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Cornea/Refractive Update

Intraocular Lens Power Calculation After Corneal

Refractive Surgery
Vahid Feiz

ABSTRACT

Cataract surgery after corneal refractive surgery can be challenging for the ocular surgeon due to the difficulty with
accurate intraocular lens (IOL) power determination and unexpected refractive surprises. As clinicians have done
more work, a number of error sources have been determined. Furthermore, an increasing number of methods to avoid
these refractive surprises have been proposed. The combination of this work has resulted in recommendations for the
modification of standard IOL power calculations to improve outcomes. The following article includes a brief on, and by
no means, inclusive, error sources and ways to compensate for them.

Key words: LASIK, cataract, intraocular lens calculation, refractive surgery, keratometry

DOI: 10.4103/0974-9233.61219

INTRODUCTION LASIK/PRK have gained wider acceptance, surgeons can expect

to encounter different refractive surprises after cataract surgery

A n increasing number of patients undergo corneal surgical

procedures to decrease dependence on glasses or contact
lenses. These procedures alter corneal effective power. Excimer
in this population.

IOL power determination IOL power calculation relies on three

laser keratectomy has quickly become the modality of choice for measurements: axial length, corneal power and anterior chamber
corneal refractive surgery, replacing older incisional surgeries depth, which are not independently measured. An error in any of
such as radial keratotomy (RK).1,2 these three parameters can lead to a possible refractive surprise.

As surgeons gain experience with cataract extraction in post-
refractive surgery patients, they are finding that standard
intraocular lens (IOL) formulas and keratometry can lead
to “refractive surprises.” The most common observation is
underestimation of IOL power and unexpected hyperopia
after cataract surgery in patients who have undergone corneal
refractive surgery for correction myopia, regardless of the
procedure.3-11 Moreover, these refractive surprises seem to
be directly related to the amount of keratectomy performed.
Clinically, this means that greater refractive corrections correlate
with greater errors of IOL power.12-14
Experience with IOL power determination after corneal surgery
to correct hyperopia remains limited. A few reported cases of
cataract surgery after hexagonal keratectomy (now abandoned)
resulted in myopic surprises.15 As procedures like hyperopic
Historically, axial length measurements have been the source
of most refractive surprises, although refinements in biometry
techniques and instruments have decreased these errors.16,17
Assuming accurate biometry, axial length measurements are
unlikely to contribute significantly to IOL power errors after
corneal refractive surgery. Two studies analyzing axial length
before and after RK and excimer keratectomy found no
significant differences.18,19
Effective lens position (ELP) or anterior chamber depth affects
post-cataract surgery refraction so that a greater myopic shift is
observed with more anterior IOL position. Anterior chamber
depth cannot be independently measured because even after
in-the-bag implantation, it is hard to predict the exact distance
between the cornea and the IOL. If corneal surgery significantly
changes anterior chamber depth and therefore the ELP, the

Department of Ophthalmology, UC Davis Medical Center, Sacramento, CA, USA

Corresponding Author: Dr. Vahid Feiz, Department of Ophthalmology, UC Davis Medical Center, Sacramento, CA, USA. E-mail: vfeiz@ucdavis.edu

