A-Scan Biometry

Author: Rhonda G Waldron, MMSc, COMT, CRA, ROUB, CDOS; Chief Editor:
Timothy Jang, MD more...

http://emedicine.medscape.com/article/1228447-overview

Ultrasound Principles
Sound is defined as a vibratory disturbance within a solid or liquid that travels in a wave
pattern. When the sound frequency is between 20 hertz (Hz) and 20,000 Hz, the sound is
audible to the human ear. To be considered ultrasound, sound waves must have a frequency of
greater than 20,000 Hz (20 KHz), rendering them too high in frequency to be audible to the
human ear.[1] In ophthalmology, most A-scan and B-scan ultrasound probes use a frequency of
approximately 10 million Hz (10 MHz) that is predesigned by the manufacturer. This
extremely high frequency allows for not only restricted depth of penetration of the sound into
the body but also excellent resolution of small structures. This meets unique needs, because,
at times, the probe is placed directly on the organ to be examined, and its structures are quite
small, requiring excellent resolution.
The velocity of sound is determined completely by the density of the medium through which
it passes. Sound travels faster through solids than through liquids, an important principle to
understand because the eye is composed of both. In A-scan biometry, the sound travels
through the solid cornea, the liquid aqueous, the solid lens, the liquid vitreous, the solid
retina, choroid, sclera, and then orbital tissue; therefore, it continually changes velocity.
The known sound velocity through the cornea and the lens (average lens velocity for the
cataract age group, ie, approximately 50-65 y) is 1641 meters/second (m/s), and the velocity
through the aqueous and vitreous is 1532 m/s. The average sound velocity through the phakic
eye is 1550 m/s. The sound velocity through the aphakic eye is 1532 m/s, and the velocity
through the pseudophakic eye is 1532 m/s plus the correction factor for the intraocular lens
(IOL) material.[2] The cornea is not routinely factored in because of its thinness. If one were to
consider 1641 m/s at about 0.5 mm, only 0.04 mm would need to be added to the total eye
length, which in no way alters the IOL calculation.
In A-scan biometry, one thin, parallel sound beam is emitted from the probe tip at its given
frequency of approximately 10 MHz, with an echo bouncing back into the probe tip as the
sound beam strikes each interface. An interface is the junction between any two media of
different densities and velocities, which, in the eye, include the anterior corneal surface, the
aqueous/anterior lens surface, the posterior lens capsule/anterior vitreous, the posterior
vitreous/retinal surface, and the choroid/anterior scleral surface.
The echoes received back into the probe from each of these interfaces are converted by the
biometer to spikes arising from baseline. The greater the difference in the two media at each
interface, the stronger the echo and the higher the spike.[2] If the difference at an interface is
not great, the echo is weak and the displayed spike is short (eg, vitreous floaters, posterior
vitreous detachments). No echoes are produced if the sound travels through media of

identical densities and velocities, eg, young, normal vitreous or the nucleus of a
noncataractous lens, in which the A-scan display goes down to baseline. See the image below.

High quality contact A-scan of the

phakic eye. Note the 5 high-amplitude spikes and the steeply rising retinal spike, as well as
the good resolution of the separate retinal and scleral spikes.
In the case of a cataractous lens, multiple spikes occur within the central lens area as the
sound beam strikes the differing densities within the lens nucleus. This spike height, or
amplitude, is therefore what gives the information on which to base the quality of the
measurements. In fact, the "A" in A-scan is from the word "amplitude."
Spike height is not only affected by the difference in density as it travels through the eye but
also by the angle of incidence, which is determined by the probe orientation to the visual axis.
If the probe is held so that the emitted sound beam strikes the corneal vertex, anterior lens,
posterior lens, and retina in a perpendicular manner, it is in the proper position to receive the
echoes back into the probe tip so they can be converted to spikes. Because sound waves can
be reflected and refracted the same as light rays, if the probe is held in a nonparallel manner,
part of the echo is diverted at an angle away from the probe tip, and, therefore, is not received
by the machine.[2] The greater the angle of incidence, the weaker the signal and the shorter the
spike amplitude. See the image below.

When the sound beam incidence

is parallel and coaxial to the visual axis (upper image), most returning echoes are received
back into the probe tip to be interpreted on the display as high-amplitude spikes. When the
sound beam incidence is oblique to the visual axis (lower image), part of the returning echo is
reflected away from the probe tip, with only a portion received by the probe. As a result, the
spikes will be compromised.
The shape and smoothness of each interface also affects spike quality. An irregularity in the
surface of an interface causes reflection and refraction of the returning sound waves away
from the probe tip and, therefore, weaker echoes.[2] That is why it is important to know
whether macular pathology is present that could adversely affect spike quality. A perfect high,
steeply rising retinal spike may be impossible when macular pathology is present (eg,
macular edema, macular degeneration, epiretinal membranes, posterior staphylomas). See the
image below.

