Intraocular Lens Calculations After Corneal Refractive Surgery Kenneth J. Mandell, MD, PhD Ula V.

Jurkunas, MD Roberto Pineda, II, MD

Introduction

As of 2007, more than 8 million people in the United States of America had undergone corneal refractive surgery (Market Scope, LLC, St. Louis, MO). As this population ages, many of these patients will require cataract surgery. Refractive surprises after cataract surgery have historically been a problem in postrefractive patients.1 The main reason for this problem is that refractive surgery modifies the shape of the cornea, and these changes alter the accuracy of keratometry measurements used to perform intraocular lens (IOL) calculations for cataract surgery. This review will discuss the limitations of conventional keratometry techniques and potential benefit to newer corneal topography technology for improving IOL calculations in postrefractive patients. Keratometry in Postrefractive Patients The cornea contributes approximately 45D of refractive power to the optical system of the eye. The majority of the corneal refractive power comes from the air-tear-cornea interface on the anterior surface. The second component of refractive power is cornea-aqueous interface on the posterior surface. The corneal power can therefore be estimated using the following formula2:
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1 P n2 _ n1=r1 n3 _ n2=r2 where n1=refractive index of air=1.000; n2=refractive index of the cornea=1.376; n3=refractive index of aqueous humor=1.336; r1=anterior radius of curvature; and r2=posterior radius of curvature. So this formula can be used to calculate the true corneal power provided that the anterior and posterior curvatures of the cornea are known. Until recently, technology to measure the posterior curvature was not readily available, and historically keratometry techniques have relied solely on anterior curvature measurements. This single refracting surface formula was developed by Javal more than 100 years ago and continues to be used today for routine keratometry measurements3: 2 P n _ 1=r where n=standard keratometric index=1.3375 and r=anterior radius of curvature. This formula can then be simplified to the form: 3 P 0:3375=r This formula assumes a uniform relationship between the anterior and posterior corneal surfaces with respect to the radii of curvature and total corneal thickness. For patients who have not undergone corneal refractive surgery, this relationship holds true and the formula allows for consistent estimation of corneal power based on the anterior surface alone. In patients who have had corneal refractive surgery, however, the curvature and/or thickness of the cornea is dramatically altered by the refractive procedure. For example, correction of myopia by laser assisted in situ keratomileusis (LASIK) results in thinning of the central cornea and flattening of the anterior surface relative to the surrounding periphery. In such cases, the ratio between central corneal anterior and posterior curvature is altered, and calculations based on a standard

keratometric index are no longer valid resulting in steeper keratometric measurements (actual keratometry is flatter). In addition, keratometric measurements obtained from points outside of the zone of ablation result in overestimation of the true corneal power in patients who have had myopic LASIK as well as radial keratotomy and photorefractive keratectomy. Conversely, hyperopic refractive procedures result in underestimation of true corneal power due to the steepening within the central optical zone relative to the peripheral cornea. The above examples demonstrate that the surgical changes induced by corneal refractive surgery adversely affect the accuracy of keratometry measurements. These keratometric errors in turn affect IOL calculations required for cataract surgery. Various computational methods have been developed to compensate for the limitations of conventional keratometry, and the advent of newer corneal topography systems offers promise for more accurate assessment of true corneal power. The benefits and drawbacks to of each of these methods are discussed in more detail below.
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Clinical

