Sources of Error in Toric Intraocular Lens Power Calculation.

PURPOSE: To evaluate the influencing factors on remaining astigmatism after implanting a toric intraocular lens (IOL) during cataract surgery. METHODS: This retrospective study included parameters that were considered to have an influence on toric IOL power calculation. Therefore, data from the literature and the authors' own data were used. This included axial eye length, anterior chamber depth, central corneal thickness, corneal radii (anterior and posterior), diurnal changes of the cornea, inter-device differences, rotational misalignment of the IOL, tilt and decentration of the IOL, pupil size, angle kappa, and surgically induced astigmatism. Ray-tracing and Gaussian error propagation analysis was performed to quantify the sources of error. RESULTS: In total, 4,949 eyes (4,365 eyes of 42 studies and 584 eyes of retrospectively analyzed study data) were included in the study and the difference vector between aimed and calculated remaining astigmatism was 0.81 diopters (D). The main source of error was the preoperative measurement of the cornea (27%), followed by IOL misalignment (14.4%) and IOL tilt (11.3%). Other factors, such as angle kappa (10.9%), pupil size (8.1%), surgically induced astigmatism (7.8%), anterior chamber depth (7.5%), axial eye length (7.5%), and decentration (5.6%), also contributed to the refractive astigmatic error. CONCLUSIONS: The main source of error in toric IOL power calculation is the preoperative corneal measurement followed by IOL misalignment and tilt. [J Refract Surg. 2020;36(10):646-652.].

Prediction of the true IOL position.

PURPOSE: To develop algorithms for preoperative estimation of the true postoperative intraocular lens (IOL) position to be used for IOL power calculation. SETTING: Moorfields Eye Hospital NHS Foundation Trust, London, UK. METHODS: Fifty patients were implanted randomly with a 3-piece IOL model in one eye and a 1-piece model in the other eye. Preoperatively, the IOLMaster was used to determine axial length, anterior chamber depth and mean corneal radius. Lens thickness and corneal width were measured with the ACMaster. Postoperative IOL position was measured with the ACMaster. Partial least squares (PLS) regression analysis of IOL position in terms of preoperative parameters was performed with a commercially available software package. RESULTS: The PLS regression analysis showed that age, refraction, corneal width, lens thickness and corneal radius are not significant predictors of postoperative position of the anterior IOL surface, while axial length and in particular anterior chamber depth are. Regression relationships in terms of the above-mentioned predictors were determined for the two models implanted. Surprisingly, it turned out that the position of the posterior IOL surface could be described by a single regression relationship valid for both models. The residual SD for prediction of IOL position was about 0.17 mm for all relationships. CONCLUSIONS: Accurate relationships to determine the true postoperative IOL position were obtained. In addition to axial length and corneal radius, which are required for the IOL power calculation as such, they require measurement of preoperative anterior chamber depth only.

Using continuous intraoperative optical coherence tomography measurements of the aphakic eye for intraocular lens power calculation.

BACKGROUND/AIMS: To include intraoperative measurements of the anterior lens capsule of the aphakic eye into the intraocular lens power calculation (IPC) process and to compare the refractive outcome with conventional IPC formulae. METHODS: In this prospective study, a prototype operating microscope with an integrated continuous optical coherence tomography (OCT) device (Visante attached to OPMI VISU 200, Carl Zeiss Meditec AG, Germany) was used to measure the anterior lens capsule position after implanting a capsular tension ring (CTR). Optical biometry (intraocular lens (IOL) Master 500) and ACMaster measurements (Carl Zeiss Meditec AG, Germany) were performed before surgery. Autorefraction and subjective refraction were performed 3 months after surgery. Conventional IPC formulae were compared with a new intraoperatively measured anterior chamber depth (ACD) (ACDIntraOP) partial least squares regression (PLSR) model for prediction of the postoperative refractive outcome. RESULTS: In total, 70 eyes of 70 patients were included. Mean axial eye length (AL) was 23.3 mm (range: 20.6-29.5 mm). Predictive power of the intraoperative measurements was found to be slightly better compared to conventional IOL power calculations. Refractive error dependency on AL for Holladay I, HofferQ, SRK/T, Haigis and ACDintraOP PLSR was r(2)=-0.42 (p<0.0001), r(2)=-0.5 (p<0.0001), r(2)=-0.34 (p=0.010), r(2)=-0.28 (p=0.049) and r(2)<0.001 (p=0.866), respectively, CONCLUSIONS: ACDIntraOP measurements help to better predict the refractive outcome and could be useful, if implemented in fourth-generation IPC formulae.

Fluctuations in corneal curvature limit predictability of intraocular lens power calculations.

