Corneal Refractive Power Estimation and

Intraocular Lens Calculation after

Hyperopic LASIK
Shady T. Awwad, MD,1,2 Patrick S. Kelley, MD,1 R. Wayne Bowman, MD,1
H. Dwight Cavanagh, MD, PhD,1 James P. McCulley, MD1

Purpose: To identify key independent variables in estimating corneal refractive power (KBC) after hyperopic
LASIK.
Design: Retrospective study.
Participants: We included 24 eyes of 16 hyperopic patients who underwent LASIK with subsequent
phacoemulsification and posterior chamber intraocular lens (IOL) implantation in the same eye.
Methods: Pre-LASIK and post-LASIK spherical equivalent (SE) refractions and topographies, axial length,
implant type and power, and 3-month postphacoemulsification SE were recorded. Using the double-K Hoffer Q
formula, corneal power was backcalculated for every eye (KBC), regression-based formulas derived, and
corresponding IOL powers calculated and compared with published methods.
Main Outcome Measures: The Pearson correlation coefficient (PCC) and arithmetic and absolute corneal
and IOL power errors.
Results: Adjusting either the average central corneal power (ACCP3mm) or SimK based on the laser-induced
spherical equivalent change (⌬SE) resulted in an estimated corneal power (ACCPadj and SimKadj) with highest
correlation with KBC (PCC ⫽ 0.940 and 0.956, respectively) and lowest absolute corneal estimation error
(0.37⫾0.45 and 0.38⫾0.39 diopter [D], respectively). The ACCPadj closely mirrored published ⌬SE-based
adjustments of central corneal power on different topographers, whereas ⌬SE-based SimK adjustments varied
across platforms. Using ACCPadj or SimKadj in the double-K Hoffer Q, using ACCP3mm or SimK in single-K Hoffer
Q and adjusting the resultant IOL power based on ⌬SE, or applying Masket’s formula all yielded accurate and
similar IOL powers. The Latkany method consistently underestimated IOL power. The Feiz–Mannis and clinical
history methods yielded poor IOL correlations and large IOL errors.
Conclusion: After hyperopic LASIK, adjusting either corneal power or IOL power based on ⌬SE accurately
estimates the appropriate IOL power.
Financial Disclosure(s): Proprietary or commercial disclosure may be found after the references.
Ophthalmology 2009;116:393– 400 © 2009 by the American Academy of Ophthalmology.

Determination of the refractive corneal power after laser ker-
atorefractive surgery has been the subject of numerous studies
over the past decade.1–11 Fortunately, continuous clinical re-
search that spurred creation and refinement of formulas, along
with newer imaging systems, have helped to improve refrac-
tive outcomes.12–14 Most published works, however, have tar-
geted patients with previous myopic keratorefractive surgery;
there are few data on corneal power estimation and intraocular
lens (IOL) power calculation after hyperopic keratorefractive
surgery.15–17 Using the double-K IOL formula concept, we
have used data from patients who have undergone cataract
extraction after hyperopic LASIK to backcalculate the ideal
refractive corneal power and performed multiple regression
analysis to identify key variables with their corresponding
formulas that would best predict corneal refractive power
(KBC) in an accurate, and most important, reproducible man-
ner.
Patients and Methods
A retrospective chart review was conducted to locate patients with
a history of hyperopic LASIK who subsequently underwent phaco-
emulsification and posterior chamber IOL implantation in the same
eye between January 2001 and June 2006 at the University of
Texas Southwestern Medical Center at Dallas. All patients had to
have full prephacoemulsification refractive history, comprising
pre-LASIK keratometry (Kpre-LASIK), pre-LASIK refraction, post-
LASIK refraction before cataract development, and post-LASIK
topography. Exclusion criteria included vitreoretinal or corneal
disease, history of any other ocular surgery, as well as uveitis,
trauma, or systemic diseases affecting vision, and intraoperative
complications. Data on 25 eyes could be located, with a total of 24
eyes of 16 patients meeting the criteria and being included in the
study. All eyes had a corneal topography using the Topography
Modeling System (TMS, Tomey Inc, Phoenix, AZ), and axial
length measurement with optical coherence interferometry using
the IOLMaster (Carl Zeiss GmbH, Jena, Germany). The 3-month