History Method Many methods for IOL calculation have been developed to account for the changes in corneal power after refractive surgery. The clinical history method, also known as the calculation method or perioperative data method, relies on 3 known parameters: (1) corneal power before refractive surgery, (2) spherical equivalent manifest refraction before refractive surgery, (3) and the spherical equivalent manifest refraction soon after refractive surgery.4,5 In this case, the current corneal power is calculated by subtracting the change in refractive error from the corneal power measured before refractive surgery. The formula for the clinical history method is: K=Kpre+RxpreRxpo. For example, if a myopic patient with corneal power of 44.00D undergoes LASIK, the refractive error may change from 5.00D to emmetropia. The post-LASIK corneal power is calculated as 44.00 5.00=39.0 D. This makes sense, because myopic LASIK flattens the anterior cornea, so the net change in refractive error should be equivalent to the decrease in corneal power by stromal ablation. A simplified version of the clinical history method uses the spherical equivalent refractive change at the spectacle plane to assess the change in refractive power. In reality, the change at the spectacle plane is slightly different from the change at the corneal plane. Consequently, a second calculation is required to convert from the power at the spectacle plane to the power at the corneal plane using a formula that accounts for the vertex distance. This is but a minor detail which, in all likelihood, does not affect patients with low degrees of myopia or hyperopia. For patients with high amounts of myopia or hyperopia, the change in refraction measured at the spectacle plane may differ substantially from that at the corneal plane. In such cases, the conversion to the corneal plane should be applied as demonstrated by Speicher.6 The most apparent limitation to the clinical history method is that it requires historical information from medical records obtained before the refractive surgery. It is common for patients to have cataract surgery many years after their refractive surgery, and often at a different facility from their original refractive procedure. Consequently, prerefractive data are not usually available to the cataract surgeon, and thus the clinical history method is not a practical option. Alternative methods for estimating corneal power in postrefractive patients must therefore be considered. Contact Lens Overrefraction

The contact lens overrefraction (CLO) method does not require any historical data. For this method, manifest refraction is performed both
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with a plano hard contact lens of known base curve and without the contact lens.4,5 The difference between these refractive measurements is equivalent to the difference between the base curve of the plano hard contact lens and actual curvature of the cornea. In this way, corneal power can be determined by adding the difference in refractive error with and without the hard contact lens to the known base curve of the contact lens. The equation for the CLO method is: K=BCL+PCL+RxCL RxnoCL. For example, if a patients refraction is 4.0D with a plano contact lens of base curve 40.0 D. Without the contact lens, the refraction is 1.0 D. The contact lens seems to be more steeply curved than the actual cornea, thus it is inducing a myopic shift of 3.0 D. The actual corneal power is therefore 3.0D less than the base curve of the hard contact lens: 40.0 3.0=37.0 D. One limitation of the CLO method is that it requires patients to have adequate visual acuity and cognitive ability to perform reliable manifests refraction.6 A study by Zeh and Koch7 suggests this method to be reliable for patients with visual acuity of 20/20 to 20/40, but the accuracy of CLO decreases with increasing amounts of media opacification. The authors claim, however, that it is acceptable for visual acuity up to 20/70.7 In any case the ability of the patient to reliably cooperate with manifest refraction should be taken into consideration when performing the CLO method. Calculations Based on Anterior Surface Keratometry Videokeratography systems provide detailed topographic information about the anterior corneal surface. In postrefractive patients for whom preoperative and postoperative corneal power is available, it is possible to estimate the true corneal power based on the net difference in anterior surface power measured by videokeratography. This change in anterior surface power can be applied to the estimated corneal power obtained from the standard keratometric index formula (Equation 2). The resulting number is an estimate of the corneal power after refractive surgery. The calculations for this method are relatively complex, and more detailed examples are provided by Speicher.6 Like the clinical history method, such calculation-based methods require prerefractive corneal measurements, and such information may not be routinely available at the facility where cataract surgery is performed. No-History Method In contrast to the above method that requires prerefractive clinical data,8 Shammas and Shammas9 developed a no-history method based only on post-LASIK keratometry measurements. This method is based
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largely on a prior study involving a linear regression model obtained from 200 patients who had undergone LASIK.9 It seems to be a mathematically sound approach that yields consistent, reproducible results within the patient population studied. The only drawback to such regression-based models is that the results may not be readily applied to other populations in which the patient demographics or surgical technique employed differ from the group that was studied. Consensus-K Technique In contrast to the no-history method described above, the ConsenusK technique reported by Randleman et al10 uses all available techniques to calculate IOL power in postrefractive patients. This study by the group was a retrospective comparative series in which keratometric data

