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26]

Review Article

Pediatric Intraocular Lens Power Calculation

Sandra Chandramouli Ganesh, Shilpa G. Rao, Farhadul Alam
Department of Pediatric Ophthalmology and Strabismus, Aravind Eye Hospital, Coimbatore, Tamil Nadu, India

Abstract
Pediatric cataracts pose multiple challenges in terms of management and postoperative rehabilitation. Difficulties in obtaining accurate
measurements for axial length and keratometry are encountered due to poor cooperation in children and instrumentation errors. There exist
multiple formulae for intraocular lens (IOL) power calculation, which are based on various factors and have varying degrees of accuracy.
Children exhibit a tendency for myopic shift due to the anatomical differences from adult eyes and due to the growth of eyeball, as a result of
which they require undercorrection, when IOL implantation is planned.

Keywords: Intraocular lens, intraocular lens power calculation formulae, myopic shift, pediatric cataract, undercorrection

Introduction data from adult eyes. The application of these formulae to

pediatric eyes may not hold true for all biometric aspects in
Pediatric cataract affects around 200,000 children worldwide,
children.[3] Pediatric eyes are expected to behave differently
with an estimated prevalence ranging from three to six per compared to the adult eyes owing to postoperative growth in
10,000 live births,[1] accounting for 12% (range: 7%–20%) of the size of the pediatric eyeball, and with an IOL of constant
preventable blindness[2] in children; their treatment, by surgical power implanted in the eyes, there exists a higher possibility of
removal of the lenticular opacity, is of paramount importance, myopic shift in pediatric pseudophakes and chance of delayed
as failure to do so results in irreversible visual handicap. Visual refractive surprises.[4]
impairment produces an adverse impact on the scholastic
performance of the child and his or her professional abilities
and quality of life, which translates into further economic loss
Instrumentation
and social burden. Measurement acquisition in pediatric biometrics is challenging
because young children are not cooperative, and a few of the
Multiple challenges are encountered by the surgeon in measurements may need to be taken under general anesthesia,
the management of pediatric cataract. In addition to being immediately after induction and before insertion of the eye
technically exacting, there exists a fair possibility that speculum. Among the twin parameters of AL and keratometry,
functional or visual rehabilitation maybe suboptimal following it has been noted that errors in AL estimation have a greater
a meticulously performed surgery producing a good anatomical impact on power calculation and the final refractive outcome
outcome. as compared to erroneous keratometric readings. Inaccurate
Several perioperative factors may be responsible for the above keratometric values cause errors of 0.8–1.3 diopters in both
phenomena of early and delayed refractive surprises. Difficulty adults and children. Inaccurate AL measurement can account
for 3–4 diopters of error for each millimeter difference in IOL
in obtaining precise measurements in children with respect to
power in adults and 4–14 diopters or higher in pediatric eyes.[5]
corneal curvature, anterior chamber depth (ACD), and axial
length  (AL) both in terms of cooperation and accuracy of
instruments used can cause errors in intraocular lens  (IOL) Address for correspondence: Dr. Sandra Chandramouli Ganesh,
power calculation. This is further confounded by the fact that Department of Pediatric Ophthalmology and Strabismus, Aravind Eye
IOL power prediction formulae in common usage today are Hospital, Coimbatore, Tamil Nadu, India.
E‑mail: [email protected]
based on the theoretical models or regression from normative

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DOI:
10.4103/tjosr.tjosr_105_18 How to cite this article: Ganesh SC, Rao SG, Alam F. Pediatric intraocular
lens power calculation. TNOA J Ophthalmic Sci Res 2018;56:232-6.

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Ganesh, et al.: Pediatric IOL power calculation

Instruments using partial coherence interferometry such as

Table 1: Recommended intraocular lens power calculation
IOLMaster  (Carl Zeiss Meditec, Jena, Germany) and the
formulae as per axial length
Lenstar  (Haag‑Streit AG, Koeniz, Switzerland) are used in
older children and younger adults. Measurement of AL under Axial length (mm) IOL power calculation formula
anesthesia is performed with A‑scan ultrasound biometry, 22 Hoffer Q, Holladay 2
using either applanation or immersion techniques. Applanation 22-26 Holladay I, Hoffer Q, SRK/T
involves holding the probe in contact with the cornea which >26 SRK/T, Holladay 2
may induce measurement error in the form of shorter AL and SRK: Sanders, Retzlaff, and Kraff, IOL: Intraocular lens
ACD measurements due to corneal compression, leading to
incorrect IOL power calculations. Immersion A‑scan uses a Table 2: Desired postoperative target refraction for
coupling fluid between the probe and the cornea to reduce different age groups according to Enyadi et al.
indentation and has been shown to be more accurate than
the applanation method[6] and in fact is considered the gold Age of the child (years) Postoperative target refraction
standard. 1 +6
2 +5
Keratometry and errors in its measurement produce a 3 +4
comparably less unfavorable outcome on the final IOL power. 4 +3
Hand‑held keratometry can be used under anesthesia in 5 +2
young children, but results may be flawed owing to the lack 6 +1
of fixation and centration. Obtaining multiple readings of the 7 Plano
same and recording the average reading are considered helpful >8 −1-−2
in overcoming the error.