© 2009 by the American Academy of Ophthalmology ISSN 0161-6420/09/$–see front matter 393
Published by Elsevier Inc. doi:10.1016/j.ophtha.2008.09.045
 Ophthalmology Volume 116, Number 3, March 2009
postcataract surgery spherical equivalent refraction (SEPCE), type
and power of the implanted IOL, axial length, and topographic
data extracted from the TMS topographer, simulated keratometry
(SimK) and average central corneal power over the central 3 mm
of the cornea (ACCP3mm), were all recorded. The ACCP3mm is the
average of the mean powers of the central placido rings over the
central 3 mm area, and is analogous to the effective refractive
power of the cornea (EffRP) available on the Holladay Diagnostic
Summary on the EyeSys topographer, without the Stiles-Crawford
compensation effect, and similar to the annular central power
(AnnCP) on the Humphrey topographer.3,17,18 The types of IOL
implanted were AcrySof SA60AT and SN60AT, AcrySof IQ, and
AcrySof Restor (Alcon Labs, Fort Worth, TX). Cataract surgeries
were performed by RWB, HDC, and JPM, and the IOL constants
optimized for the partial coherence interferometery method of
axial length measurement. Laser correction surgery was performed
using the VISX S2, S3, and S4 systems (VISX, Santa Clara, CA)
with an optical zone of 6.0 mm and a transition zone of 8.5 mm.
The study was performed with the approval of the University of
Texas Southwestern Medical Center Institutional Review Board
and in accordance with the Declaration of Helsinki guidelines for
human research and the Health Insurance Portability and Account-
ability Act.
Two types of methods are currently available to calculate IOL
power in postkeratorefractive eyes. One method adjusts the mea-
sured corneal power, and then uses the adjusted value in a double-K
modified IOL formula. The second method simply inputs the
measured corneal power in a single-K IOL formula, and then
adjusts the resultant IOL power according to the laser induced
refractive change.
Regression Analysis Derivation: Corneal
Power Adjustment
For each eye, the ideal KBC was backcalculated using the dou-
ble-K Hoffer Q formula and the 3-month SE, the implanted IOL
power and constant, and axial length. The KBC was considered the
gold standard, and both corneal power measurements, ACCP3mm
and simulated K (SimK) were adjusted according to KBC using
multiple regression analyses of the form Y ⫽ aX ⫹ bZ ⫹ C, where
Y represents the dependent variable and is KBC, and X and Z are
independent variables. X and Z can include either ACCP3mm or
SimK, together with the laser-induced SE change: pre-LASIK SE
(SEpre-LASIK) ⫺ post-LASIK SE (SEpost-LASIK). Four regression
analyses were created based on 4 sets of parameters:
1. KBC and ACCP3mm
2. KBC and SimK
3. KBC, ACCP3mm, and (SEpre-LASIK ⫺ SEpost-LASIK)
4. KBC, SimK, (SEpre-LASIK ⫺ SEpost-LASIK)
Regression Analysis Derivation: Intraocular Lens
Power Adjustment
To compare to published formulas that adjust the final IOL power
calculated from single-K third-generation formulas, bypassing cor-
neal power adjustment (the Masket and Latkany methods), regres-
sion analyses were created based on IOL power adjustment. In this
scenario, the implanted IOL power (IOLi) was considered the gold
standard, and the resulting postphacoemulsification spherical
equivalent (SEPCE) was used as the target correction to calculate
the IOL power via the single-K Hoffer Q formula. The calculated
IOL power was then adjusted by regression analysis according to
the laser-induced refractive change. For every eye, 2 values of IOL
power were calculated, IOLACCP3mm and IOLSimK, depending on
394
whether ACCP3mm or SimK were used in the single-K formula,
hence leading to 2 more regression formulas with the following
parameters:
5. IOLi, IOLACCP3mm, and (SEpre-LASIK ⫺ SEpost-LASIK)
6. IOLi, IOL SimK, and (SEpre-LASIK ⫺ SEpost-LASIK)
The first 4 regression formulas were used in every eye to compute
the corresponding refractive corneal power, which was compared
with KBC. For each formula, the Pearson correlation coefficient
was calculated, and the corneal power estimation error was calcu-
lated as such:
Arithmetic corneal power estimation error
⫽ estimated corneal power ⫺ KBC
The absolute corneal power estimation error was derived using the
absolute value of the arithmetic corneal power estimation error.
The proportion of eyes within ⫾ 1.0 diopters (D) of corneal power
error was evaluated. The results were compared with the clinical
history method (CHM). For the CHM, the pre-LASIK and post-
LASIK spherical equivalents (SEpre-LASIK and SEpost-LASIK) were
converted to the corneal plane, and then the difference in SE was
subtracted from the pre-LASIK keratometric value to obtain the
refractive power (KCHM).12
The last 2 regression formulas (5 and 6) were also used in every
eye to compute the corresponding IOL (IOLc), which was com-
pared with the IOLi, with the IOL power estimation error being
equal to (IOLc ⫺ IOLi). For every formula, the Pearson correlation
coefficient, the arithmetic and absolute IOL power estimation
error, and the proportion of eyes within ⫾ 1.0 D of IOL power
error were calculated. The results were compared with available
methods for computing and adjusting IOL power after posthyper-
opic keratorefractive surgery, and assuming the postoperative re-
fraction target to be equal to the actual postoperative spherical
equivalence in each case (SEPCE). The latter formulas included the
Feiz–Mannis,5,16 modified Feiz–Mannis,16 Masket,7 modified
Masket (Hill WE. IOL power calculation after keratorefractive
surgery. Paper presented at: the Annual Meeting of the American
Society of Cataract and Refractive Surgery, San Francisco, Cali-
fornia, March 2006), and Latkany method.16 These methods all use
the single-K IOL formulas and are summarized below.
1. Feiz–Mannis method: IOL is computed using Kpre-LASIK as
the corneal power value, then is adjusted using the following
correction factor: (SEpre-LASIK ⫺ SEpost-LASIK)/0.7; hence,
IOL ⫽ IOL Kpre-LASIK ⫺ (SEpre-LASIK ⫺ SEpost-LASIK)/0.7.
2. Modified Feiz–Mannis method: Similar to the original
method, the modified formula is theoretically more exact,
in that the laser-induced change in spherical equivalence is
input as the target refraction in the IOL formula. Kpre-LASIK is
still used as the corneal power value.
3. Masket method: IOL ⫽ IOLSimK ⫺ 0.326 ⫻ (LSE) ⫹ 0.101,