from multiple techniques were pooled for each subject. Outliers K values were excluded if they were greater than 1.5D from the mean. The resulting consensus value was used to calculate a predicted IOL implant power that was compared with the ideal IOL power backcalculated from postcataract surgery refraction. This difference between the predicted IOL power and ideal IOL power was used to assess the accuracy of the consensus-K technique. Their results suggested that the consensus-K method was more accurate than any individual keratometry technique alone with the exception of the clinical history method. Corneal Topography for Estimation of True Corneal Power Two commercially available corneal topography systems are the Orbscan by Bausch & Lomb (Rochester, NY) and Pentacam by Oculus (Lynnwood, WA). Both systems produce detailed topographic models of the anterior and posterior corneal surfaces and provide estimates of total corneal power. The Orbscan system uses scanning slit technology that has limitations within the central 2-mm optical zone due to the position of its measurement camera. In general, it provides lower resolution images than the Pentacam system, and it has been shown to be less reliable with regard to the repeatability and reproducibility of its measurements.11 The Orbscan system has specifically been criticized for the poor quality posterior images in which ectactic artifacts have been observed. In contrast, the Pentacam uses rotating Scheimpflug technology to image the entire cornea including the central 2-mm optical zone. The results of recent tests have shown high reproducibility and reliability with the Pentacam system.11 A major advantage of the Pentacam system over conventional keratometry techniques is that it allows for imaging of the entire cornea,
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including the central optical zone.11 It provides detailed topographic information about the anterior and posterior contours as well as corneal thickness estimates throughout the entire cornea. These measurements are important in postrefractive corneas where the anterior radius of curvature and cornea thickness may have been modified by the refractive procedure. Thus changes in stromal thickness within the optical zone and deviation from the normal ratios of anteriortoposterior curvature can be incorporated into corneal power calculations. Instead of calculating corneal power using the anterior curvature and standard keratometric index (Equation 2), the Pentacam software uses the 2-surface formula that accounts for both anterior and posterior curvature (Equation 1). The result of this formula is an estimate of true corneal power. The Pentacam software then converts true corneal power to an equivalent K reading (EKR), which is an adjustment for IOL calculations that are usually performed with the standardized singlesurface formula (Equation 2). In theory, the benefit of the Pentacam system over conventional keratomtery is that it incorporates topographic information about the anterior and posterior surfaces of the cornea and allows measurement of the central optical zone. In patients who have had refractive surgery, this reduces the potential for keratometric errors and fewer refractive surprises after cataract surgery. To date, however, there is a paucity of clinical data to fully substantiate these concepts. One major question that remains unanswered is how to use the data generated from the corneal power map? The Pentacam system produces a table containing a series of EKR readings derived from 8 concentric optical zones ranging from 1 to 7mm in diameter (Fig. 1A). The EKR values are represented pictographically in false color on an EKR map (Fig. 1B). There is also a

plot illustrating the relationship between the choice of optical zone size and EKR estimate resulting from that zone (Fig. 1C). It is clear from these data that EKR estimates are highly dependent on the region of the cornea from which they are measured, with the lowest EKR values generated from the smallest optical zones. Selection of too large or too small optical zone can undoubtedly affect the accuracy of IOL calculation based on these numbers. By default, the Pentacam software uses an EKR zone of 4.5mm, a value recommended by Holladay12 and Hill.13 Some studies, however, suggest that a smaller EKR zone may be more accurate for estimating corneal power in postrefractive patients. For example, Savini et al14 showed that corneal power estimates derived from EKR zones of 1 to 3mm were similar to those obtained from the clinically history method. One limitation of this study was that it did not evaluate the predictive value of such data in IOL calculations for cataract surgery. Surgeons should carefully consider the EKR zone selected for use in IOL calculations. More studies are required to determine the optimal Pentacam EKR zone for postrefractive patients.
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IOL