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Feiz: IOL power calculations after refractive surgery
result can effectively change post-cataract surgery refraction.
Several investigators have looked at anterior chamber depth after
refractive surgery. One study reported a small forward shift of
the posterior cornea after myopic LASIK. This observation,
however, has not been confirmed in a similar study.20,21 These
changes, even if real, appear too small to account for changes in
refraction and therefore probably do not significantly contribute
to IOL power errors after myopic treatments.
Corneal power calculations rely on determining the radius of
curvature of the anterior cornea in meters (r), which is converted
into a diopteric power (P) using an index of refraction (n)
utilizing the following formula.
P = (n − 1)/r
Radius of curvature is measured by manual keratometry,
automated keratometry or topography. Two assumptions
regarding topography or keratometry are that: (1) the cornea
is a true spherical surface and (2) the power of the cornea’s
para-central 3–4 mm is not significantly different from that of
the central cornea. These assumptions are clinically acceptable
in most normal eyes. In reality, however, the cornea is a prolate,
aspheric refractive media with progressive flattening toward the
periphery.
SOURCES OF ERROR IN CORNEAL
POWER DETERMINATION
Considering that different types of refractive surger y
fundamentally alter corneal shape and power, the usual
assumptions no longer apply and may be the sources of error
in determining corneal power. In this review of possible error
sources, we have divided corneal refractive surgery into RK and
excimer keratectomy (PRK, LASIK, LASEK).
RK
RK steepens the peripheral cornea and flattens the central
cornea, resulting in a hyperopic shift and a proportionally greater
flattening of the cornea in the center compared with the para-
central cornea.22 This creates an abrupt change from treated to
untreated cornea. Because keratometry and topography units
measure radius of curvature in the cornea’s para-central 3–4
mm, the measured diopteric power is significantly steeper than
the central cornea. The measured zone also increases in size
further from the central cornea as the cornea becomes flatter,
resulting in overestimation of cornea power.23,24
Myopic excimer keratectomy
The ability of large optical zones to decrease post-operative glare
and halos has become evident with increased LASIK and PRK
experience, and optical zones >5–6 mm are now considered
routine. As a result, the para-central radius of curvature would
64 Middle East African Journal of Ophthalmology, Volume 17, Number 1, January - March 2010
be expected to closely approximate central corneal curvature.
In clinical experience, however, when the radius of curvature is
converted to diopteric power, this calculated value overestimates
central corneal power.4-12 This occurs for two main reasons:
First, after excimer keratectomy, the anterior corneal surface
changes but the posterior corneal surface remains unaltered.
Sonergo-Krone et al. found small changes in the posterior
corneal power after LASIK but large changes in the anterior–
posterior power ratio.25 Changing the anterior–posterior power
alters the cornea’s effective refractive index in direct relation to
the amount of keratectomy. In the original Gullstrand model,
for every 9% change in ratio, the effective corneal power is
changed by 0.5 diopters.26
The second factor is the variation in corneal refractive index
of the different layers of the cornea. This was shown by Patel
et al., who found the index of refraction to be slightly different
in different layers.27 Because excimer laser selectively removes
anterior stromal layers and leaves the posterior stroma intact,
it changes the cornea’s total refractive index. Removing more
tissue is also expected to produce a greater change in the
refractive index. This is supported by the observed correlation
between depth of ablation and error in IOL power after myopic
PRK.12,28
Hyperopic excimer keratectomy
Little, if any, experience with cataract surgery after hyperopic
excimer keratectomy has been reported. Because these
treatments cause steepening of the central cornea with large
optical zones, para-central radius of curvature, measured by
manual keratometry or topography, should be a fairly accurate
estimation of central curvature. As in myopic treatments, the
anterior–posterior corneal power ratio is expected to change,
although in the opposite direction. Therefore, using the standard
refractive index would theoretically underestimate corneal
power and result in unexpected myopia after IOL implantation.
In our center, we analyzed eight eyes after hyperopic LASIK, using
pre-LASIK keratometry and amount of hyperopic treatment to
predict a fictitious post-LASIK IOL power. In each case, the
predicted IOL power was lower than the IOL power determined
by standard post-LASIK keratometry.13 Despite a lack of actual
implantation, this study indicated that using post-hyperopic
LASIK standard keratometry could theoretically result in IOL
power overestimation and unexpected myopia.
Summary
Manual keratometr y after myopic LASIK, PRK and RK
overestimates corneal power and underestimates IOL power.
The causes differ for RK and LASIK/PRK. In LASIK/PRK, error
is directly proportional to the amount of keratectomy. Manual
keratometry after hyperopic LASIK and PRK theoretically
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Feiz: IOL power calculations after refractive surgery
underestimates corneal power and results in IOL power
overestimation, also in direct proportion to the amount of
correction.
METHODS TO IMPROVE IOL POWER
DETERMINATION
Several methods can improve IOL power accuracy after corneal
refractive surgery. No single approach has been studied in a
large sample, and some are based purely on theory. Most cases
also require knowledge of pre-refractive surgery data that
may not be available to cataract surgeons. Proposed methods
include use of topography to measure central corneal power,
advanced IOL calculation formulas, contact lens over-refraction,
clinical history, nomogram-based adjustment, corneal power
determination by directly determining posterior curvature and
intentional overcorrection targeting for myopia.
Topography
Topography-measured corneal power has been suggested to
improve central corneal power measurements in post-refractive
surgery eyes. Hussein et al. developed the topography method
to calculate the corneal power within the pupil.28 The study
showed that the average central power differed from standard
keratometry in post-refractive surgery eyes having small optical
zones and large attempted corrections. Theoretically, this
method offers advantages in eyes with small optical zones.
By contrast, Seitz et al. found manual keratometry to be superior
to topography-derived values in post-myopic PRK eyes.12,29
In summary, using topography to determine central corneal
power may be beneficial after RK with small optical zones.
However, topography has not been found to be superior to
standard keratometry in post-PRK/LASIK corneas, and its
reliability and accuracy have not been verified.
Using advanced formulas
Modern theoretic optical formulas (Holladay, Hoffer Q, SRK-T)
may offer improved accuracy of IOL power determination in
post-refractive surgery eyes. Koch et al.4 found the Binkhorst
and Holladay formulas to be superior to SRK II in post-RK
eyes. Odenthal et al. noted that using the Hoffer Q formula after
myopic LASIK decreased, but did not eliminate, IOL power
underestimation.30
Another popular formula proposed by Aramberri, know as the
double K method, utilizes pre-refractive surgery Ks to estimate
an ELP and post-refractive surgery Ks are used to determine
IOL power taking into account the ELP.31
A number of other formulas have been proposed by other
authors. Some include Haigis-L, Latkany formula, etc. A review
Middle East African Journal of Ophthalmology, Volume 17, Number 1, January - March 2010
of all these is beyond the scope of this article.
Although these studies offer no clear-cut conclusions regarding
the accuracy of different modern theoretic formulas, their use
is probably advantageous in post-refractive surgery eyes.
Contact lens over-refraction
This method uses a hard contact lens of known power and
base curve to determine true corneal power. After patients
have undergone refraction, a plano hard contact lens is placed
on the eye and over-refraction is performed. If no difference
exists between refractions, corneal power is the same as the
contact lens base curve. If over-refraction is more myopic than
refraction without the contact lens, the lens is steeper than the
cornea. The change in refraction is subtracted from the contact
lens base curve to yield corneal power. If over-refraction is more
hyperopic than the contact lens refraction, the cornea is steeper
than the lens. Change in refraction is added to the contact lens
base curve to calculate corneal power.
Contact lens-derived corneal powers have been shown to
correlate well with manual keratometry in normal corneas when
visual acuity is better than 20/70.32 Once the visual acuity is
lower than 20/70, which may be the case in many patients with
cataract, the correlation is poor. The accuracy of this technique
is not established in post-refractive surgery eyes.
Clinical history
Originally proposed by Holladay to determine corneal power
after RK, this method was advocated by Hoffer for use in post-
LASIK/PRK eyes.33,34 Using this method requires knowledge
of keratometry prior to refractive surgery as well as induced
refractive change before the development of cataract. These
values are used to determine a calculated corneal power as
follows:
For post-myopic (post-RK/myopic excimer) procedures:
Corneal diopteric power = pre-refractive surgery Ks – change
in SE.
For post-hyperopic (post-hyperopic excimer) procedures:
Corneal diopteric power = pre-refractive surgery Ks + change
in SE.
The major shortcomings of this approach are that accuracy and
reliability have not been established in large series and that it
requires knowledge of keratometry values prior to refractive
surgery, which cataract surgeons may not have. Its major flaw,
however, is assuming a one-to-one relation between corneal
diopteric power and refraction (i.e., if corneal power changes
by one diopter, refraction changes by one diopter). Studies by
Patel et al. and Hugger et al. analyzed changes in refraction and
corneal power after refractive surgery in a large sample.35,36 Both
studies found less change in corneal power than in refraction
and concluded that this was due to a change in the cornea’s
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Feiz: IOL power calculations after refractive surgery