where LSE is the vertex distance corrected laser vision cor-
rection SE.
4. Modified Masket method: IOL ⫽ IOLSimK ⫺ 0.4385 ⫻
LSE ⫹ 0.0295.
5. Latkany method: IOL ⫽ IOLSimK ⫺ (0.27 ⌬SE ⫹ 1.53),
where ⌬SE is the difference between preoperative and
postoperative spherical equivalents (SE pre-LASIK ⫺
SEpost-LASIK).
The Feiz–Mannis and modified Feiz–Mannis methods bypass
the problem of the effective lens position (ELP) estimation error
by using the Kpre-LASIK for the corneal power in the single-K IOL
 Awwad et al 䡠 IOL Calculations after Hyperopic LASIK
formula and adjusting with laser-induced change in refraction. As
for the Masket and Latkany methods, both use the single-K IOL
formula and account for both the corneal power estimation error
and the ELP estimation error by adjusting the IOL power based on
the laser-induced refractive change.
The double-K adjustment of the original Hoffer Q formula with
its updated errata and with its derivation of the backcalculated
refraction was carefully programmed in Excel and is detailed in
Appendix 1 (available online at http://aaojournal.org).19 The Hof-
fer Q formula, as programmed in Excel, was tested against the
Hoffer Q formula programmed in the Holladay IOL Consultant
software (officially licensed to calculate Hoffer Q formula) using
SimK as the default corneal power with and without double-K
adjustment and results were found to match for all eyes. The Excel
version was subsequently used to run simultaneous tandem calcu-
lations on all eyes using different parameters each time and to
integrate the data efficiently for statistical analysis. The statistical
data in Excel was exported to Sigmastat software (Jandel Scien-
tific, San Rafael, CA) for analysis. The paired Student t-test
(2-tailed distribution) was used to compare the algebraic and
absolute IOL errors, and the McNemar test for nonparametric
analysis of related samples was used to compare proportions
between related groups. P⬍0.05 was considered significant.
Results
Patient Demographics and Characteristics
The average patient age was 62.5⫾7.13 years. The axial length
measurements averaged 22.91⫾0.58 mm, ranging from 22.10 to
23.81 mm. The average of the effective refractive correction (⌬SE ⫽
SEpre-LASIK ⫺ SEpost-LASIK), which takes into consideration the
refractive regression effect, was 2.34⫾0.95 D (range, ⫹0.25 to
⫹3.87 D).
Regression Formulas
Regression analysis using KBC as the dependent variable and
different combinations of independent variables yielded the fol-
lowing equations:
ACCP' ⫽ 0.909 ⫻ ACCP3mm ⫹ 4.198 (r2 ⫽ 0.874;
P⬍0.001); [1]
and
SimK' ⫽ 0.917 ⫻ SimK ⫹ 4.016 (r2 ⫽ 0.895; P⬍0.001).
[2]
Both formulas are roughly 90% of the K reading plus 4:
ACCPadj ⫽ 0.857 ACCP3mm ⫹ 0.242 (SEpre-LASIK ⫺ SEpost-LASIK)
⫹ 6.021 (r2 ⫽ 0.888; P⬍0.001).
Using KBC ⫺ ACCP3mm as a dependent variable, we get:
ACCPadj ⫺ ACCP3mm ⫽ 0.144 (SEpre-LASIK ⫺ SEpost-LASIK)
⫺ 0.256.
Hence, the equation:
ACCPadj ⫽ ACCP3mm ⫹ 0.144 (SEpre-LASIK ⫺ SEpost-LASIK)
⫺ 0.256 [3]
SimKadj ⫽ 0.864 SimK ⫹ 0.255 (SEpre-LASIK ⫺ SEpost-LASIK)
⫹ 5.826 (r2 ⫽ 0.914; P⬍0.001).
Using KBC ⫺ SimK as a dependent variable, we get:
SimKadj ⫺ SimK ⫽ ⫹0.165 (SEpre-LASIK ⫺ SEpost-LASIK)
⫺ 0.105
Hence, the equation:
SimKadj ⫽ SimK ⫹ 0.165 (SEpre-LASIK ⫺ SEpost-LASIK)
⫺ 0.105. [4]
A regression analysis bypassing the double-K method was also
devised with IOLi ⫺ IOLACCP3mm, taken as the dependent vari-
able, and ⌬SE as the independent variable (IOLACCP3mm being the
IOL power derived via the single-K Hoffer Q formula and using
ACCP3mm as the corneal power):
IOLi ⫺ IOLACCP3mm ⫽ ⫺0.350 ⌬SE ⫹ 0.085
IOLadj_ACCP ⫽ IOLACCP3mm ⫺ 0.35 ⌬SE ⫹ 0.085 [5]
Another regression analysis bypassing the double-K method,
that could be used when Kpre-LASIK is unknown, was also devised
with IOLi ⫺ IOLSimK, taken as the dependent variable, and ⌬SE as
the independent variable (IOLSimK being the IOL power derived
via the single-K Hoffer Q formula and using SimK as the corneal
power):
IOLi ⫺ IOLSimK ⫽ ⫺0.359 ⌬SE ⫹ 0.092.
IOLadj_SimK ⫽ IOLSimK ⫺ 0.359 ⌬SE ⫹ 0.092 [6]
The Pearson Correlation Coefficient and
Arithmetic and Absolute Refractive Corneal
Power Estimation Errors
The Pearson correlation coefficients for the estimated refractive
corneal power derived using the different regression formulas and
the arithmetic and absolute errors are summarized in Table 1,
together with their corresponding arithmetic and absolute corneal
power estimation error. ACCP3mm approximated the refractive
corneal power slightly better than SimK, which tended to under-
estimate it (arithmetic and absolute corneal power of ⫺0.082⫾
0.61 and 0.41⫾0.44, respectively, vs ⫺0.28⫾0.55 and 0.48⫾0.39,
respectively, for SimK). On the other hand, SimK had a slightly
better Pearson correlation with the refractive corneal power rep-
resented by KBC than ACCP3mm (0.946 vs 0.935, respectively).
Regression analyses based on SimK and ⌬SE (SEpre-LASIK ⫺
SEpost-LASIK), (SimKadj; equation 4), yielded the highest correla-
tion coefficients (0.956), followed by regression based on SimK
alone (SimK=; equation 2; 0.946), and regression based on
ACCP3mm and ⌬SE (ACCPadj; equation 3; 0.940). The CHM
yielded the lowest correlation with only 0.821.
The SimKadj improved the correlation and the arithmetic and
absolute corneal power error of SimK (⫺0.28⫾0.55 vs 0.00⫾0.53
[P⬍0.001] and 0.38⫾0.39 vs 0.48⫾0.39 [P ⫽ 0.09], respectively;
Table 1). Similarly, ACCPadj improved on the correlation and the
absolute error of ACCP3mm, although the difference in absolute
error was not significant (P ⫽ 0.170; Table 1). The difference in
absolute error between ACCPadj and SimKadj was not significant
(0.37⫾0.45 vs 0.38⫾0.39; P ⫽ 0.929). The CHM yielded the
largest absolute corneal power estimation error (0.72⫾0.63),
which was statistically significant when compared with the error of
SimKadj and ACCPadj (P⬍0.001 for both).
Table 2 summarizes the percentage of eyes within a certain cor-
neal power estimation error for all the formulas. Only 83% and 92%
of CHM eyes lay within ⫾ 1.5 D and ⫾ 2.0 D of error, as opposed
to 96% to 100% and 100% for ACCP3mm, SimK, or the rest of the
regression formulas. The difference, however, was not significant.
The adjustments that need to be made on the TMS topographic
measurements ACCP3mm and SimK based on the laser treated
395
 Ophthalmology Volume 116, Number 3, March 2009