Table 3: Desired postoperative target refraction for

Formulae for Intraocular Lens Power different age groups according to Trivedi and Wilson
Calculation Age at surgery (years) Desired postoperative refraction
Since their origin in the 1950s, formulae for IOL power 1 +6
calculation have been subject to constant evolution. There 2 +5
exist two basic kinds of formulae: theoretical, determined by 3 ‑
application of geometrical optics to the schematic and reduced 4 +4
eyes using various constants, and regression, using the actual 5 +3
postoperative results of implant power as a function of the 6 +2
variables of corneal power and AL or formulae which include 7 +1.5
a combination of both of the above. Various parameters, such 8 +1
as net corneal power, AL, effective lens position, and vertex 10 +0.5
distance, are involved in the determination of implant power >14 0
and expected postoperative refraction.
Sanders, Retzlaff, and Kraff developed SRK formula, which vitreous which may reduce ultrasound transmission and hence
affect the results.[9] Pediatric IOL calculator[10] is a computer
was the most widely used formula for a long duration.
program using the Holladay 1 algorithm and pediatric
Following this, various changes were suggested and practiced
normative data for AL and keratometry readings as established
taking into account the effective lens position. Holladay,
by Gordon and Donzis.[11] It aims to calculate the postoperative
Holladay 2, Hoffer Q, SRK/T, or Haigis were derived as a
pseudophakic refraction of a child during the immediate
result of the newer modifications that were made to the existing
postoperative period and later to predict the refractive change
formulae.
as the child grows.
Existing formulae are mainly derived from studies on adult
Most of the literature available for pediatric eyes consists of
eyes and are known to be accurate over a range of ALs between
retrospective studies and not many measure refractive changes
22 and 26  mm. Data regarding accuracy based on AL are
occurring overtime. Mezer et  al.[12] evaluated the refractive
shown in Table 1.
outcome in the postoperative period in 49 patients using two
Application of the above data to pediatric eyes is seen to regression formulas (SRK and SRK II) and three theoretical
produce inconsistent outcomes and conflicting results exist formulas  (Holladay 1, Hoffer Q, and SRK/T). Children of
between studies conducted by various authors. Apart from 6–7 years’ age group at the time of surgery were included and
inaccurate measurements, other possible sources of error mean difference between the predicted and actual postoperative
in short eyes are related to a steep cornea, shallow ACD, refractions with all formulas ranged from 1.06 to 1.2 diopters.
short ALs,[7] dense cataracts which may influence the final They concluded that all of the five IOL power calculation
measurement to a greater extent in shorter eyes,[8] and denser formulas were unsatisfactory in achieving target refraction.

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Ganesh, et al.: Pediatric IOL power calculation

