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ADVANCED IOL CALCULATIONS 2015
JACK T. HOLLADAY, MD, MSEE, FACS Page 1 of 24
3/22/2015 JTH 1
AdvancedIOL Power Calculations
Jack T. Holladay, MD, MSEE, FACSClinical Professor of Ophthalmology
Baylor College of MedicineHouston, Texas, USA WWW.AAO.ORG
0
AMERICAN ACADEMY OF OPHTHALMOLOGY
Financial Disclosure I have the following financial interests or relationships to disclose:
Abbott Medical Optics: C;
AcuFocus, Inc.: C,O;
Alcon Laboratories, Inc.: C;
ArcScan: C,O;
Carl Zeiss Inc: C;
Elenza: C,O;
Oculus, Inc.: C;
Visiometrics: C,O;
Wavetec: C
3/22/2015 JTH 47
www.docholladay.com
Handouts
3/22/2015 JTH 5
Jack T. Holladay, MD, MSEE, FACS
Clinical Professor of Ophthalmology
Baylor College of Medicine
Houston, Texas
www.docholladay.com
3/22/2015 JTH 6
Vergence Formula
Theoretical Formula has not changed in 173 years
Physiologic Assumptions may be slightly different Retinal thickness
Corneal Index of Refraction3/22/2015 JTH 7
Vergence Formula
IOLAL ELP
DPostRxV
K
ELP
1336 1336
1336
1000
1000
ADVANCED IOL CALCULATIONS 2015
JACK T. HOLLADAY, MD, MSEE, FACS Page 2 of 24
3/22/2015 JTH 8
E L PEffective Lens Position
Distance from corneal vertex to principal plane of thin IOL (no thickness)
Same as ACD, but avoids confusion with anatomy
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Prediction of E L P
<1980 Constant (0) 4.5
1981 Binkhorst 2 (1) AL
1988 Holladay 1 (2) AL, K
1995 Olsen (4) AL, K, ACD, LT
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Prediction of E L P
1996 Holladay 2 (7) AL, K,
ACD, LT, HWTW, REF, AGE
3/22/2015 JTH 12
Investigation International Study - 1993 34 investigators (15 U.S.)
Additional measurements are
taken 35 eyes < 21 mm
35 eyes > 26 mm
35 eyes = normal3/22/2015 JTH 15
Measurements taken forPredictors of ELP
Axial Length Average K Horizontal WTW ACD LT Pre-opRefraction Age
ADVANCED IOL CALCULATIONS 2015
JACK T. HOLLADAY, MD, MSEE, FACS Page 3 of 24
3/22/2015 JTH 16
HWTW Gauge
Horizontal Corneal Diameter
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ASICO # AE
3/22/2015 JTH 18 ASICO # AE 3/22/2015 JTH 20
0
200
400
600
800
1000
Anterior Segment Size
# o
f C
ase
s
Small Normal Large
Normal Eyes
2%
96%
2%
N = 824
3/22/2015 JTH 21
0
20
40
60
80
Anterior Segment Size
# of
Cas
es
Small Normal Large
Short Eyes ( < 21 mm)
20%
80%
0%
3/22/2015 JTH 22
0
20
40
60
80
Anterior Segment Size
# of
Cas
es
Small Normal Large
Long Eyes ( > 27 mm)
0%
90%
10%
ADVANCED IOL CALCULATIONS 2015
JACK T. HOLLADAY, MD, MSEE, FACS Page 4 of 24
3/22/2015 JTH 23
Normal Physiologic Values
Al: 23.5 mm + 1.25 mm
K: 43.81 D + 1.6 D
Hwtw: 11.7 mm + 0.46 mm
Ref: -0.60 D + 2.00 D
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Normal Physiologic Values
ACD: 3.1 mm + 0.30 mm
LT: 4.7 mm + 0.41 mm
Age: 72 years + 12.0 years
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Critical Data
Corneal Power
“Optical” Axial Length
Horizontal “White-to-White”(11.7) AC angle = WTW + 1.0 (12.7)
Sulcus = WTW + 1.5 (13.2)
Bag = WTW – 1.0 (10.7)
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CONCLUSION
Eye Model must include
NINE
types of eyes not only
THREE
3/22/2015 JTH 27
CONCLUSION: 9 EYES
Ant
erio
r S
egm
ent S
ize
Axial LengthShort Normal Long
Large
Normal
Small
Megalocornea Large Eye
+ axial Megalocornea Buphthalmos
hyperopia Megalocornea
+ axial myopia
axial hyperopia normal axial myopia
Small eye Microcornea
Nanophthalmia Microcornea + axial opia
(20%)
(10%)(2%)
(2%)
(80%) (96%) (90%)
(0%)
(0%)
3/22/2015 JTH 28
Relative Importance ofPredictors for ELP
Axial Length 100 Average K 76 Horizontal WTW 24 Refraction 18 ACD 8 LT 7 Age 1
ADVANCED IOL CALCULATIONS 2015
JACK T. HOLLADAY, MD, MSEE, FACS Page 5 of 24
3/22/2015 JTH 29
15 20 25 30 35
-20
0
20
40
60
80
100
Axial Length (mm)
IOL
Pow
er (
D)
Small Ant. Seg.