Table 1. Arithmetic and Absolute Corneal Power Estimation Errors of the Different Derived
Regression, as well as the Historical K Method, and the Pearson’s Correlation (r) of Their
Respective Derived Corneal Power with the Backcalculated Corneal Power for Each Eye (Kbackcalc)

Regression Formulas and Corneal Arithmetic Corneal Power Absolute Corneal Power Pearson’s
Power Estimation Methods Estimation Error (D) Estimation Error (D) Correlation*
ACCP3mm ⫺0.082⫾0.61 0.41⫾0.44 0.935
SimK ⫺0.28⫾0.55 0.48⫾0.39 0.946
Regression based on ACCP ⫺0.018⫾0.59 0.40⫾0.41 0.935
Regression based on SimK ⫺0.020⫾0.53 0.41⫾0.35 0.946
ACCPadj 0.000⫾0.59 0.37⫾0.45 0.940
SimKadj 0.000⫾0.53 0.38⫾0.39 0.956
Clinical history method 0.18⫾0.94 0.72⫾0.63 0.821

ACCPadj ⫽ Regression based on ACCP3mm and ⌬ SE; ACCP3mm ⫽ average central corneal power within the central
3 mm; D ⫽ diopters; ⌬SE ⫽ change in spherical equivalent refractions (SEpre-LASIK ⫺ SEpost-LASIK); SimK ⫽
simulated keratometric value; SimKadj ⫽ regression based on SimK and ⌬SE.
*P⬍0.0001 for all.

correction are detailed in Table 3, with the adjustments published value in the double-K Hoffer Q formula resulted in a similar
by Wang et al for phakic eyes posthyperopic keratorefractive Pearson correlation and arithmetic and absolute errors compared
surgery listed in parallel for comparison purposes.15 As can be with the Masket method (Table 4), and better Pearson correlation
seen, the adjustments on the ACCP3mm are strikingly similar to as well as smaller arithmetic and absolute IOL power estimation
those of EffRP and AnnCP, which are similar indices of the errors than the CHM (P ⫽ 0.367 and P ⫽ 0.362, respectively, for
average central corneal power on the EyeSys and Atlas topogra- arithmetic error; P ⫽ 0.013 and P ⫽ 0.007 for absolute error),
phers, respectively. On the other hand, the SimK adjustments seem Feiz–Mannis/double-K Hoffer Q (P⬍0.001 for both, in arithmetic
to be dependent of the topography platform used (Table 3). and absolute errors), modified Masket method (P⬍0.001 for both,
in arithmetic and absolute errors), as well as the modified Latkany
Comparison with Published Posthyperopic method (P⬍0.001 for both, in arithmetic and absolute errors), all
of which, except CHM, were derived from a regression-based
Keratorefractive Surgery Intraocular Lens Power adjustment of IOL power using the single-K Hoffer Q formula
Calculation Methods (Table 4). The Latkany method resulted in a systematic underes-
The Pearson correlation and the arithmetic and absolute IOL timation of the IOL power, as shown by the arithmetic IOL error,
power errors of the derived regression formulas and the published which was about equal in value to the absolute IOL error (Fig 1).
IOL power calculation methods for eyes after hyperopic keratore- On the other hand, the modified Masket method resulted in slight
fractive surgery are summarized in Table 4. Performing corneal overestimation of the IOL power (Fig 1). IOL calculation using
adjustment based on ACCP3mm and ⌬SE (ACCPadj; equation 3) or ACCP3mm and the single-K Hoffer Q and subsequent adjustment
SimK and ⌬SE (SimKadj; equation 4) and using the calculated based on ⌬SE (IOLadj_ACCP; equation 5) had an arithmetic and
absolute IOL power error of 0.01⫾0.76 and 0.50⫾0.57 D, essen-
tially similar to ⫺0.07⫾0.76 and 0.53⫾0.54 D obtained by the
double-K Hoffer Q using adjusted corneal power based on
Table 2. Percentage of Eyes with Corneal Power Estimation
ACCP3mm and ⌬SE (ACCPadj; equation 3; P ⫽ 0.805 and P ⫽
Error within a Certain Range, as a Function of Topographic
0.646, respectively; Table 4; Fig 2). In addition, IOL calculation
Parameters, Regression Formulas, as well as the Historical K
Method, in Eyes with Previous Hyperopic using SimK and the single-K Hoffer Q and subsequent adjustment
Keratorefractive Surgery based on ⌬SE (IOLadj_SimK; equation 6) had an arithmetic and
absolute IOL power error of 0.00⫾0.79 and 0.52⫾0.57 D, which
Percentage of Eyes within a Certain compares with the ⫺0.05⫾0.80 and 0.55⫾0.57 D obtained by the
Corneal Power Estimation Error double-K Hoffer Q using adjusted corneal power based on SimK
Refractive Corneal Power and ⌬SE (SimKadj; equation 4; P ⫽ 0.872 and P ⫽ 0.339,
Estimation Methods ⫾ 0.5 D ⫾ 1.0 D ⫾ 1.5 D ⫾ 2.0 D
respectively; Fig 3).
ACCP3mm 75 83 96 100 The percentage of eyes within a certain error range is summa-
SimK 62 92 96 100 rized in Table 5. When using ACCPadj (equation 3) with the
Regression based on ACCP 75 92 100 100 double-K Hoffer Q, 92% and 100% of eyes were within ⫾ 1.5 D
Regression based on SimK 75 83 100 100 and ⫾ 2.0 D of IOL power error, respectively, compared with 92%
ACCPadj 75 88 96 100 and 96%, respectively, with SimKadj (equation 4) with double-K
SimKadj 75 92 96 100 Hoffer Q, 79% and 83%, respectively, for the Feiz–Mannis and the
Clinical history method 46 79 83 92
CHM (P ⫽ 0.125 for both), 92% and 96% for both the Masket and
the modified Masket methods (P ⫽ 1.000 for both), and 54% and
ACCP3mm ⫽ average central corneal power within the central 3 mm; 79% for the Latkany method (P ⫽ 0.001 and P ⫽ 0.063, respec-
ACCPadj ⫽ regression based on ACCP3mm and ⌬SE; D ⫽ diopters; tively). The single-K regression-derived IOL adjustment method
SimK ⫽ simulated keratometric value; SimKadj ⫽ regression based on SimK and IOLadj_ACCP (equation 5) and IOLadj_SimK (equation 6) both had
⌬SE; ⌬SE ⫽ change in spherical equivalent refractions (SEpre-LASIK ⫺
SEpost-LASIK).
92% and 96% of eyes within ⫾ 1.5 D and ⫾ 2.0 D of IOL power
error, respectively (P ⫽ 1.000 for both; Table 5).