In a retrospective case series conducted by Nihalani and Vasavada et al. They differ from findings of Vasavada et al.
VanderVeen[13] in 2011, 135 eyes that underwent uncomplicated in that they found values obtained using Hoffer Q to have
pediatric cataract surgery with IOL implantation using improved accuracy.
formulae SRK II, SRK/T, Holladay 1, and Hoffer Q, prediction
IOL power calculation in children of age lesser than 2 years
error (PE) (PE = predicted refraction – actual refraction) was
is especially challenging. Retrospective case series done by
calculated and compared among the above formulae. It was
Kekunnaya et  al.[23] compared 128 eyes of 84 children for
seen that though in cases where PE was insignificant (<0.5), it
SRK II, SRK/T, Holladay, and Hoffer Q. They found that the
was similar for all the formulae; among those cases (PE >0.5),
absolute PE tended to remain high with all the formulae, but it
Hoffer Q was most predictable of the formulae, while the others
was significantly lesser with SRK II than with other formulae.
tended to produce an undercorrection. They also reported that
PE with SRK II formula was not affected by any factor such as
there was a trend toward greater PE in the eyes of younger
age, keratometry, or AL. AL influenced the absolute PE with
children  (<2  years), shorter AL  (AL  <22  mm), and steeper
Holladay and Hoffer Q formulae. Mean keratometry influenced
corneas (mean K >43.5 diopters [D]). As pediatric eyes are
PE with SRK/T formula. Children <2 years of age comprise
shorter, it is expected that the Hoffer Q formula would have
only a subgroup, and most of the studies are underpowered
better accuracy in these eyes as it was formulated for shorter
ALs. Hoffer had reported a greater accuracy of Hoffer Q to detect statistically significant differences. This age shows
formula as compared to SRK/T[14] in adults with ALs >22 mm a rapid elongation of the eyeball and flattening of the cornea,
and Holladay 1 and Holladay 2,[15] but these results were based thereby causing a significant myopic shift.
on studies done in small populations and their reliability As prevalent practices and observations stand now, and in face
was called into question. Subsequent studies by Gavin and of rapidly changing techniques and lack of consensus regarding
Hammond[16] found Hoffer Q to be of greater accuracy than preferred IOL formulae in children, there exists the need for
SRK/T in smaller eyes, whereas MacLaren et al.[17] suggested improved IOL power calculations in pediatric cataract surgery,
that both Hoffer Q and Haigis performed equally well for these especially in children of younger age and smaller eyes.
eyes. Neely et al.,[18] though, reported that among the youngest
group of children with ALs <19 mm, SRK II regression formula
gave the least amount of variability, whereas the Hoffer Q
Need for Undercorrection
gave the greatest. The prediction of long‑term refractive outcomes among
pediatric pseudophakes remains one of the biggest challenges
Holladay 2 formula uses additional factors such as in the management of pediatric cataracts. Growth of the eyeball
white‑to‑white corneal diameter, ACD, age, and lens thickness. and changing curvature of the eyeball produce a tendency for
Holladay 2 formula was compared with that of the Holladay 1, myopic shift.[24,25] Hence, an undercorrection is usually planned
Hoffer Q, and SRK/T formulas by Trivedi et al.[19] and found at the time of surgery, and the residual refractive correction is
to have the least PE specifically for the subgroup of the provided by means of contact lenses or glasses. Another school
eyes <22 mm in length, following which the authors concluded of thought advocates planning an initial small undercorrection
that Holladay 2 formula can be reliably used despite the lack or emmetropia to allay the possibility of an initial hypermetropia
of preoperative refraction. which might in itself be amblyogenic. They propose to correct
Further studies evaluating the PE with different IOL power the phenomenon of an expected myopic shift by a possible IOL
calculation formulae produced inconsistent and mixed results. exchange or refractive surgery later in life.[26]
Vasavada et al.[20] conducted that an observational case study on In spite of the lack of comparative studies between the above
117 eyes of patients, of an average of 2 years of age, compared two approaches, undercorrection at the time of IOL implantation
the PE for refractive outcome for each formula and they were remains the widely accepted and practiced approach. Among
evaluated based on initial AL. They proved with statistically the proponents of undercorrection, two of the most popular
significant data that SRK/T and Holladay 2 had the least PE (guidelines were those proposed by Enyedi et al.[25] and Dahan
in pediatric eyes. Personalizing the lens formula constant and Drusedau.[27] Dahan proposed implantation of IOL which is
reduced the PE significantly for all formulae except Hoffer Q. 20% less than the emmetropic IOL power for children <2 years
In eyes AL <20 mm, SRK/T and Holladay 2 gave the best PE. of age and 10% less for children >2 years of age, to allow for
These conclusions were also supported in a comparative case myopic shift occurring during the emmetropizing process. Enyedi
series by Vanderveen et al.,[21] which showed that Holladay 1 proposed what is popularly known as “the rule of 7,” where the
and SRK/T gave equally good results and had best predictive sum of postoperative refractive goal and age of the child is 7,
value for infant eyes. and target refraction is decided accordingly: +6 for a 1‑year‑old,
+5 for a 2‑year‑old, +4 for a 3‑year‑old, +3 for a 4‑year‑old, +2
O’Gallagher et  al.[22] evaluated children under the age of
for a 5‑year‑old, +1 for a 6‑year‑old, plano for a 7‑year‑old, and
8  years undergoing cataract surgery with IOL implantation
−1–−2 for patients >8 years of age [Tables 2 and 3].
and compared Hoffer Q, Holladay 1, SRK‑II, and SRK/T in
a small sample of patients and noted that mean absolute error Chen[26] and companions recommended matching of the
was lesser in SRK/T, which is in agreement with results of IOL power based on the spherical equivalent of the other