PURPOSE: To analyze fluctuations in corneal curvature over time. SETTING: Moorfields Eye Hospital NHS Foundation Trust, London, United Kingdom. DESIGN: Case series. METHODS: A 3-piece IOL was implanted in 1 eye and a 1-piece IOL in the other eye through a 3.2 mm clear corneal temporal incision. Keratometry was performed preoperatively and at several points in time postoperatively. Differences between measurements were analyzed by power vectors. Statistical significance was assessed by monovariate, bivariate, and trivariate paired t tests. Acute angle shifts were determined as differences between meridians at 2 points in time. RESULTS: Fifty patients were enrolled. From preoperatively to 1 year postoperatively, the changes in vector components (M, J0, J45) were, respectively, -0.02 diopter (D) ± 0.23 (SD) (P=.38), -0.07 ± 0.27 D (P=.02), and +0.04 ± 0.25 D (P=.14). Corresponding changes from 1 year to 2 years postoperatively were +0.01 ± 0.25 D (P=.73), +0.01 ± 0.23 D (P=.83), and +0.01 ± 0.16 D (P=.40). The meridian shift was -5 ± 32 degrees (P=.13) from preoperatively to postoperatively and +3 ± 22 degrees (P=.23) from 1 year to 2 years. CONCLUSIONS: Surgically induced astigmatism was composed of slight flattening in the horizontal meridian and slight steepening in the oblique meridian but was insignificant in relation to random fluctuations, which were almost equally large between postoperative measurements 1 year apart. The fluctuations were not due to imprecision in measurement. FINANCIAL DISCLOSURE: Dr. Norrby is a retiree from Abbott Medical Optics, Inc., and holder of a small amount of stock. Dr. Findl is scientific advisor to Abbott Medical Optics, Inc. No other author has a financial or proprietary interest in any material or method mentioned.

Sources of error in intraocular lens power calculation.

PURPOSE: To identify and quantify sources of error in the refractive outcome of cataract surgery. SETTING: AMO Groningen BV, Groningen, The Netherlands. METHODS: Means and standard deviations (SDs) of parameters that influence refractive outcomes were taken or derived from the published literature to the extent available. To evaluate their influence on refraction, thick-lens ray tracing that allowed for asphericity was used. The numerical partial derivative of each parameter with respect to spectacle refraction was calculated. The product of the partial derivative and the SD for a parameter equates to its SD, expressed as spectacle diopters, which squared is the variance. The error contribution of a parameter is its variance relative to the sum of the variances of all parameters. RESULTS: Preoperative estimation of postoperative intraocular lens (IOL) position, postoperative refraction determination, and preoperative axial length (AL) measurement were the largest contributors of error (35%, 27%, and 17%, respectively), with a mean absolute error (MAE) of 0.6 diopter (D) for an eye of average dimensions. Pupil size variation in the population accounted for 8% of the error, and variability in IOL power, 1%. CONCLUSIONS: Improvement in refractive outcome requires better methods for predicting the postoperative IOL position. Measuring AL by partial coherence interferometry may be of benefit. Autorefraction increases precision in outcome measurement. Reducing these 3 major error sources with means available today reduces the MAE to 0.4 D. Using IOLs that compensate for the spherical aberration of the cornea would eliminate the influence of pupil size. Further improvement would require measuring the asphericity of the anterior surface and radius of the posterior surface of the cornea.

Model eyes for evaluation of intraocular lenses.

In accordance with the present international standard for intraocular lenses (IOLs), their imaging performance should be measured in a model eye having an aberration-free cornea. This was an acceptable setup when IOLs had all surfaces spherical and hence the measured result reflected the spherical aberration of the IOL. With newer IOLs designed to compensate for the spherical aberration of the cornea there is a need for a model eye with a physiological level of spherical aberration in the cornea. A literature review of recent studies indicated a fairly high amount of spherical aberration in human corneas. Two model eyes are proposed. One is a modification of the present ISO standard, replacing the current achromat doublet with an aspheric singlet cut in poly(methyl methacrylate) (PMMA). The other also has an aspheric singlet cut in PMMA, but the dimensions of it and the entire model eye are close to the physiological dimensions of the eye. They give equivalent results when the object is at infinity, but for finite object distances only the latter is correct. The two models are analyzed by calculation assuming IOLs with different degrees of asphericity to elucidate their sensitivity to variation and propose tolerances. Measured results in a variant of the modified ISO model eye are presented.

Theoretical comparison of aberration-correcting customized and aspheric intraocular lenses.