If the macular surface is smooth (upper image)

more of the echoes are received back into the probe to be displayed as high-amplitude spikes.
If the macular surface is convex (center image), as with macular edema or pigment epithelial
detachments, part of the echoes is reflected away from the probe tip. If the macular surface is
irregular (lower image), as in macular degeneration or epiretinal membranes, reflection of the
echoes away from the probe tip also will occur.
In addition, sound is absorbed by everything through which it passes before it travels on to
the next interface. The greater the density of the structure it is passing through, the greater the
amount of absorption. This principle explains why retinal spike quality is reduced in the case
of an extremely dense cataract; the lens absorbs much of the sound and less sound actually
reaches the retinal surface.

Ultrasound Biometry Instrumentation

Ultrasound biometers use a pulse system, pulsing electricity to the probe tip where a crystal
element vibrates and emits the sound beam at its given frequency. Then, a pause of a few
microseconds occurs, so the returning echoes can be received by the probe tip and converted
to spikes on the display.[2]
The gain setting on biometers is measured in decibels and affects amplification and resolution
of the displayed spikes. When on highest gain, the spike height and the sensitivity of the
display screen are maximized, enabling visualization of the weaker signals, but the resolution
is affected adversely. When gain is lowered, the spike amplitude and the display sensitivity
are decreased, which eliminates the weaker signals but improves the resolution.
Resolution is defined as the ability of the machine to display two interfaces that lie in close
proximity, one directly behind the other, as separate echoes or spikes (eg, retinal and scleral
interfaces). When the gain is too high, the retina and sclera appear as one thickened spike
with a wide, flattened peak. The examiner should reduce the gain until the retinal and scleral

surfaces are seen as separate spikes to the right of the display. The density of the cataract
determines the need for changing the gain setting due to absorption of the sound. The more
dense the cataract, the higher the necessary gain. Patients who are aphakic require less gain to
prevent merging of the retinal and scleral spikes. Therefore, the gain setting may vary not
only from patient to patient but from one eye to the next in the same patient, depending on
cataract density.
See the image below.

When the gain setting is too high,

the resolution of the separate retinal and scleral spikes is lost, resulting in 1 thick, flattened
spike.
Gates are electronic calipers on the display screen that measure between two points.[2]
Biometers are designed so that between each pair of gates a measurement is rendered.
Biometers vary in the appearance of these gates, with some units not displaying them at all.
Gates should be readily visible for accurate editing of the scans, because if any one of them is
aligned along an incorrect spike the entire eye length measurement will be erroneous. The
biometer automatically places a gate on what it believes to be the corneal spike, the anterior
lens spike, the posterior lens spike, and the retinal spike, and it is programmed to measure the
distance between each pair of gates at a given velocity.

Gates are electronic calipers on

the display (see arrows) that between each pair render a measurement. In this 4-gate system,
each of the 3 sections of the eye is measured individually at its correct velocity, then added
together for the total eye length. Equipment will vary in the appearance of these gates.
Ultrasound is measured based on how long it takes the sound to travel from one point to the
next at a given velocity. The formula, distance = velocity X time, is programmed into
biometers to calculate the distance between each pair of gates. Then, the formula is divided
by 2 because the sound also must echo back into the probe tip. By selecting the eye type in
the measurement mode (phakic, aphakic, or pseudophakic), the equipment is instructed to use
this distance formula with the proper velocities between each gate pair for that particular eye
type.[2]
For example, in the phakic mode, the machine has been programmed to measure distance
between the first pair of gates using a velocity of 1532 m/s, the velocity through the anterior
chamber. The velocity of 1641 m/s is used between the second and third gates because this is
the velocity through the lens. The velocity of 1532 m/s is once again used in the formula
between the third and fourth gates because this is the velocity through the vitreous cavity. The
most accurate machines measure each of these 3 sections of the eye individually at the proper
sound velocity and then add them together for the total eye length. If any one gate is
incorrectly placed, the machine will calculate the 2 sections involved using the incorrect
velocity and time, which will make the total length erroneous.
Proper gate placement is on the ascending edge of each appropriate spike. If a gate has been
placed incorrectly, move it to the appropriate spike before it is stored and used in the
calculation. Equipment varies greatly in the ability to see and move gates; refer to the manual
for each specific unit to determine if it is possible to move the gates, and, if so, the steps
required to do so. If the biometer does not allow for movement of gates, scans must be
repeated until they automatically align properly.
When the machine is set for phakic average, only 2 gates are present, measuring the total eye
at its average velocity of 1550 m/s. The 2 gates should align along the corneal surface and the
retinal surface, respectively. The disadvantages to this setting are that the anterior chamber
depth and the lens thickness cannot be monitored and that the use of average sound velocity
is simply not as accurate. The average sound velocity of 1550 m/s is only accurate through an