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Ganesh, et al.: Pediatric IOL power calculation

eye (children 2–4 years, 1.25 diopters less power than SE of and IOL implantation, demonstrated no statistically
the fellow eye) and, in children >4 years of age, match the significant difference between initial AL and myopic shift.
spherical equivalent refraction of the fellow eye. The same study showed a greater tendency toward myopic
shift in the eyes with bilateral cataract and shorter initial
Multiple recommendation tables have been published by
AL; these findings were in support to a study by Trivedi
experts and pediatric ophthalmologists to guide surgeons in
and Wilson.[34] It also demonstrated a significant relation
selecting IOL power in children, including those by Plager
between laterality and the shift, with statistically significant
et al.[28] and Trivedi and Wilson.[29]
occurrence in unilateral eyes as compared to bilateral ones.
In our practice, we follow guidelines set out by Trivedi and Kora et al.,[35] Vasavada et al.,[36] and Hoevenaars et al.[37]
Wilson. concurred with the above findings in independent studies.
Many authors have reported that the greatest myopic shift
A retrospective observational study conducted by Sachdeva
occurs in the early years of life, at younger than 2 years of
et  al. [30] on 84 eyes of 56 children who had undergone
age.
undercorrection according to Enyedi et al. and were followed
up in the long term showed that most children achieved an Children enrolled in the Infant Aphakia Treatment Study who
acceptable final refractive error. Myopic shift was seen highest underwent IOL implantation were evaluated for the refractive
in the youngest age group  (0–2  years of age) and least in changes at 5 years of age. It showed that the rate of myopic
4–7  years of age group. Multivariate analysis suggests that shift occurs most rapidly during the first 1.5  years of life.
the most important factor which might influence the results is It was suggested that for a goal of emmetropia by 5  years,
the age at surgery, with reduction in error by 0.31 with every then the immediate postoperative hypermetropic targets
passing year. should be +10.5 D at 4–6 weeks and +8.50 D from 7 weeks
to 6 months.[38]
Apart from a fixed undercorrection, some authors like
McClatchey[10] aimed to develop a computer‑based software to Another surgical innovation proposed by Wilson et al.[39] is
predict the refractive error of the children undergoing cataract the concept of pediatric polypseudophakia or the pediatric
surgery in both aphakia and pseudophakia, called the pediatric piggyback IOL, which involves an in the bag placement of
IOL calculator. He also proposed a table outlining expected IOL along with a second “piggyback” lens in the sulcus, both
postoperative target refraction based on the age.[31] Pediatric of which may be calculated using a piggyback pediatric IOL
IOL calculator[11] was open‑access computer program which calculator.[40] As the child attains emmetropia or myopic shift,
was written for Windows and was based on average eyes and the piggyback IOL, accounting for 20% of the total power, can
refractive changes, and this did not entertain the “outliers.” be removed,[41] to provide a more emmetropic refraction. Other
It calculates the initial refraction planned based on the technological breakthroughs such as mechanically adjustable
keratometry, AL and IOL, and the Holladay formula and was or light adjustable IOLs which are being tested among adults
found to give good predictions in initial trials in pseudophakic have not yet come into pediatric practice.
children and older children.
Jasman et  al. [32] conducted a comparative study of 31
Rehabilitation
eyes  (24  patients) among children under 12  years of age Socioeconomic situation, educational status, and parental
that underwent cataract surgery and IOL implantations. concerns are factors to be taken into consideration while
Patients were randomized into two groups: SRK II group planning rehabilitation in pediatric pseudophakes and
and pediatric IOL calculator group. At the end of 3‑month attempts must be made to involve parents and provide
follow‑up, no statistically significant differences were first‑hand knowledge of various aspects pertaining to
found in PE and accuracy of predictability of postoperative the child’s well‑being such as use of glasses, amblyopia
refraction between the two groups, hence proving the IOL therapy if needed, and need for regular visits to the doctor.
The choice of spectacles or contact lenses may be given to
calculator as a new tool in predicting refractive outcomes.
the parents, but spectacles are advocated in most cases in
Nevertheless, caution has to be exercised while using
view of safety.
the same as very few studies regarding the pediatric IOL
calculator are available and the above study is based on a In the age of newer and evolving instrumentation and scientific
very small sample size. techniques and IOL often times being implantated in younger
children; studies on the ideal postoperative refractive state and
Myopic Shift novel approaches to a dynamic refractive solution appear to
be need of the hour.
The phenomenon of myopic shift is often discussed in the
context of age at surgery, initial AL, and laterality of the Financial support and sponsorship
cataract. Nil.
A retrospective cohort study by Valera Cornejo and Flores Conflicts of interest
Boza,[33] over a period of 3 years following cataract surgery There are no conflicts of interest.

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Ganesh, et al.: Pediatric IOL power calculation

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