Normal Ant. Seg.
Large Ant. Seg.
EMMETROPIC IOL POWER
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THE HOLLADAY 2 FORMULA
More Measurements
More Accuracy
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RESULTS
New Holladay 2:
Normal eye: 50% + 0.40 D
Unusual eye: 50% + 0.80 D
Previous results:
Normal eye: 50% + 0.50 D
Unusual eye: 50% + 5.00 D3/22/2015 JTH 32
FORMULA PERFORMANCE
15 20 25 300
1
2
3
4
5
6
Axial Length (mm)
Mea
n A
bsol
ute
Err
or (
D)
Holladay 1
Hoffer Q
SRK/T
Holladay 2
N = 997
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CONCLUSIONS
Prediction Errors in Short Eyes:significantly improved by more measurements
Prediction Errors in Long Eyes:due to bad Axial Lengths, B-Scan
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Myopic Staphyloma
ADVANCED IOL CALCULATIONS 2015
JACK T. HOLLADAY, MD, MSEE, FACS Page 6 of 24
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Subtractfrom Ascanmeasured
Axial Length~ 0.8 mm
Zeiss - IOL Master - 2000Zaldivar-Holladay JCRS May 2000
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J Cataract Refract Surg 2011; 37:2018–2027
3/22/2015 JTH 38
Linear Regression to compensate for AVERAGE Index of Refraction in Long Eyes
Measured 36 34 mm
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Zeiss-Humphrey IOL MasterLenStar
Difficult CasesAsteroid Hyalosis (vit. debris)Extreme Length (26.5 mm)
Uses Average Index Too LongExtreme Short (< 21 mm)Pseudophakic EyesSilicone in Vitreous
3/22/2015 JTH 40
orizontal Angle & Alpha & Kappa
PCVA
< Κ
Angle Kappa on IOL Master, LenStar and penlight ~ 0.33 mm
If > 0.70 mm then concern!
●Karhanová M, Marešová K, Pluháček F, Mlčák P, Vláčil O, Sín M. Cesk Slov Oftalmol. The importance of angle kappa for centration of multifocal intraocular lenses. 2013 Jun;69(2):64-8. [Article in Czech]● G Prakash, DR Prakash, A Agarwal, DA Kumar, A Agarwal and S Jacob. Predictive factor and kappa angleanalysis for visual satisfactions in patients with multifocal IOL implantation. Eye (2011) 25, 1187–1193
ADVANCED IOL CALCULATIONS 2015
JACK T. HOLLADAY, MD, MSEE, FACS Page 7 of 24
3/22/2015 JTH 41
Horizontal Angle & Alpha & Kappa
OC
PC
VA
< α
< Κ
BEST CENTRATIONOF IOL
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LENSTAR – HAAG-STREIT
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IOL MASTER - ZEISS
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Horizontal Angle & Alpha & Kappa
OC
PC
VA
< α
< Κ
BEST CENTRATIONOF IOL
3/22/2015 JTH 45
Data ScreeningMonocular and Binocular
Using Mean and St. Dev. an exact p-value for each measurement can be calculated
Any measurement beyond two Std. Dev. from the mean should be double checked (p<0.05)
3/22/2015 JTH 46
Data ScreeningMonocular and Binocular
Monocular: AL = 19.75 mm
p = 0.001
Binocular: Kright - Kleft = 1.5 D
p = 0.0005
ADVANCED IOL CALCULATIONS 2015
JACK T. HOLLADAY, MD, MSEE, FACS Page 8 of 24
3/22/2015 JTH 47
Cataract Surgery …
IOL Power Calculations
Following Refractive
Surgery3/22/2015 JTH 48
Preoperative Assessment
Endothelial Cell Count
Pachymetry
Direct Ophthalmoscope @ 16”
Corneal Topography
Determining Corneal Power
IOL Calculation
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3/22/2015 JTH 51