PURPOSE: To assess the performance and optical limitations of standard, aspheric, and wavefront-customized intraocular lenses (IOLs) using clinically verified pseudophakic eye models. METHODS: White light pseudophakic eye models were constructed from physical measurements performed on 46 individual cataract patients and subsequently verified using the clinically measured contrast sensitivity function (CSF) and wavefront aberration of pseudophakic patients implanted with two different types of IOLs. These models are then used to design IOLs that correct the astigmatism and higher order aberrations of each individual eye model's cornea and to investigate how this correction would affect visual benefit, subjective tolerance to lens misalignment (tilt, decentration, and rotation), and depth of field. RESULTS: Physiological eye models and clinical outcomes show similar levels of higher order aberration and contrast improvement. Customized correction of ocular wavefront aberrations with an IOL results in contrast improvements on the order of 200% over the control and the Tecnis IOLs. The customized lenses can be, on average, decentered by as much as 0.8 mm, tilted > 10 degrees , and rotated as much as 15 degrees before their polychromatic modulation transfer function at 8 cycles/degree is less than that of the Tecnis or spherical control lens. Correction of wavefront aberration results in a narrower through focus curve but better out of focus performance for +/- 0.50 diopters. CONCLUSIONS: The use of realistic eye models that include higher order aberrations and chromatic aberrations are important when determining the impact of new IOL designs. Customized IOLs show the potential to improve visual performance.

Development of an accommodating intra-ocular lens--in vitro prevention of re-growth of pig and rabbit lens capsule epithelial cells.

Cataract surgery is routinely performed to replace the clouded lens by a rigid polymeric intra-ocular lens unable to accommodate. By implanting a silicone gel into an intact capsular bag the accommodating properties of the natural lens can be maintained or enhanced. The implantation success of accommodating lenses is hampered by the occurrence of capsular opacification (PCO) due to lens epithelial cell (LEC) growth. In order to prevent LEC proliferation, a treatment regime using actinomycin D, cycloheximide and water was developed. The effectiveness of treatment was analyzed using an in vitro, MTT-based cell culture system and an ex vivo pig eye model in which the implanted lens-in-the-bag is cultured as a whole. LEC were exposed to treatment solutions for 5 min, then the cells were allowed to recover and to re-colonize the substratum. MTT conversion by cells was transiently inhibited by cycloheximide dissolved in water and by water alone. Exposure to actinomycin D resulted in a lasting inhibition of MTT conversion and consequently cell proliferation. These in vitro data could not be fully reproduced in the ex vivo pig eye model due to essential differences between both models. Treatment with actinomycin D containing solutions, however, resulted in a nearly complete absence of cells on the capsular wall. The pig eye model is a promising approach to further evaluate the effects of peri-surgical treatment during the accommodating intra-ocular lens implantation.

Accommodative lens refilling in rhesus monkeys.

PURPOSE: Accommodation can be restored to presbyopic human eyes by refilling the capsular bag with a soft polymer. This study was conducted to test whether accommodation, measurable as changes in optical refraction, can be restored with a newly developed refilling polymer in a rhesus monkey model. A specific intra- and postoperative treatment protocol was used to minimize postoperative inflammation and to delay capsular opacification. METHODS: Nine adolescent rhesus monkeys underwent refilling of the lens capsular bag with a polymer. In the first four monkeys (group A) the surgical procedure was followed by two weekly subconjunctival injections of corticosteroids. In a second group of five monkeys (group B) a treatment intended to delay the development of capsular opacification was applied during the surgery, and, in the postoperative period, eye drops and two subconjunctival injections of corticosteroids were applied. Accommodation was stimulated with carbachol iontophoresis or pilocarpine and was measured with a Hartinger refractometer at regular times during a follow-up period of 37 weeks in five monkeys. In one monkey, lens thickness changes were measured with A-scan ultrasound. RESULTS: In group A, refraction measurement was possible in one monkey. In the three other animals in group A, postoperative inflammation and capsular opacification prevented refraction measurements. In group B, the maximum accommodative amplitude of the surgically treated eyes was 6.3 D. In three monkeys the accommodative amplitude decreased to almost 0 D after 37 weeks. In the two other monkeys, the accommodative amplitude remained stable at +/-4 D during the follow-up period. In group B, capsular opacification developed in the postoperative period, but refraction measurements could still be performed during the whole follow-up period of 37 weeks. CONCLUSIONS: A certain level of accommodation can be restored after lens refilling in adolescent rhesus monkeys. During the follow-up period refraction measurements were possible in all five monkeys that underwent the treatment designed to prevent inflammation and capsular opacification.

Artificial crystalline lens.

If presbyopia is caused by hardening of the crystalline lens, replacing it with a material with mechanical properties similar to the young crystalline lens should restore accommodative ability. Such a silicone material has been developed. Refilling the capsular bag with this material results in 3 to 5 D of accommodation in primates in response to pilocarpine.

