimation of the corneal

power by approximately 1 D for every 7 D of correction
obtained and results in hyperopic refractive surprise.
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Post refractive surgery
 Formula error
 Except for the Haigis formula, all the modern IOL power
formulas (eg, Hoffer Q, Holladay 1 and 2, and SRK/T) use
the AL values and K readings to predict the postoperative
position of the IOL (ELP).

 The flatter- than- normal K value for eyes that have under
gone myopic refractive surgery causes an error in this
prediction because the anterior chamber dimensions do not
actually change in these eyes commensurately with the
much flatter K.
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Power Calculation Methods in the Post
keratorefractive Eye

The Double-K method

 Uses prerefractive surgery corneal power (or 43.50 D if
unknown) is used to estimate the ELP and the postrefractive
surgery corneal power is used to calculate the IOL power.

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IOL Power in Corneal Transplant Eyes

 Hoffer recommended that the surgeon wait for the cornea to

completely heal before implanting an IOL

 If simultaneous IOL implantation and corneal transplant are

necessary,
-The K reading of the fellow eye or
-The average postoperative K of a previous series of transplants

 For patients with corneal scar who are having IOL implantation only,
other eye readings can be used

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Silicone Oil Eyes

2 major problems
 Obtaining an accurate AL measurement with the ultrasonic
biometer velocity of sound differ in silicone oil versus for
vitreous. To solves this problem:
 Using optical biometry to measure AL.
 Perform an AL measurement before silicone oil placement

 Silicon oil filling vitreous cavity acts like a negative lens

power in the eye when a biconvex IOL is implanted.
- This must be offset by an increase IOL power of 3- 5 D.

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Pediatric eyes
 Pediatric eye is not a miniaturized adult eye.

 It has shorter axial length, steeper cornea with higher

keratometry value and smaller anterior chamber depth.

 Errors in axial length measurement affect IOL power

calculation the most, it increases to 3.75 D per mm in
children.

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 Pediatric eyes

IOL power selection for children much more complex than that for
adults.
1. Difficulty obtaining accurate AL and keratometry
measurements .
2. Shorter AL causes greater IOL power errors,
3. Use of power formulas that were developed for adults
4. Selecting an appropriate target IOL power; prevent amblyopia
and allow adequate vision in adulthood /emmetropization/

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References

1. BCSC: sections 3 , 8 and 11

2. IOL power, Kenneth J. Hoffer
3. Borish’s Clinical Refraction
4. Internet

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THANK YOU !

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