Corneal Power afterLASIK, PRK, RK
Ideally, Calculation from both surfaces …
Calculation from Prior Data Trial Hard Contact Lens Corneal Topography Automated Keratometry Manual Keratometry
3/22/2015 JTH 52
Corneal Power afterLASIK, PRK, RK
Methods listed in order of reliability
Methods 3, 4 and 5 almost always exceed true power & result in hyperopic error
Use lowest reliable value
ADVANCED IOL CALCULATIONS 2015
JACK T. HOLLADAY, MD, MSEE, FACS Page 9 of 24
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ToPography: Measures Total Power andTotal Astigmatism of Lenticle
ToMography: Measures Front SurfacePower of Lenticle and then uses backradius of 0.82 of front radius forTotal Power and can ADD 0.22 DATR for Total Astigmatism
Keratometry: Measures FrontSurface Ring or annulus Power ofLenticle (nominal 2.0 to 3.2 mm for44 D cornea) then uses back radius of0.82 of front Radius for Total Power andcan ADD 0.22 D ATR for Total Astigmatism
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Ring Diameteraffects Keratometry
3/22/2015 JTH 58
4 mm OZ with 6 cuts ~~ - 4.00 D
3/22/2015 JTH 59
ADVANCED IOL CALCULATIONS 2015
JACK T. HOLLADAY, MD, MSEE, FACS Page 10 of 24
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3 mm pinhole
Rigid Contact Lens
Trial Frame
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1. Calculation from Prior Data(Pre K & Δ MR known)
Pre KR Mean K = 44.00 D
Change in SEQ Ref = -4.50 D
Calc Mean K = 39.50 D
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2. Calculation from Prior Data(Post Std. K’s & Δ MR only)
Post Mean K = 40.58 D
Change in SEQ Ref = -4.50 D
STD K’s: -0.24 * SEQ = -1.08
Calc Mean K = 39.50 D3/22/2015 JTH 65
3. Calculation from Prior Data(Post Ctr Top Power & Δ MR only)
Post Mean K = 40.27 D
Change in SEQ Ref = -4.50 D
Ctr Top: -0.15 * SEQ = -0.77
Calc Mean K = 39.50 D
ADVANCED IOL CALCULATIONS 2015
JACK T. HOLLADAY, MD, MSEE, FACS Page 11 of 24
3/22/2015 JTH 66 3/22/2015 JTH 67
4. Trial Hard Contact Lens(Rigid Contact lens only)
Plano HCL Base Curve = 41.50 D
SEQ Ref without CL = +0.50 D
SEQ Ref with CL = -1.00 D
Front K = 41.50 - 1.50 = 40.00 D
40.00 D – 10% (4.50) = 39.50 D
Mean K = 39.50 D
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Post-operative
Initial Hyperopic Shift
Long Term Hyperopic Drift
ATR Astigmatism Drift
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ADVANCED IOL CALCULATIONS 2015
JACK T. HOLLADAY, MD, MSEE, FACS Page 12 of 24
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Accuracy of EKRPrior
Sx
STD 4.5
(D)LASIK 0.56
RK 0.94
Holladay JT, Hill WE, Steinmueller A. Corneal Power Measurements Using Scheimpfl ug Imaging in Eyes With Prior Corneal Refractive Surgery. J Refractive Surgery 2009:25:862-868. (October 2009 Issue of J Refr Surgery)
3/22/2015 JTH 84
J Cataract Refract Surg Feb 2015; 41:339–347
3/22/2015 JTH 85Holladay Report Equivalent Keratometric Power
ADVANCED IOL CALCULATIONS 2015
JACK T. HOLLADAY, MD, MSEE, FACS Page 13 of 24
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3/22/2015 JTH 90
Normal LASIK RK
41 to 44 D3 D Range
36 to 41 D5 D Range
32 to 45 D13 D Range
ADVANCED IOL CALCULATIONS 2015