396
 Awwad et al 䡠 IOL Calculations after Hyperopic LASIK

Table 3. Adjustment of Measurements from Tomey Topographic Modulation System (TMS) Topographer with Comparison with
Adjustment Figures Published by Wang et al on the EyeSys and Atlas Topographers in Eyes after Hyperopic LASIK15

Adjustment for Hyperopic LASIK (D)

LASIK-Induced Refractive
Correction (D) TMS ACCP3mm TMS SimK EyeSys EffRP EyeSys SimK Atlas AnnCP Atlas SimK
0.5 ⫺0.18 ⫺0.02 ⫺0.20 ⫺0.11 ⫺0.30 ⫺0.17
1.0 ⫺0.11 0.06 ⫺0.12 0.03 ⫺0.20 0.05
1.5 ⫺0.04 0.14 ⫺0.04 0.18 ⫺0.11 0.26
2.0 0.03 0.22 0.04 0.32 ⫺0.01 0.48
2.5 0.10 0.31 0.13 0.47 0.08 0.69
3.0 0.18 0.39 0.21 0.61 0.18 0.91
3.5 0.25 0.47 0.29 0.75 0.27 1.13
4.0 0.32 0.56 0.37 0.90 0.37 1.34
4.5 0.39 0.64 0.45 1.04 0.46 1.56
5.0 0.46 0.72 0.53 1.19 0.56 1.77
5.5 0.54 0.80 0.61 1.33 0.65 1.99
6.0 0.61 0.89 0.69 1.48 0.75 2.21

ACCP3mm ⫽ average central corneal power within the central 3 mm; AnnCP ⫽ Annular central power (3 mm area); D ⫽ diopters; EffRP ⫽ effective
refractive power (3 mm area); SimK ⫽ simulated keratometric value.

Discussion
Although numerous publications and studies have tackled
the problem of IOL calculation and corneal power predic-
tion in eyes after myopic keratorefractive surgery, very few
studies have evaluated the IOL and corneal power calcula-
tions after hyperopic laser keratorefractive procedures.
Wang et al evaluated phakic eyes after hyperopic LASIK
without cataract surgery and IOL insertion, and using the
CHM as the gold standard, tried to improve the accuracy of
the corneal power estimation by taking into consideration
the change in spherical equivalence from the laser proce-
dure.15 Two topography systems were used and both SimK
and average central corneal powers were evaluated (EffRP
for EyeSys and AnnCP for the Humphrey system); inter-
estingly, the suggested modifications to the measured val-
ues, based on regression analysis, were similar between the
2 topographers for the average central corneal power, but
different for SimK (Table 3). Most important, the average
corneal power modifications derived are very similar to our
regression-derived modifications for ACCP3mm on the TMS
system (Table 3).
On the other hand, Latkany et al recently reported their
results on posthyperopic LASIK eyes that underwent phaco-
emulsification and IOL insertion. Using backcalculation,
and only average keratometry and SimK values, they deter-
mined that the best predictive IOL formula would rely on
the concept of Feiz–Mannis, which also was not statistically

Table 4. Arithmetic and Absolute Intraocular Lens (IOL) Power Estimation Errors of the
Regression-Derived Formulas, Compared with Popular Methods to Calculate IOL Power in Eyes after
Hyperopic Keratorefractive Surgery, with Their Corresponding IOL Pearson Correlation with the
Implanted IOL Power (IOLimplanted)

Regression Formulas and IOL Power Arithmetic IOL Power Absolute IOL Power Pearson’s
Estimation Methods Estimation Error (D) Estimation Error (D) Correlation
Double-K methods
ACCPadj and double-K Hoffer Q† ⫺0.07⫾0.76 0.53⫾0.54 0.957
SimKadj and double-K Hoffer Q† 0.05⫾0.80 0.55⫾0.57 0.958
Historical K and double-K Hoffer Q ⫺0.20⫾1.34 0.93⫾0.96* 0.788
Single-K methods
Feiz–Mannis method 0.00⫾1.36 0.99⫾0.90* 0.780
Modified Feiz–Mannis method ⫺0.17⫾1.41 1.01⫾0.98* 0.767
Masket method ⫺0.06⫾0.78 0.54⫾0.57 0.956
Modified Masket method 0.28⫾0.79 0.62⫾0.55 0.956
Latkany method ⫺1.41⫾0.79* 1.45⫾0.71* 0.952
IOLadjACCP† 0.01⫾0.76 0.50⫾0.57 0.958
IOLadjSimK† 0.00⫾0.79 0.52⫾0.57 0.956

ACCP3mm ⫽ average central corneal power within the central 3 mm; ACCPadj ⫽ regression based on ACCP3mm and
⌬SE; D ⫽ diopters; F(x,y) ⫽ regression formula with x and y as dependent variables; IOL power error ⫽ IOLcalculated ⫺
IOLimplanted; ⌬SE ⫽ pre-LASIK ⫺ SEpost-LASIK; SimK ⫽ simulated keratometric value; SimKadj ⫽ regression based on
SimK and ⌬SE.
*Statistical significance compared to ACCPadj or SimKadj and double-K Hoffer Q.
†
Formula derived by regression analysis.