average length eye. In eyes that are shorter or longer than average, this method of measuring
produces an innate error.
When setting the measurement mode to aphakic, 2 gates will be present (on the respective
corneal and retinal surfaces), and the biometer will calculate the distance at a velocity of 1532
m/s, the correct velocity for the aqueous and vitreous.
When setting the measurement mode to pseudophakic, depending on how many
pseudophakic options the equipment possesses, the eye length is calculated using 1532 m/s
for the aqueous and vitreous, then the correction factor for the given implant material is
added. If only one pseudophakic mode option is available, it only will be accurate for
polymethyl methacrylate (PMMA) IOLs.
Routinely using automatic mode on most equipment increases the risk of error because every
biometer will capture poor quality scans. Biometers are programmed to capture any scans
with spikes that are of high amplitude within their given area. However, they often cannot
determine if the spike arose steeply from baseline or if a slope or step is present in the spike
origin. Manual mode is sometimes preferable, in which the examiner presses a foot switch to
capture the scan when it is seen to be of high quality. Equipment varies greatly with some
manufacturers only using a 4-gate system on automatic mode, which means that anterior
chamber depth can be monitored only in automatic mode. If this is the case, automatic mode
is preferable, but the examiner must carefully edit the scans stored by the machine.

Accuracy and Standard Dimensions

It is critical that the examiner use methods that are standard of care in performing biometry. A
0.1 mm error in an average length eye will result in about a 0.25 diopter (D) postoperative
refractive error.[3] Therefore, an error of 0.5 mm will result in approximately 1.25 D refractive
error, and an error of 1.0 mm will result in approximately 2.50 D postoperative refractive
error.
Longer eyes are more forgiving, with a 1.0 mm error in an eye of 30 mm length resulting in a
post-operative error of about 1.75 D. Small eyes are the least forgiving, and even more
postoperative error occurs from inaccurate measurements. For example, an error of 1.0 mm in
an eye that is 22.0 mm long will result in a post-operative error of about 3.75 D. If the error is
in measuring the eye erroneously small, such as is common from corneal compression, the
postoperative refractive error will be in the myopic direction. Conversely, if the examiner
measures the eye erroneously long, which is common when the sound beam is not
perpendicular to the retinal surface, the postoperative refractive error will be in the hyperopic
direction.
A good biometrist must be able to recognize when readings appear abnormal; therefore, one
must first know standard dimensions of the eye. The average axial eye length is 23.5 mm,
with a range of 22.0-24.5 mm.[2] In general, the smaller the eye, the more hyperopic the
refractive error. The longer the eye, the more myopic the refractive error. Of note, a patient
can be myopic because of steep corneal curvature rather than long axial length, and a patient
can be hyperopic because of flat corneal curvature rather than short axial length.

Once the eye length is measured, compare it to the precataract refractive error of the patient
to ensure that the readings appear accurate. The precataract refractive error is important
because the cataractous lens changes can induce a more myopic prescription. The reference
range between the right eye and the left eye of the same patient is within 0.3 mm, unless
evidence suggests the contrary (eg, previous scleral buckling, anisometropia, corneal
transplantation, keratoconus, refractive surgery, hypotony).
The average anterior chamber depth is 3.24 mm but varies greatly.[2] If the biometrist is
documenting a shallow anterior chamber depth, examine the medical chart for clinical
correlation of this finding. The average lens thickness is 4.63 mm but this also varies, and,
with cataractous changes, the lens will increase in thickness to as much as 7.0 mm in
extremely dense cases.
The average keratometry (K) reading is 43.0-44.0 D, with one eye typically within a diopter
of each other. Check these readings against the refractive error of the patient for accuracy. If
one eye is found to differ from the other by more than 1 D, immediately begin researching the
cause and alert the physician. For instance, if the patient had refractive surgery, corneal
transplantation, an injury with a resultant corneal scar, or has keratoconus, the K readings
may vary between the eyes. It is rare for the patient to have disparate K readings biologically.
If any of the above eye measurements is found to be unusual, another technician should
recheck the measurements and immediately alert the physician.
Just as precise keratometry and biometry are critical for good surgical outcomes, correct IOL
placement by the surgeon is essential. A 0.19 D postoperative refractive error occurs for every
0.1 mm posterior chamber intraocular lens (PCIOL) displacement. A 0.12 D postoperative
refractive error occurs for every 0.1 mm anterior chamber intraocular lens (ACIOL)
displacement. Lens displacement can also be caused by the patient's ciliary body pushing the
lens out of position rather than by the surgeon's placement of the lens.
Using the correct IOL calculation formula is important for good surgical outcomes. Current
2-variable formulas that are considered the most accurate include the Hoffer Q, SRK/T, and
Holladay I. Two-variable formulas are those that only take into consideration the axial length
and the corneal curvature. Multivariable formulas have proven to be the most accurate due to
more of the eye anatomy being considered.
The Haigis formula is a 3-variable equation, using not only axial length and corneal curvature
but also the anterior chamber depth of the eye. The Holladay II formula is a 7-variable
equation widely thought to be the most accurate formula; it takes into account axial length,
corneal curvature, horizontal white-to-white, anterior chamber depth, lens thickness,
precataract refractive error, and age of the patient.
Predicting lens position is one of the most common causes of a postoperative surprise; by
taking more of the eye anatomy into account, this can be more accurately predicted. For
average-length eyes with average Ks, these formulas give almost identical calculations.[3]
However, when the eye is small, formula selection is more critical. In eyes that are less than
22 mm in length, the Hoffer Q and the Holladay II IOL Consultant formulas are the most
accurate. For long eyes, the SRK/T and the Holladay II IOL Consultant formulas are the most
accurate.