JACK T. HOLLADAY, MD, MSEE, FACS Page 14 of 24
3/22/2015 JTH 92
Summary Optimal Zone LASIK: 4.5 mm RK: 5.0 mm Customize for small/large pupils
Accuracy LASIK: 0.56 D RK: 0.94 D
Error on MYOPIC side3/22/2015 JTH 93
IOL CALCS in Keratoconus
Corneal is Bifocal
Patient does not look through cone for distance (may use at 10 cm as magnifier
Look at Power Distribution
Use Paracentral Power
(65% Mean Power)
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Keratoconus #1
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Keratoconus #1
3/22/2015 JTH 96
Keratoconus #1Keratoconus #1
3/22/2015 JTH 97
`Keratoconus #1
ADVANCED IOL CALCULATIONS 2015
JACK T. HOLLADAY, MD, MSEE, FACS Page 15 of 24
3/22/2015 JTH 98
Keratoconus Calculation #1OS
Used Km = 46.5 D => +1.00 D
Should have used 65% Mean 45.5 D => plano
should have targeted -0.50 D
(-0.50 always better than +0.50)
3/22/2015 JTH 99
Keratoconus Calculation #2Dear Dr. Holladay,> Will you please review this case and give me some insight. A KKC with Intacs patient undewent ECCE/IOL the doc targeted -4.OO so as to not make him anisometropic. I used the Pentacam 3.0mm zone EKR and the Holladay ll formula. The patient came out Pl -0.75x 135= 20/30! UCVA = 20/40. Patient is very very happy. But, this was an unintended outcome. How does one measure the central corneal power in an Intacs pt?. Can you determine the cause of this outcome?. It appears that the cornea must be flatter than what the instruments measured? Is that a correct assumption. The suggested IOL power was 26.0D. for a target 0f -4.00. When I click the keratoconous box (after the fact) for the same target the suggested IOL power was 27.50.?????? What should I have done differently!> > Please Advise! THANK YOU 1000x> Yvonne
3/22/2015 JTH 100
Keratoconus #2
3/22/2015 JTH 101
Keratoconus #2
3/22/2015 JTH 102
Keratoconus Calculation #2
Used Km = 39.60 D => Plano, but targeted for -4.00 D
Should have used 65% Mean 37.7 D => +2.00 D
If had KKC => +0.50 D
(not will use steeper K to size eye)
3/22/2015 JTH 103
Keratoconus Case #3 Dear Dr. Holladay,
I am so pleased and excited to tell you about a very successful outcome involving IOL calcs on KCN patient and the assistance Holladay distribution scale on the Pentacam. I thought you might find this case interesting and gratifying at the least.
Pre Op Refraction: +5.75 -8.00x 075= 20/40 IOLM ks 47/54.17 x 91
1wk Post-Op Refraction : -0.50-3.25X65 = 20/50 The surgeon placed a temporal suture. Will this 1 suture significantly impact the astigmatism?
I ran IOL calcs based on instructions you gave me on a similar case ,previously. You instructed me to use the Ks from a paracentral region derived from the EKR Distribution scale on Holladay report. I used the Ks from the smaller peak which I approximated to be about 44D. With those Ks and Holladay consultant we obtained the above results. I think this case demonstrates the invaluable utility of the Holldaday report when calculating IOL power in pts with KCN.
I attached the screenshots of Pentacam and IOL calcs. The technician who perfromed the IOL Master was unable to get ACD with IOLM and failed to get ACD with Immersion ultrasound- thats the reason that field is blank.