397
 Ophthalmology Volume 116, Number 3, March 2009
Figure 1. Scatter plot of implanted intraocular lens power (IOLi) versus
calculated IOL power (IOLc) using the Masket, Masket modified, and
Latkany methods (based on SimK), and the regression-derived single-K
IOL adjustment based on average central corneal power (ACCP3mm),
(IOLACCP3mm ⫺ 0.53 ⌬SE ⫹ 0.085) in posthyperopic LASIK eyes. D ⫽
diopters; SE ⫽ spherical equivalent.
different from a simplistic SimK-based regression formula
they determined to be: IOL⫽ IOLSimK ⫺ (0.27 ⫻ ⌬SE ⫹
1.53 [the Latkany method]). This formula, together with the
SimK-based modified Masket formula, yielded poor results
when applied to our patients’ sample. This finding, together
with the discrepancies found by Wang et al among SimK-
based regression formulas generated from different topog-
raphers, indicate that SimK measurements in posthyperopic
LASIK eyes are highly platform dependent.15 On the other
hand, average central corneal power measurements, such as
EffRP (EyeSys), ACCP3mm (TMS), and AnnCP (Hum-
phrey), seem to have little platform dependency, as the
adjustments that need to be made to the measured values
Figure 2. Scatter plot of implanted intraocular lens (IOL) power versus
calculated IOL power using adjusted average central corneal power
(ACCPadj), (ACCP3mm ⫹ 0.144 ⌬SE ⫺ 0.256), and adjusted simulated
keratometric values (SimKadj), (SimK ⫹ 0.165 ⌬SE – 0.105), as the
post-LASIK K values in the double-K Hoffer Q formula in posthyperopic
LASIK eyes. D ⫽ diopters; SE ⫽ spherical equivalent.
398
Figure 3. Scatter plot of implanted intraocular lens (IOL) power versus
calculated IOL power using regression derived single-K IOL adjustment
(IOLACCP3mm ⫺ 0.53 ⌬SE ⫹ 0.085) and the double-K Hoffer Q formula
with adjusted average central corneal power (ACCPadj), (ACCP3mm ⫹
0.144 ⌬SE ⫺ 0.256) as the post-LASIK K value in post hyperopic LASIK
eyes. The average laser-induced spherical equivalent change was 2.34⫾
0.95 diopters (D; range, ⫹0.25 to ⫹3.87 D). SE ⫽ spherical equivalent.
after posthyperopic LASIK eyes are strikingly similar; the
average central corneal power adjustments suggested by
Wang et al on the EyeSys and Humphrey systems compare
rigidly with those derived by our regression analysis on the
TMS system (Table 3).
It is interesting to note that although the original Masket
formula was developed with the majority of included eyes
being postmyopic LASIK and only 7 eyes after hyperopic
LASIK,7 it yielded nearly similar results when compared
with the regressions based on average central corneal power
in our patients’ sample. However, because it relies on SimK
measurements, the extension of the obtained results to other
platforms needs to be verified; the modified Masket for-
mula, for instance, had somehow inferior results in our
study sample. As for CHM and Feiz–Mannis methods, they
yielded suboptimal results. We believe this is due to the fact
that these 2 formulas, although theoretically correct and able
to be considered as gold standards, fail to perform well in
real life. Many errors could be introduced in pre- and
postoperative refraction owing to accommodation, regres-
sion, or myopic shift of an early and yet clinically occult
cataract. In addition, the error produced in any step is
carried to the final postphacoemulsification refraction on a
1:1 basis, unlike regression-based formulas where a coeffi-
cient is multiplied by the change in spherical equivalence,
hence decreasing the final error and imparting more leeway
and forgiveness to the formula. For instance, with ACCPadj ⫽
ACCP3mm ⫹ 0.144 ⌬SE ⫺ 0.256, an error of 1 D in ⌬SE is
multiplied by 0.144.
Ater hyperopic LASIK, unlike after radial keratotomy
and myopic LASIK, results with adjusted SimK were sim-
ilar to those with adjusted average central corneal power.3,17
However, adjustment based on the latter seems to be uni-
versal across all topography platforms, whereas SimK ad-
justment seems to be machine dependent. Hence, unlike the
 Awwad et al 䡠 IOL Calculations after Hyperopic LASIK

Table 5. Percentage of Eyes within a Certain Intraocular Lens (IOL) Power Error for the Regression-
Derived Formulas, Compared with Popular Methods to Calculate IOL Power in Eyes after Hyperopic
Keratorefractive Surgery

Percentage of Eyes within a Certain IOL

Power Estimation Error
IOL Power Prediction Methods ⫾ 0.5 D ⫾ 1.0 D ⫾ 1.5 D ⫾ 2.0 D
Double-K methods
ACCPadj and double-K Hoffer Q† 63 79 92 100
SimKadj and double-K Hoffer Q† 63 88 92 96
Historical K and double-K Hoffer Q 46 67 79 83
Single-K methods
Feiz–Mannis method 33* 67 79 83
Modified Feiz–Mannis method 38 71 79 79
Masket method 63 88 92 96
Modified Masket method 54 83 92 96
Latkany method 13* 25* 54* 79*
IOLadjACCP† 67 88 92 96
IOLadjSimK† 63 88 92 96

ACCP3mm ⫽ average central corneal power within the central 3 mm; ACCPadj ⫽ ACCP3mm ⫹ 0.144 ⌬SE ⫺ 0.256;
D ⫽ diopters; IOLadjACCP ⫽ single-K IOLACCP3mm ⫺ 0.35 ⌬SE ⫹ 0.085; IOLadjSimK ⫽ single-K IOLSimK ⫺ 0.359
⌬SE ⫹ 0.092; ⌬SE ⫽ SEpre-LASIK ⫺ SEpost-LASIK; SimK ⫽ simulated keratometric value; SimKadj ⫽ SimK ⫹ 0.165
⌬SE – 0.105.
*Statistical significance compared to ACCPadj or SimKadj and double-K Hoffer Q.
†
Formula derived by regression analysis.