The Holladay II IOL Consultant formula is also the only formula that calculates for
piggyback IOL procedures (ie, when 2 IOLs are implanted, which may be necessary when the
eye is so small that 1 implant does not contain enough converging power, or when a
piggyback lens is inserted to correct a postoperative surprise that results from the first
implant) and is highly recommended for patients that have had previous refractive surgery.

Contact and Immersion Techniques

Historically, the contact (or applanation method) of biometry was accomplished by gently
placing the probe on the corneal vertex and directing the sound beam through the visual axis.
This handheld method was most easily and accurately performed with the patient in a
reclined position with the patient's head placed in front of the display screen of the biometer.
The examiner was seated on an adjustable stool to the other side of the patient, resting his or
her arm on the patient's shoulder and the side of his or her hand on the patient's cheek. The
patient was instructed to look at a target affixed to the ceiling. Using a gentle on-and-off
technique allowed for less corneal compression since the examiner's hand was braced more
firmly. It was also easier for the patient to brace the head against the headrest in this reclined
position and for the examiner to simultaneously monitor both the display screen and the
patient's fixation.
Because of the indentation of the globe caused by the contact (or applanation method) of
biometry as well as the current patient expectations, this method is being completely
abandoned in favor of more accurate noncontact instrumentation.
The immersion technique of biometry is accomplished by placing a small scleral shell
between the patient's lids, filling it with saline, and immersing the probe into the fluid, being
careful to avoid contact with the cornea. This method is more accurate than the contact
method because corneal compression is avoided.[4] Eyes measured with the immersion
method are, on average, 0.1-0.3 mm longer than when measured by the contact method since
no indentation of the globe occurs.[2, 3] The display screen will exhibit 6 (rather than 5) spikes
in the phakic patient because the probe and the cornea are no longer in contact with each
other, thus appearing separate.
Of note, some machines have the probe spike shifted so far to the left in the immersion mode
that it does not appear on the display screen; therefore, the corneal spike will be seen first.
The correct axial pattern past the probe spike consists of 5 tall spikes that represent the
cornea, the anterior lens, the posterior lens, the retina, and the sclera. Perpendicularity is
achieved when all spikes are of high amplitude and the retinal spike is steeply rising from the
baseline.
Another advantage of the immersion technique is that the corneal spike will have two peaks
corresponding to the epithelium and endothelium. If both of these peaks are not equally high,
the sound beam is not directed through the corneal vertex and, therefore, is not aligned along
the visual axis. Care should be taken to keep the gain low enough to appreciate and resolve
these two peaks. If the gain is set too high, poor resolution of these two interfaces will occur
and the corneal peak will appear wide and flattened.
See the image below.

Immersion scan of the phakic eye.

The probe and cornea are now separate spikes since they are not in contact with each other,
and the corneal spike demonstrates 2 peaks (see arrow), representing the epithelium and
endothelium. If these 2 peaks are not both high, the sound beam is not aligned through the
corneal vertex. Gain must be reduced enough to appreciate and resolve these 2 peaks.
Other advantages of the immersion technique are that it is a faster method than the contact
technique and that it reduces technician dependency. When using the contact technique, axial
lengths will vary on subsequent scans by the same technician, as well as between technicians
depending on the amount of corneal compression. When using the immersion technique, as
long as the spikes are of high quality, the axial lengths will not vary from one scan to the next
or from one biometrist to the next. Any practice that changes from the contact technique to
the immersion technique must repersonalize their IOL constants in their IOL calculations,
since they are achieving true rather than slightly shortened eye length measurements. A study
should be completed of at least 20 eyes with the new technique, the same surgeon, and the
same IOL to determine the correct personalization of the constant.
Another current method for highly accurate axial length measurements does not use
ultrasound at all, but rather optical coherent light. In this method, optical coherent light
passes through the visual axis and reflects back from the retinal pigment epithelium. Because
the light reflects back from a layer deep into the retina, rather than from the internal limiting
membrane as with ultrasound (which all of the formulas used today expect), Dr. Wolfgang
Haigis calibrated the system to immersion biometry during its development. Based on his
comparison of 600 eyes with optical coherence biometry and with immersion, an amount is
subtracted from the measurement to the RPE based on axial length. The result should
coincide to an immersion A-scan to within 0.1 mm if both are good readings; because this is a
noncontact method, its accuracy is superior to contact ultrasound biometry.
However, this method cannot be used in the event of significant media opacity (eg, dense
cataracts or corneal or vitreal opacity) due to absorption of the light, or an inability of the
patient to fixate on the target. For those practices using optical coherence, immersion
ultrasound is necessary for patients who cannot be measured by optical coherence to ensure
the same high level of accuracy. In recent years, optical coherence has tended to measure
long eyes (>25 mm) too long. Although correction equations have been published,[5] care
should be taken because occasionally the measure is not inaccurate. The best way to be

certain the axial length is correct is by verifying with both immersion A-scan and B-scan
biometry.