Yvonne
ADVANCED IOL CALCULATIONS 2015
JACK T. HOLLADAY, MD, MSEE, FACS Page 16 of 24
3/22/2015 JTH 104 3/22/2015 JTH 105
3/22/2015 JTH 106
Keratoconus Calculation
Kmean = 48.8 D
Used 44 D => SEQ = -2.12 D
(-0.50-3.25X65 = 20/50)
65% mean = 46.2 D => +0.08 D
Always KKC
Use 65% mean K3/22/2015 JTH 107
IOL Calcs Using Axial Length
Cataract or Clear Lens Removal Primary Piggy-Back IOL’s
Multifocal IOL’s
Toric IOL’s
Silicone in Vitreous Compartment
3/22/2015 JTH 108
Axial Length Measurements
Phakia AL1555
Aphakia AL1532
Pseudophakia PMMA AL1532 + 0.4
Silicone AL1532 - 0.6
Acrylic AL1532 + 0.23/22/2015 JTH 109
Primary Piggy-Back IOL’s
Current Formulas are very inaccurate
ELP underestimated due to AL
Back lens displaced posteriorly
Severe hyperopic errors (+5 D)
ADVANCED IOL CALCULATIONS 2015
JACK T. HOLLADAY, MD, MSEE, FACS Page 17 of 24
3/22/2015 JTH 110
Primary PIGGY-BACKINTRAOCULAR LENSES
3/22/2015 JTH 111
3/22/2015 JTH 112
Polypseudophakia
Up to 4 IOL’s
3/22/2015 JTH 113
3/22/2015 JTH 118
PIGGY-BACKINTRAOCULAR LENSES
J.T. Holladay James P. Gills
Jane Leidlein Myra Cherchio
“Achieving Emmetropia In Extremely Short Eyes With Two Piggy-Back Posterior
Chamber Intraocular Lenses.”
Ophthalmology Journal. Vol. 103.
July 1996 Blue Journal”3/22/2015 JTH 122
Primary Piggy-BackComplications
AcrylicInterlenticular membrane3 to 5 D hyperopic shift @ 3 yr
SiliconeInterlenticular membraneFlat Spot
ADVANCED IOL CALCULATIONS 2015
JACK T. HOLLADAY, MD, MSEE, FACS Page 18 of 24
3/22/2015 JTH 127
Minimizing Prediction Error
Holladay 2 Formula
Personalize Constant
Prediction Error vs. IOL power
Constants for Sub-groups Axial Length, K’s and Refraction
3/22/2015 JTH 132
Toric IOL’s
Current Formulas do not work because calculate different ELP for steep and flat meridian
Predicted ELP must be the same for each meridian --only one IOL position
3/22/2015 JTH 134
Toric IOL’s
Calculate IOL power for steep and flat meridian using same ELP
Difference in IOL powers is the toricity necessary to completely correct corneal astigmatism
3/22/2015 JTH 135
Toric IOL’s Always choose toricity to
undercorrect cornealastigmatism – WRONG!
LEAVE MIN RESIDUAL CYL!
Eg: Steep calc yields 24.0 DFlat calc yields 27.0 D
Ideal Toricity is 3.0 D
(Use 24.0 D with < 3.0 D of toricity)
A-constant—> 116.346 117.203 118.059 118.916 119.773 120.630Surgeon Factor—> 0.287 0.772 1.257 1.742 2.227 2.713
ELP—> 4.000 4.500 5.000 5.500 6.000 6.500IOL POWER
10 1.359 1.424 1.494 1.571 1.654 1.74522 1.277 1.330 1.387 1.450 1.519 1.59534 1.198 1.239 1.284 1.334 1.390 1.45246 1.121 1.151 1.185 1.223 1.267 1.316
Effective Lens Position (ELP)
Resulting Ratio of IOL Toricity to 2 D of Corneal Astigmatism
TABLE 1
A-constant(D) —> 116.346 117.203 118.059 118.916 119.773 120.630Surgeon Factor(mm) —> 0.287 0.772 1.257 1.742 2.227 2.713
ELP(mm) —> 4.000 4.500 5.000 5.500 6.000 6.500IOL POWER
10 2.718 2.848 2.988 3.141 3.308 3.49022 2.554 2.659 2.774 2.900 3.038 3.19034 2.396 2.477 2.568 2.668 2.780 2.90446 2.242 2.302 2.369 2.446 2.533 2.631
Effective Lens Position (ELP)
Required IOL Toricity for 2 D of Corneal Astigmatism
TABLE 2
Ratio and Power of IOL Cylinder to Corneal Cylinder
3/22/2015 JTH 139
ADVANCED IOL CALCULATIONS 2015
JACK T. HOLLADAY, MD, MSEE, FACS Page 19 of 24
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3/22/2015 Jack T. Holladay, M.D. 142
Dioptric Error vs. Angular Errorfor a 1.00 D of astigmatism
Angle Error ( ) Dioptric Error (D)
Dioptric Error = 2 * Cyl * sin (angular error)
% Error0° 0.00 0%
15° 0.52 52%
30° 1.00 100%
45° 1.41 141%
60° 1.73 173%
75° 1.93 193%
90° 2.00 200%