Latkany and Masket methods, a regression method that
bypasses the double-K concept should seemingly rely on
the average central corneal power, not SimK, to be uni-
versally applicable on all topographers; this has been
proven by our results and those of Wang et al on corneal
power estimation.15
Although the original and modified Masket methods use
the Hoffer Q for hyperopic eyes with axial length ⬍23.0
mm, the Latkany method was originally described using
SRK/T. In our comparison, we used the Hoffer Q for all
methods to avoid confounding variables in our comparison
and because of its known performance in eyes with short
axial length. One limitation of our study is that we did not
measure the actual ELP of eyes after phacoemulsification
(calculated as measured ACD added to half the IOL
thickness). Had the actual true ELP been measured, then
the refractive corneal power could have been calculated
using the single-K Hoffer Q and it would have been more
accurate when compared with the values obtained from
using a personalized ACD in the double-K Hoffer Q
formula. Another limitation of our study is that our
sample size of 24 eyes, although relatively large com-
pared with previous studies on posthyperopic LASIK
pseudophakic eyes, is still considered small on a statis-
tical level.
In summary, for accurate IOL calculations after hyper-
opic keratorefractive surgery, we recommend adjusting the
average central corneal power according to the induced
refractive change ⌬SE (ACCPadj ⫽ ACCP3mm ⫹ 0.144
(SEpre-LASIK ⫺ SEpost-LASIK) ⫺ 0.256 [equation 3]) or as
displayed in Table 3, then using the obtained value in the
double-K Hoffer Q formula. This method ensures both
accurate results and potentially reproducible outcomes
among topographers. In the absence of historical data on the
patient’s refractive status, the average central corneal power
can be adjusted as such: ACCP= ⫽ 0.909 ⫻ ACCP3mm ⫹
4.198 (equation 1), then used in the double-K Hoffer Q
formula with pre-LASIK keratometric value assumed to be
43.86. If the average central corneal power is not available,
we recommend adjusting the SimK according to the refrac-
tive change: SimKadj ⫽ SimK ⫹ 0.165 (SEpre-LASIK ⫺
SEpost-LASIK) ⫺ 0.105 (equation 4), and if the refractive
change is also missing, then using SimK= ⫽ 0.917 ⫻ SimK ⫹
4.016 (equation 2) would be appropriate. If the clinician
does not have access to the double-K Hoffer Q formula,
using the average central corneal power or the SimK values
as such in the single-K Hoffer Q formula and adjusting the
final IOL power based on the SE seems to be equally
accurate: IOLadj_ACCP ⫽ IOLACCP3mm ⫺ 0.35 ⌬SE ⫹ 0.085
and IOLadj_SimK ⫽ IOLSimK ⫻ 0.359 ⌬SE ⫹ 0.092 (equa-
tions 5 and 6, respectively). In this scenario, the original
Masket formula seems also to perform very well and can be
used as well (IOL ⫽ IOLSimK ⫺ 0.326 ⫻ [LSE] ⫹ 0.101).
However, it is important to bear in mind that, especially for
regression methods using SimK, prior validation on the
clinician’s topographer is recommended to confirm repro-
ducibility of the suggested formulas. In addition, although
the suggested formulas bypassing the double-K method
(including Masket’s formula) seem simple and accurate, it
would be wise to await reproducibility on a large sample of
eyes before recommending it across the board, because the
accuracy of such method for large values of SE changes has
not yet been tested. The advent of slit-beam videokeratog-
raphy with the ability to measure both the anterior and the
posterior surface of the cornea seems promising in improv-
ing the accuracy of KBC measurement after keratorefractive
surgery. In the meantime, relying on accurate, and most
importantly, reproducible, regression-derived formulas on