Biometry Through Various Intraocular Lens Materials

Biometry through an already pseudophakic eye most commonly is performed to compare to
the fellow phakic eye for accuracy. Other reasons to measure the pseudophakic eye include
patients who are scheduled to undergo an IOL exchange or checking an unwanted
postoperative refractive error. Measurement through the pseudophakic eye will result in
multiple reverberation echoes in the vitreous cavity that tend to decrease in amplitude from
left to right. The number and strength of these reverberations is dependent on the IOL
material. Decreasing the gain in the pseudophakic eye is helpful, so that spike amplification
of these artifacts is reduced, reinforcing correct gate placement on the retinal spike.
See the image below.

Reverberation artifacts in the

vitreous cavity resulting from intraocular lens. The left image demonstrates the longer chain
of artifact spikes from polymethyl methacrylate implants. The image on the right
demonstrates the shorter chain of artifact spikes from foldable implants.
To obtain accurate measurements through the pseudophakic eye, knowledge of the implant
material is essential. Most IOLs are currently made of PMMA, acrylic, or silicone. The
velocity of sound through each of these materials is different because of their differing
densities and if measured with the wrong modality can result in significant error. If an eye
with an acrylic IOL is measured on pseudophakic PMMA mode, a 0.2 mm error will occur. If
an eye with some silicone IOLs is measured on PMMA mode, a 1.2 mm error will occur.
The velocity of sound through the pseudophakic eye is 1532 m/s plus the correction factor for
the implant material. The velocity through PMMA is 2718 m/s, through acrylic is 2120 m/s,
and through silicone is 980-1107 m/s, depending on the silicone used.[2] (Because acrylic and
silicone lenses are foldable, they are not as dense as PMMA and, therefore, have a slower
velocity.)
If a biometer only has one pseudophakic setting, it will be accurate for PMMA only because
it was manufactured when PMMA was the only implant material being used, and some
biometers do not have upgrades for the various IOL materials. If this is the case, the way to
achieve accurate measurements is to use the aphakic setting, which uses a sound velocity of
1532 m/s. Then, the examiner should manually add the correction factor for the IOL material
to the results obtained on aphakic mode. The correction factor is +0.4 mm for PMMA, +0.2
mm for acrylic, and -0.4 mm to -0.8 mm for silicone, depending on the silicone velocity.[2]
Therefore, if an eye measured 23.32 mm on aphakic mode and the IOL is made of PMMA,

the correct axial length is 23.72 mm. If the IOL is acrylic, the correct axial length is 23.52
mm. If it is low-velocity silicone, the correct length is 22.52 mm.
When any new implant material is produced, the correction factor can be calculated using the
CT of the IOL and the sound velocity of the material at body temperature (35C), which must
be supplied by the manufacturer. The formula for this calculation is the CT multiplied by 1
minus 1532 divided by the velocity of that material, or CT X (1-1532/vel).[2] For example, if
the IOL has a CT of 0.8 mm, and the sound velocity of the material is found to be 1040 m/s,
then 0.8 X (1-1532/1040) = 0.8 X -0.473 = -0.378. Therefore, the correction factor for this
eye is -0.378 from the length obtained on aphakic setting.
Another problem arises when the implant material is unknown. If the patient has a wallet card
showing the implant used, the manufacturer may need to be called to determine implant
material if the model is unfamiliar to the examiner. If the patient does not have a wallet card,
contact the surgeon's office to determine the implant used. If the patient cannot recall the
surgeon's name, it may be necessary to contact a family member in the case of an IOL
exchange. However, the implant reverberation pattern may prove helpful because PMMA has
a longer chain of reverberation echoes, followed by acrylic and then silicone.

Common Errors and Challenging Situations

A problem should be suspected if a difference between the 2 eyes of more than 0.3 mm is
present or if a difference in consecutive measurements occurs on the same eye of more than
0.1 mm. In these instances, consult the patient's history to see if a medical reason exists for a
difference or macular pathology that could explain the variation on the same eye (eg,
posterior staphyloma).
The most common error in the contact technique is corneal compression. This inevitably
occurs because the eye is pliable and the cornea is indented even with minimal pressure from
the probe tip. The lower the intraocular pressure the softer the eye and the more significant
the corneal compression. Therefore, the amount of compression can vary even with the same
technician. If the contact technique must be used, the anterior chamber depth must be
monitored and the shallower anterior chamber depths deleted even if the spikes appear to be
of high quality. Of course, the immersion method completely avoids corneal compression,
which is why the contact method is becoming obsolete.
See the image below.