Formulas and Effective Lens Position It would seem that more accurate assessment of corneal power with topographic systems such as the Pentacam would be enough to improve accuracy of IOL calculations and prevent refractive surprises. Recent studies, however, suggest that errors in corneal power assessment do not alone account for residual refractive error in postrefractive patients who underwent cataract surgery.13,15,16 The reason for this is that most thirdgeneration IOL formulas such as the SRK/T, Hoffer Q, and Holladay 1 rely on assumptions about effective lens position (ELP) that are not valid in postrefractive patients. That is, such formulas presume a relationship between anterior chamber depth and corneal power such that an eye with a relatively flat cornea would be assumed to have a proportionately shallow anterior chamber. In a cornea that has undergone ablation for myopia, however, such equations erroneously underestimate anterior chamber depth and assume an ELP that is more anterior. Despite proper assessment of central cornea power, the IOL power predicted by thirdgeneration formulas may be artificially low in patients who have undergone myopic LASIK. One way around this problem is to use 2 separate K values for IOL calculations. For example, the SRK/T formula can be adapted to use a prerefractive K value for ELP calculation and a postrefractive K value for the remainder of the IOL calculations. This
BC
Zone Diameter (mm) 1.0 2.0 3.0 4.0 4.5 5.0 6.0 7.0 Mean Zonal EKR 36.4 36.9 37.7 38.7 39.3 40 41.3 42.7

A
Figure 1. An example of EKR data produced from the Oculus Pentacam system in a postrefractive patient. A, Mean zonal EKR values as a function of zone diameter (mm). B, Topographical representation of EKR readings throughout the surface of the cornea. C, A plot of mean zonal EKR values versus of zone diameter (mm) illustrating that the smallest EKR value is often obtained in the central EKR zone, which corresponds to the blue false color in panel (B). EKR indicates equivalent K reading.
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double-K method has been studied and it has shown to be effective.15 In addition, there are nomograms available to estimate the residual refractive error based solely on the axial length and amount of refractive correction performed.16 For patients for whom preoperative data are not available, the Holladay Consultant software uses a default K value of 44 to compute ELP.13 In practice, precise historical data are often not available at the facility where cataract surgery is performed. Thus, only rough estimates of the original K value can be incorporated into the IOL

calculations using a nomogram or a fixed value of 44D as suggested by the Holladay software. In any case, it is important for the surgeon to consider this additional factor involving ELP when computing IOL power in postrefractive patients. Summary Many patients who have had corneal refractive surgery ultimately require cataract surgery several years later. Estimation of corneal power is important for IOL calculations, but conventional keratometry techniques lead to inaccurate results in postrefractive patients. Although the knowledge of prerefractive keratometry reading may be useful in making adjustments to such calculations, such historical data are often not available. There is a need for more direct nonhistorical keratometry techniques and the Oculus Pentacam or similar devices (Ziemer Galilei) have the potential for use in such settings. However, more studies are required to evaluate the optimal parameters for Pentacam-based IOL calculations in postrefractive patients. References
1. McDonneil PJ. Can we avoid an epidemic of refractive surprises after cataract surgery? Arch Ophthalmol. 1997;115:542543. 2. Elkington AR, Frank HJ. Clinical Optics. Oxford. Boston. St. Louis, Mo.: Blackwell Scientific Publications; 1991:197. 3. Javal E . Memoires Dopthalmometrie Annotes Et Precedes Dune Intr oduction. Paris: G. Masson; 1890:627. 4. Hoffer KJ. Intraocular lens power calculation for eyes after refractive keratotomy. J Refract Surg. 1995;11:490493. 5. Holladay JT. IOLs in LASIK patients. How to get them right the first time. Rev Ophthalmol. 2000:5962. 6. Speicher L. Intra-ocular lens calculation status after corneal refractive surgery. Curr Opin Ophthalmol. 2001;12:1729. 7. Zeh WG, Koch DD. Comparison of contact lens overrefraction and standard keratometry for measuring corneal curvature in eyes with lenticular opacity. J Cataract Refract Surg. 1999;25:898903. 8. Odenthal MT, Eggink CA, Melles G, et al. Intraocular lens power calculation for cataract surgery after photorefractive keratectomy. Arch O