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PREOP 6 D Toric IOLLEFT
ADVANCED IOL CALCULATIONS 2015
JACK T. HOLLADAY, MD, MSEE, FACS Page 20 of 24
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PREOP 6 D Toric IOL -- ODLEFT
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PREOP 6 D Toric IOL -- OSLEFT
3/22/2015 JTH 152
Mean Dev = -0.72 D
3/22/2015 JTH 153
Silicone in Vitreous Cavity
Use Convexo-Plano IOL to minimize effect of Silicone(add 3 D to calculated IOL)
If Biconvex IOL(add 6 D to calculated IOL)
When Silicone removed -- 2 to 5 D of induced myopia
3/22/2015 JTH 154
IOL Calculations
using a
Refractive Formula
(ignore axial length)
3/22/2015 JTH 155
IOL Calculation without AL
Secondary AC or PC IOL for Aphakia
Secondary Piggy-Back AC or PC IOL for Pseudophakia
Primary AC IOL in Phakia
ADVANCED IOL CALCULATIONS 2015
JACK T. HOLLADAY, MD, MSEE, FACS Page 21 of 24
3/22/2015 JTH 156
REFRACTION FORMULA
IOL
PreRxV
KELP
DPostRxV
KELP
13361336
10001000
13361336
10001000
3/22/2015 JTH 157
Secondary Piggy-Back IOL’sIndications
Intolerable Pseudophakic Refractive Error
3/22/2015 JTH 158
Refractive Surprises
Previous RK, PRK, LASIK
Bad axial length - short/long
Mislabeled IOL
Axially displaced
Misc.
3/22/2015 JTH 159
Secondary Piggy-Back CalcAdvantages over Exchange
Mislabeled IOL irrelevant
Less risk to capsule or zonules
Mismeasured AL irrelevant
No AP shift of existing IOL
Fewer unknown variables
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ADVANCED IOL CALCULATIONS 2015
JACK T. HOLLADAY, MD, MSEE, FACS Page 22 of 24
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IOL Power Calcs for Phakic IOLs
(2º Piggy-Back & IOL Exchange after
Refractive Surprise)
Jack T. Holladay, MD, MSEE, FACSClinical Professor of Ophthalmology
Baylor College of MedicineHouston, Tx
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Phakic IOL’s
Compete with corneal refractiveprocedures for high myopiaand med & high hyperopia
ACL, ICL or Iris Clip ?
3/22/2015 JTH 177
3/22/2015 JTH 178
Phakic IOL’s(Secondary Piggy Back IOL’s)
Refraction
Formula3/22/2015 JTH 180
Phakic IOL CalculationInput Variables
Refraction and Vertex
Keratometry
Desired Refraction
Predict ELP (ACD)Effective Lens Position
ADVANCED IOL CALCULATIONS 2015
JACK T. HOLLADAY, MD, MSEE, FACS Page 23 of 24
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REFRACTION FORMULA
IOL
PreRxV
KELP
DPostRxV
KELP
13361336
10001000
13361336
10001000
Holladay, J.T.: "Refractive Power Calculations for IntraocularLenses in the Phakic Eye." American Journal of Ophthalmology.
Volume 116:63-66, July 1993.
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Phakic IOL CalculationInput Variables
Refraction and Vertex
Soft Contact Lens @ Vtx = 0
w Small Over-Refraction (< 2 D)is most accurate.
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Effective Lens Position (ELP)OLD ACD
Verisye Avg ELP = 4.27 mm
AACD (20 y/o) = 3.60 mm
AACD + 0.67 mm = ELPx
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Effective Lens Position (ELP)OLD ACD
Visian ICL Avg ELP = 4.00 mm
AACD (20 y/o) = 3.60 mm
AACD + 0.40 mm = ELPx
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Effective Lens Position (ELP)OLD ACD
Visian ICL Avg ELP = 4.00 mm
3/22/2015 JTH 186
Phakic IOL Calculations
+ IOL’s to Specs ~ 1.5 to 1
- IOL’s to Specs ~ 1.0 to 1
Approximation only
ADVANCED IOL CALCULATIONS 2015
JACK T. HOLLADAY, MD, MSEE, FACS Page 24 of 24
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• • • • The International Society of Refractive Surgery • • • •
April 23,2002Sydney
Thank you !