Clinical application of the lens haptic plane concept with transformed axial lengths.

PURPOSE: To clinically evaluate the lens haptic plane (LHP) concept in combination with thick-lens ray tracing for intraocular lens (IOL) power calculation. SETTING: St. Erik's Eye Hospital, Stockholm, Sweden. METHODS: Prospective study of normal cataract cases implanted with Pharmacia CeeOn 809C IOL. Axial length was measured by A-scan. The measured value was first transformed by addition of a constant value to correct for systematic error. Using the transformed axial length and corneal radius measured by keratometry, the LHP position was determined. Knowing the IOL design and the power implanted, expected refractive outcome was calculated and compared to manifest refraction at 6 weeks in terms of mean absolute error (MAE). Thick-lens ray tracing in the paraxial limit was used for the optical calculation. RESULTS: The mean transformed axial length was 23.87 mm. An LHP position algorithm in linear terms of transformed axial length and corneal radius gave an MAE of 0.38 D. There was no trend with axial length. On the present data, the Holladay 1, Hoffer Q, and SRK/T formulas produced MAEs of 0.39 D, 0.39 D, and 0.41 D, respectively, with optimized formula constants. The differences were not statistically significant (P > .05). CONCLUSIONS: The LHP concept in combination with thick-lens ray tracing achieved MAE comparable to that with currently used formulas. The lack of trend with axial length is important for patients with short and long eyes.

The Dubbelman eye model analysed by ray tracing through aspheric surfaces.

Dubbelman and co-workers have determined intraocular spacings and surface shapes in living eyes by means of corrected Scheimpflug images in a large number of subjects of different age at several levels of accommodation. They give relationships for key anterior segment parameters as a function of age and level of accommodation. These are used in this paper to build a schematic eye incorporating aspheric surfaces. This eye model is analysed by means of ray tracing with a technique developed for use with a common spreadsheet computer program. The Dubbelman eye model appears to be well corrected for spherical aberration. Compared with measurements on real eyes it agrees well in general, but spherical aberration is negative, while in real eyes it tends to be positive.

Adaptive optics simulation of intraocular lenses with modified spherical aberration.

PURPOSE: Adaptive optics systems can be used to investigate the potential visual benefit associated with correcting ocular wave-front aberration. In this study, adaptive optics techniques were used to evaluate the potential advantages and disadvantages associated with intraocular lenses (IOLs) with modified spherical aberration profiles. METHODS: An adaptive optics vision simulator was constructed that allows psychophysical tests to be performed while viewing targets through any desired ocular wave-front profile. With this simulator, the subjective visual performance of four subjects was assessed by letter acuity and contrast sensitivity (at 3, 6, and 15 cyc/deg) for two different values of induced spherical aberration. The values of spherical aberration were chosen to reproduce two conditions: the average amount measured in pseudophakic patients with implanted IOLs having spherical surfaces and the complete correction of the individual's spherical aberration. Visual performance was assessed in both white and green light, at best focus and for defocus of +/-0.5 and +/-1.0 D. RESULTS: There was an average improvement in visual acuity associated with the correction of spherical aberration of 10% and 38% measured in white and green light, respectively. Similarly, average contrast sensitivity measurements improved 32% and 57% in white and green light. When spherical aberration was corrected, visual performance was as good as or better than for the normal spherical aberration case for defocus as large as +/-1 D. CONCLUSIONS: Correcting ocular spherical aberration improves spatial vision in the best-focus position without compromising the subjective tolerance to defocus.

Using the lens haptic plane concept and thick-lens ray tracing to calculate intraocular lens power.

PURPOSE: To develop a methodology for intraocular lens (IOL) power calculation in which the task of predicting the postoperative position of the IOL is separated from the calculation itself. SETTING: Pharmacia, Groningen, The Netherlands. METHODS: The minimum biometry input needed for IOL power calculation is the mean anterior corneal radius and axial length of the eye. The lens haptic plane (LHP) is the plane where the IOL haptics make contact with eye tissue. It is an anatomical site (eg, the equator of the capsular bag) and is independent of the IOL model. The position of the IOL optic in relation to the LHP is determined from the exact design of the IOL. Gullstrand's eye model is adopted to obtain the posterior corneal radius, thickness of the cornea, and refractive indices of the eye media. Thick-lens ray tracing in the paraxial limit is used for the optical calculation. RESULTS: A spreadsheet is given for the calculation. CONCLUSIONS: The methodology developed allows for IOL power calculation from first principles (ie, using true physical distances, radii, and refractive indices as input for the optical calculation).