effective refractive index. This indicates that the clinical history Table 1: Nomogram for intraocular lens (IOL) power
method reduces IOL power errors but the degree of accuracy adjustment for emmetropia after myopic LASIK
is not yet established. Change in Spherical Equivalent at the Increase in
Spectacle Plane Induced by myopic LASIK/ Intraocular
Nomogram-based correction Photorefractive Keratectomy (Diopters) Lens Power
(Diopters)
By analyzing eyes after myopic and hyperopic LASIK, we
1.00 0.36
developed a theoretic nomogram to correct IOL power after
1.50 0.66
these procedures.13 The nomogram is based on four established 2.00 0.96
clinical premises: 2.50 1.26
1. IOL power after myopic corneal surgery has to be higher 3.00 1.55
than before surgery. 3.50 1.85
2. IOL power after hyperopic corneal surgery is expected to 4.00 2.15
be lower than before surgery. 4.50 2.45
3. To maintain emmetropia, the difference between IOL 5.00 2.74
5.50 3.04
powers before and after refractive surgery must compensate
6.00 3.34
for refraction changes.
6.50 3.64
4. For every diopter of change in IOL power, refraction at the 7.00 3.93
spectacle plane with a vertex distance of 12.5 mm changes 7.50 4.23
by only 0.67 diopters.37 8.00 4.53
8.50 4.83
These formulas allowed the development of a nomogram to 9.00 5.12
adjust IOL power based on post-LASIK standard keratometry 9.50 5.42
[Tables 1 and 2] and eliminated the need for pre-LASIK 10.00 5.72
keratometry. Compared with the clinical history method, this 10.50 6.02
11.00 6.31
nomogram gave a higher IOL power after myopic LASIK and
11.50 6.61
lower IOL power after hyperopic LASIK.
12.00 6.91
This table is reprinted with permission from Feiz V, Mannis MJ, Garcia FF, et
This nomogram has been tested and appears to be reliable in al. Intraocular lens power calculation after laser in situ keratomileusis for
a limited number of studies.13 Further prospective data of this myopia and hyperopia. Cornea 2001;20:702–97. The copyright is held by the
publisher Lippincott Williams & Wilkins.
method’s accuracy are currently being collected.