Corneal compression is
demonstrated in the A-scan on the right. Note the more shallow anterior chamber depth of
2.63 mm as compared to the scan of the same eye on the left, with an anterior chamber depth
of 3.20 mm, indicating 0.57 mm of corneal compression. Note also that the total eye length is

shortened from 24.60 mm in the scan on the left to 24.18 mm in the scan on the right. This
error would result in an unwanted postoperative refractive error of about -1.25 D.
The second most common error is misalignment, either by not obtaining perpendicularity to
the macular surface or by not directing the sound beam through the visual axis.
Perpendicularity to the macular surface is achieved when the retinal spike and scleral spike
are of high amplitude, and the retinal spike arises steeply from baseline. No sloping of the
retinal spike should be present and no jags, humps, or steps should be present on the
ascending edge of that spike.
See the image below.

Misalignment errors. The A-scan

on the left demonstrates a contact scan with a sloping retinal spike. The A-scan on the right
demonstrates an immersion A-scan with steps in the initial rise of the retinal spike.
If either the posterior or anterior lens spike are not of high amplitude, the sound beam could
be misaligned at an angle through the lens and, therefore, not through the visual axis. The
posterior lens spike may be slightly shorter than the anterior lens spike because the convex
curvature of the posterior lens is steeper than the convex curvature of the anterior lens
surface, allowing for reflection of the echoes away from the probe tip. Also, if a dense
nuclear sclerotic cataract is present, more sound absorption could occur within the lens,
causing the posterior lens spike to be shorter. In these instances, the gain can be increased to
obtain better posterior lens and retinal/scleral spikes.
See the image below.

Misalignment demonstrated by
the decreased amplitude of the posterior lens spike (arrow). When either of the lens spikes is

too short, the sound beam is aligned at an angle through the lens rather than through its
center, and thus not aligned along the visual axis.
Misalignment along the optic nerve is an error that is easily recognized, since the scleral
spike will be absent. The retinal spike will be present and of high amplitude and can even
appear steeply rising, but, if the scleral spike is not as high in amplitude as the retina, the
sound beam is misaligned along the nerve. No sclera is present at the optic nerve; the sound
beam is passing through the nerve cord with only short amplitude echoes present, because the
sound beam is striking blood vessels within the nerve cord. In the normal eye, there will
generally not be a great difference in axial length when aligned along the optic nerve, but, in
cases of a full optic disc, papilledema, or optic disc drusen, this will result in an erroneously
short axial length measurement. In cases of optic nerve cupping, as seen in glaucomatous
eyes, this error results in an erroneously long axial length measurement.
See the image below.

Misalignment along the optic

nerve. Note the missing scleral spike.
Another possible error in the contact method is a fluid meniscus between the probe tip and
the cornea caused from ointment use, methylcellulose in the eye from previous examinations,
or abnormally thick tear film. If either of these is suspected, rinse the eye with sterile saline
prior to biometry.
Extremely dense cataracts can be a challenge because of absorption of the sound beam as it
passes through the lens. A higher gain setting may be necessary to achieve high-amplitude
spikes from the retina and sclera. Improper gate placement also can occur easily, because a
dense cataract produces multiple spikes within the lens. The posterior lens gate may
erroneously align along one of the echoes within the lens nucleus, resulting in an erroneously
thin lens thickness and erroneously long vitreous length, which results in an error in the total
length of the eye. In this case, manually realign the gate to the correct posterior lens spike,
and if the equipment does not allow for manual gate placement, repeat scans until the gates
automatically align properly.
Posterior staphylomas are among the greatest biometry challenges. These occur primarily in
high myopes, where the globes are so elongated and thin that the posterior uvea bulges

outward into the sclera, most commonly in the posterior pole. This causes the macula to be
sloped in configuration, which in turn causes reflection of the sound beam away from the
probe tip and a poor retinal spike. It is impossible to obtain perpendicularity to a macular
surface that is sloped; thus, it is impossible to obtain a proper retinal spike. Also because of
the sloped surface, the measurements will be not only long but extremely variable. Patients
must be alerted that because their eye is misshapen, they have a higher risk of the
postoperative result not being as accurate as a patient with a normally shaped, round globe.
In these cases, a B-scan examination is necessary, with a horizontal macular scan performed
and the axial length measured from the B-scan. The proper B-scan probe position for this
measurement is to have the patient in primary gaze with the B-scan probe face (using a
generous amount of gel-type tear solution) centered on the corneal vertex and the probe
marker aimed nasally. (The probe marker is either a line or a dot on one side of the probe,
near the probe face.)
When this probe position is achieved, the B-scan display will demonstrate the epithelial and
endothelial corneal echoes centered to the left, the posterior lens surface just to the right, and
the optic nerve void just above the center to the far right. The macula will lie centered on the
right, about 4.5 mm below the center of the optic disc. Simply place calipers on the vertex of
the epithelial corneal echo and on the macula to measure the axial length at average sound
velocity of 1550 m/s. Compare this axial length measurement to the various biometry
measurements, and use the measurement that has the most comparable vitreous length in the
IOL calculation, preferably within 0.1 mm.
See the image below.