399
 Ophthalmology Volume 116, Number 3, March 2009
the placido systems after hyperopic keratorefractive surgery is
key to satisfactory patients’ outcomes.
References
1. Kalski RS, Danjoux JP, Fraenkel GE, et al. Intraocular lens
power calculation for cataract surgery after photorefractive
keratectomy for high myopia. J Refract Surg 1997;13:
362– 6.
2. Holladay JT. Corneal topography using the Holladay Diag-
nostic Summary. J Cataract Refract Surg 1997;23:209 –21.
3. Maeda N, Klyce SD, Smolek MK, McDonald MB. Disparity
between keratometry-style readings and corneal power within
the pupil after refractive surgery for myopia. Cornea 1997;16:
517–24.
4. Seitz B, Langenbucher A. Intraocular lens calculations status
after corneal refractive surgery. Curr Opin Ophthalmol 2000;
11:35– 46.
5. Feiz V, Mannis MJ, Garcia-Ferrer F, et al. Intraocular lens
power calculation after laser in situ keratomileusis for myopia
and hyperopia: a standardized approach. Cornea 2001;20:
792–7.
6. Wang L, Booth MA, Koch DD. Comparison of intraocular
lens power calculation methods in eyes that have undergone
LASIK. Ophthalmology 2004;111:1825–31.
7. Masket S, Masket SE. Simple regression formula for intraoc-
ular lens power adjustment in eyes requiring cataract surgery
after excimer laser photoablation. J Cataract Refract Surg
2006;32:430 – 4.
8. Walter KA, Gagnon MR, Hoopes PC Jr, Dickinson PJ. Accu-
rate intraocular lens power calculation after myopic laser in
situ keratomileusis, bypassing corneal power. J Cataract Re-
fract Surg 2006;32:425–9.
9. Ianchulev T, Salz J, Hoffer K, et al. Intraoperative optical
refractive biometry for intraocular lens power estimation with-
Footnotes and Financial Disclosures
Originally received: January 8, 2008.
Final revision: August 31, 2008.
Accepted: September 25, 2008. Manuscript no. 2008-45.
1 The authors have no proprietary or commercial interest in materials dis-
Department of Ophthalmology, University of Texas Southwestern Med-
ical Center, Dallas, Texas.
2
Department of Ophthalmology, American University of Beirut Medical
Center, Beirut, Lebanon.
Supported in part by an unrestricted grant from Research to Prevent
Blindness, New York, New York.
400
out axial length and keratometry measurements. J Cataract
Refract Surg 2005;31:1530 – 6.
10. Camellin M, Calossi A. A new formula for intraocular lens
power calculation after refractive corneal surgery. J Refract
Surg 2006;22:187–99.
11. Aramberri J. Intraocular lens power calculation after corneal
refractive surgery: double-K method. J Cataract Refract Surg
2003;29:2063– 8.
12. Hamed AM, Wang L, Misra M, Koch DD. A comparative
analysis of five methods of determining the corneal refractive
power in eyes that have undergone myopic laser in situ kera-
tomileusis. Ophthalmology 2002;109:651– 8.
13. Borasio E, Stevens J, Smith GT. Estimation of true corneal
power after keratorefractive surgery in eyes requiring cataract
surgery: BESSt formula. J Cataract Refract Surg 2006;32:
2004 –14.
14. Qazi MA, Cua IY, Roberts CJ, Pepose JS. Determining cor-
neal power using Orbscan II videokeratography for intraocular
lens calculation after excimer laser surgery for myopia. J
Cataract Refract Surg 2007;33:21–30.
15. Wang L, Jackson DW, Koch DD. Methods of estimating
corneal refractive power after hyperopic laser in situ kerato-
mileusis. J Cataract Refract Surg 2002;28:954 – 61.
16. Chokshi AR, Latkany RA, Speaker MG, Yu G. Intraocular
lens calculations after hyperopic refractive surgery. Ophthal-
mology 2007;114:2044 –9.
17. Awwad ST, Dwarakanathan S, Bowman RW, et al. Intraocular
lens power calculation after radial keratotomy: estimating the
refractive corneal power. J Cataract Refract Surg 2007;33:
1045–50.
18. Langenbucher A, Haigis W, Seitz B. Difficult lens power
calculations. Curr Opin Ophthalmol 2004;15:1–9.
19. Hoffer KJ. The Hoffer Q formula: a comparison of theoretic
and regression formulas [published correction appears in J
Cataract Refract Surg 1994;20:677]. J Cataract Refract Surg
1993;19:700 –12.
Financial Disclosure(s):
J.P.M. is a consultant for Alcon Labs, Fort Worth, Texas.
cussed in this article.
Correspondence:
James P. McCulley, MD, Department of Ophthalmology, University of Texas
Southwestern Medical Center at Dallas, 5323 Harry Hines Blvd. Dallas, Texas
75390-9057. E-mail: james.mcculley@utsouthwestern.edu.
 Awwad et al 䡠 IOL Calculations after Hyperopic LASIK
Appendix 1
Double-K modification of the Hoffer Q Formula
Recommended constants:
Refractive index of cornea ⫽ 1.336
Retinal thickness factor ⫽ 0
Measured and extrapolated values:
Kpre-LASIK ⫽ average K-reading before LASIK (D)
Kpost-LASIK ⫽ estimated refractive corneal power after
LASIK (D)
AL ⫽ measured axial length (mm)
Chosen values
V ⫽ vertex distance of pseudophakic spectacles (mm),
default ⫽ 12 mm
pACD ⫽ personalized anterior chamber depth constant
pACD ⫽ 0.58357 ⫻ A constant ⫺ 63.896
Calculated variables
P ⫽ power of the IOL (D)
R ⫽ refractive error at corneal plane (D)
Rx ⫽ target refractive error at spectacle plane (D)
Equations
Equation 1: Anterior chamber depth
ACD ⫽ pACD ⫹ 0.3(AL ⫺ 23.5) ⫹ tan(Kpre-LASIK)2
⫹ (0.1 * M * [23.5 ⫺ AL]2 ⫻ [tan{0.1(G ⫺ AL)2}])
⫺ 0.99166
M: if AL ⱕ 23.00, M ⫽ 1; if AL ⬎ 23 mm, M ⫽ ⫺1
G: if AL ⱕ 23.00, G ⫽ 28.00 mm; if AL ⬎ 23 mm,
G ⫽ 23.5 mm
If AL ⬎ 31, AL ⫽ 31.0; if AL ⬍ 18.5, AL ⫽ 18.5
Equation 2: Refractive error at corneal plane
R ⫽ Rx ⁄ (1 ⫺ 0.012 Rx)
Equation 3: Intraocular lens power
P ⫽ (1336 ⁄ [AL ⫺ ACD ⫺ 0.05])
⫺ (1.336 ⁄ [{1.336 ⁄ (Kpost-LASIK ⫹ R)}
⫺ {(ACD ⫹ 0.05) ⁄ 1000}])
Equation 4: Refractive error
R ⫽ (1.336⁄ [1.336 ⁄ {1336 ⁄(AL ⫺ ACD ⫺ 0.05) ⫺ P}
⫹ {ACD ⫹ 0.05} ⁄ 1000]) ⫺ Kpost-LASIK
Rx ⫽ R ⁄ (1 ⫹ 0.012R)
400.e1