Optical formula corneal power calculations Table 2: Nomogram for IOL power adjustment for emmetropia
Using Gaussian optics, the cornea’s true power can theoretically after hyperopic LASIK
be determined regardless of previous surgical procedures. This Change in Spherical Equivalent at Decrease in
approach considers the cornea to have two refractive surfaces, the Spectacle Plane Induced by Intraocular Lens Power
anterior and posterior. The theoretic power of the cornea is hyperopic LASIK/Photorefractive (Diopters)
Keratectomy (Diopters)
calculated using corneal thickness and refractive indexes of air,
1.00 0.00
cornea and aqueous humor through a series of formulas. 2.00 0.97
3.00 1.84
Hamed et al. used this method to look at 100 post-myopic 4.00 2.70
LASIK eyes. The authors used a mathematical optical formula 5.00 3.56
to directly calculate corneal refractive power.38 6.00 4.42
This table is reprinted with permission from Feiz V, Mannis MJ, Garcia FF, et
al. Intraocular lens power calculation after laser in situ keratomileusis for
Good theoretical correlation was noted between this calculated myopia and hyperopia. Cornea 2001;20:702–97. The copyright is held by the
corneal power and the clinical history method. To our knowledge, publisher Lippincott Williams & Wilkins.
no actual IOL implantations based on this formula have been
performed. power could be determined regardless of the refractive status
if anterior and posterior corneal curvatures could be directly
Direct corneal power measurements measured. However, direct measurement of the posterior
The major shortcoming with all the above-mentioned techniques curvature was not possible until recently.
is the need to know the pre-refractive surgery values, such as
refraction and keratometry. An ideal method would determine Introduction of slit-beam scanning combined with placido-disk
corneal power accurately without these values. True corneal topography Orbscan allows posterior power measurements.

66 Middle East African Journal of Ophthalmology, Volume 17, Number 1, January - March 2010
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Feiz: IOL power calculations after refractive surgery
This technology also allows analysis of central optical zones as
small as 1–2 mm.39
Sonego-Krone et al. as well as Seitz et al. used this technology
for post-myopic LASIK, comparing refractive changes at the
corneal level induced by LASIK with Orbscan-measured central
total powers within the central 2-mm zone.25,40 They found a
good correlation between expected central diopteric power and
measured values, and recommended using central 2-mm power
measured by Orbscan for IOL power determination after myopic
LASIK. Qazi et al. also used a similar method for post-myopic
LASIK patients with good results.41
Although a promising technology, the accuracy and applicability
of these power measurements have not been established clinically.
TARGETING MYOPIA
When regular keratometry is performed after myopic refractive
surgery, selective choice of an IOL to target myopia when
other data are not available may reduce refractive surprises. In
analyzing eyes undergoing cataract surgery after RK, Chen et al.
found that selecting an IOL targeting −1.50 in post-RK eyes
reduced the frequency of post-cataract hyperopia by 60%. Some
initial hyperopia immediately after cataract surgery also regresses
over several weeks, possibly because of inherent instability of
the post-RK cornea.42-44
CONCLUSION
Current methods of IOL power determination after corneal
refractive surgery are limited by a lack of actual clinical experience
on a large scale and by the theoretic nature of all the calculation
methods. However, based on accumulated clinical experience,
several useful guidelines can be followed.
In addition to the recommendations below, refractive surgeons
should consider providing patients with pre-refractive surgery
keratometry and refraction and having them keep these records
for possible cataract surgery in the future.
1. If only pre- and post-corneal surgery refraction are available,
use post-refractive surgery keratometry and axial length and
adjust IOL power using a theoretic nomogram [Tables 1 and
2].
2. If pre-refractive surgery keratometry values and refraction
are available, predict IOL power theoretically using clinical
history or nomogram-based methods. If using the clinical
history method, determine changes in spherical equivalent
at the spectacle plane rather than the corneal level.
3. If data are not available and patients have visual acuity
>20/70, consider the contact lens method.
4. If data are not available and patients have visual acuity
<20/70, consider targeting −1.50 to −2.00 for post-
Middle East African Journal of Ophthalmology, Volume 17, Number 1, January - March 2010
myopic refractive surgery patients and +1.00 for post-
hyperopic refractive surgery patients.
5. Some hyperopia in the immediate post-cataract surgery can
regress in RK patients, so delay intervention through lens
exchange or further refractive surgery until the refraction
is stable.
6. Inform patients who have had previous corneal refractive
surgery of limitations in accurate IOL power calculations.
As part of their informed consent for cataract surgery,
specifically discuss the possible need for corrective refractive
aids, repeat corneal refractive surgery or IOL exchange.
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Source of Support: Nil, Conflict of Interest: None declared.