High myope with a long eye. Note

the poor quality of the retinal spike on the A-scan. The axial length from the anterior corneal
surface to the central macula was measured on the B-scan (left image), and compared to the
variable A-scan measurements. The A-scan that was within 0.1 mm of the B-scan
measurement was used in the intraocular lens calculation.
Optical coherence biometry has been shown to be beneficial in the case of the highly myopic
globe because it measures to the fixation point of the patient and the lack of perpendicularity
is not prohibitive. But again, optical methods are not always usable if the patient has a dense
cataract or other media opacity or the inability to fixate, so ultrasound techniques still need to
be used in these situations.
Known macular retinal detachments are yet another challenging situation. In retina practices,
the physician may decide to remove the cataract while the patient is undergoing retinal
detachment repair and will need accurate IOL calculations. In these cases, the retinal spike
will appear further to the left in the vitreous cavity, depending on the elevation of the macula.
In these instances, the retinal gate should be moved from the detached retina to the next more

posterior spike, since the retina should lie back into this position once repaired. The examiner
should inquire if the surgeon plans to place a scleral buckle around the globe to repair the
detachment, and if so manually add another 0.5-1.0 mm to the total eye length to account for
lengthening of the globe by the buckle postoperatively.

IOL Calculations Following Refractive Surgery

When cataract surgery is performed on a patient who has had a previous refractive procedure,
accurate keratometry readings are not obtainable by standard manual or automated
keratometers. Because myopic refractive procedures flatten the central cornea, keratometer
mires are spread over a larger area and now measure approximately the central 4.5 mm of the
cornea rather than the central 3.0 mm. Therefore, use of standard corneal measurements for
IOL calculations results in hyperopic postoperative refractive errors. Topography also is not
accurate for postrefractive corneal curvature measurements.
While this section is in no way a comprehensive listing of the methods suggested by the
experts for calculating corneal curvature following refractive surgery, the more common
methods will be described.
One of the popular methods for determining corneal curvature after refractive surgery has
been the clinical history method, although it is falling out of favor over time.[3] The data
needed in this method include the spherical equivalent refractive error prior to refractive
surgery, the average keratometry reading prior to the refractive procedure, and the spherical
equivalent refractive error postrefractive procedure. The examiner should use caution not to
use the current refractive error, as the patient may have a myopic shift due to the presence of
the cataract.
The formula for this method for patients who are myopic and undergoing refractive surgery is
as follows: K = Preoperative average K minus the change in manifest reaction prerefractive
and postrefractive surgery. Because any change in refractive error from a refractive procedure
is due to corneal flattening, the change in refractive error from the refractive procedure
subtracted from the average K prior to the procedure is the current central corneal curvature.
For example, if a patient had an average K of 45.75 D and a refractive error of -8.25 D prior
to refractive surgery with a plano postoperative result, that is a change of 8.25 D of corneal
flattening. The K reading to use in the IOL calculation is 37.5 D (ie, 45.75 D - 8.25 D = 37.5
D). The examiner should not be concerned with the resultant low corneal curvatures. As high
myopes, many patients underwent extensive corneal flattening from the refractive procedure.
If the patient underwent hyperopic refractive surgery, the history method can still be used;
however, rather than subtracting the amount of correction, it should be added because the
cornea was in effect steepened rather than flattened by the procedure.
Many experts suggest using a consensus approach for determining corneal curvature after
refractive surgery, rather than one method alone.[6] Online calculators are available to help
with this approach.
Other methods currently being used include the corneal power correction equation by
Shammas.[3] This equation involves measuring the Ks now and then averaging them into one
number. So, the corrected K = 1.14 (average K) - 6.8.

Another method, referred to as the topography method, as published by Wang et al, involves
measuring the eye with topography, multiplying that number by 1.114, and then subtracting
the correction factor of 6.1.
Another is the method from Wake Forest University, sometimes known as the corneal bypass
method. In this method, the original K's prior to the refractive surgery are entered into the
calculation formula along with today's axial length measurement. In order to achieve
emmetropia, however, the refractive target entered into the calculation is the amount of
correction from the refractive surgery. In their study, all patients had better outcomes than
using the standard clinical history method and the implants were calculated to be closer to the
perfect IOL power.[7]
Another method faring well in recent studies is the Masket Formula.[8] This formula involves
an adjustment in the final IOL power rather than an adjustment of the keratometry readings in
the refractive surgery patient. In Dr. Masket's study, keratometry and biometry were
performed with the IOL Master as with standard cataract patients, and then the following
formula was used to adjust the calculated power from those measurements: IOL adjustment =
LSE X (-.326) + 0.101, where LSE = the spherical equivalent of change after laser vision
correction.
If the patient had myopic correction, the LSE should be a negative number, and if hyperopic
correction, a positive number. In other words, if a myopic refractive patient has standard
calculations of +16.0 D, and LSE was 6 D of myopia, -6 X (-0.326) + 0.101 = +2.057, which
should be added to the calculated +16 D for a final IOL power of +18 D. If a patient had
hyperopic refractive surgery and the calculation yielded a power of +22 D, and LSE was 3 D
of hyperopia, +3 X (-0.326) + 0.101 = -0.877, which is added to the calculated implant power
of +22 D, for a final IOL power of +21 D.
An online calculator is recommended for these patients because mathematical errors can
occur. The most popular calculator is from the American Society of Cataract and Refractive
Surgeons. This calculator is constantly maintained and contains the most highly
recommended methods. Multiple methods are embedded with instant results for comparison,
with the user merely inputting the required measurements. The methods used and their results
are divided into 3 columns: Those that require history for both the change in corneal
curvature and refractive change, those that require history for the refractive change only, and
those that require no history at all. The general consensus is that the nonhistorical methods
tend to outperform those that require history. Because records are difficult to obtain in many
cases, this is a tremendous relief. These patients should be forewarned that they have a higher
risk of an imperfect resultbecause of their previous refractive surgery and that another
procedure may be required afterward to get them back to their desired visual acuity. These
procedures could include an IOL exchange, a piggyback lens, or more refractive surgery.

Velocity Conversion
The velocity conversion equation is helpful in many biometric circumstances, including cases
of silicone oil in the vitreous, using an incorrect velocity setting on the biometer or measuring
an eye filled with silicone oil.[2] The equation is as follows:
Velocity (correct)/Velocity (measured) X Apparent Length = True Length

In the event of an incorrect eye type setting, this equation is quite simple to use and will
preclude the need for the patient to return for repeat measurements. For example, an aphakic
eye was measured incorrectly with the phakic average setting. The correct velocity for this
eye is 1532 m/s. The velocity used was 1550 m/s. If the eye length obtained was 24.1 mm on
the phakic average setting, then 1532/1550 X 24.1 = 23.82 mm = true eye length.
For eyes that have silicone oil in the vitreous cavity, this formula is used to determine the true
vitreous length. Silicone oil is used surgically to replace the vitreous in some cases of
recurrent retinal detachment and macular hole. The oil is removed several months later, but
while in the eye, it causes a cataract, often requiring the removal of the cataract at the time of
oil removal. The velocity conversion equation is necessary because the velocity through
silicone oil is only 980 m/s, much slower than the 1532 m/s the biometer uses in determining
vitreous length. Therefore, the biometer measures the vitreous erroneously long, and,
consequently, the total length also is erroneously long. In a 4-gate system with silicone oil,
the ACD and lens thickness are accurate, so they should be subtracted from the total length to
isolate the erroneous apparent vitreous length. Then, the formula used is as follows:
980/1532 X Apparent Vitreous Length = True Vitreous Length
The corrected vitreous length is now added back to the anterior chamber depth and lens
thickness for an accurate total eye length. Biometry is best performed with these patients
sitting upright so the bubble will not separate from the retinal surface, causing a spike to arise
at the back of the bubble, which can be confused easily with the retinal spike. If an aphakic
patient has silicone oil in the eye, it must be determined whether or not the oil is in the
anterior chamber or only the posterior chamber. If the oil is only in the posterior chamber, the
ACD should be subtracted from the total length, the vitreous length corrected using the
velocity conversion equation, then added back to the ACD.
See the image below.

An eye with silicone oil in the vitreous cavity. The

erroneous vitreous length was isolated from the measurements and the velocity conversion
equation used to correct for the sound velocity through silicone oil. The corrected vitreous
length was added back to the anterior chamber depth and lens thickness for a true eye length
measurement.
If the oil reaches anteriorly to the back of the corneal endothelium, the entire eye length
should be corrected using the following equation:
980/1532 X Apparent Eye Length = True Eye Length
If oil is in the vitreous cavity of the pseudophakic patient, the ACD should be subtracted to
isolate the posterior chamber, using the following equation:
980/1532 X Apparent Vitreous Length = True Vitreous Length
Then, add back to the ACD along with the correction factor for the IOL in place.
Some newer ultrasound units have adjustable velocities or silicone filled eye types. In these
cases, the vitreous velocity is simply changed to the appropriate velocity through the silicone
oil, and the measurement is taken while the patient is sitting upright. Also, optical coherence
biometry has been shown to be effective in measuring these eyes, although the cataract must
be mild enough for it to be used and the patient must have the ability to fixate.
If the silicone oil is to be left in the eye permanently, power must be added to account for the
index of refraction of the silicone oil. Consulting the Holladay II IOL Consultant formula for
this calculation is best. Also, a silicone IOL should not be implanted in these eyes, because it
will adhere to the silicone oil.