This document discusses advancements in eye exams and intraocular lens (IOL) calculations to improve refractive outcomes after cataract surgery. It notes that premium IOLs like toric and multifocal lenses require the most accurate calculations. New technologies allow measuring additional parameters beyond corneal curvature and axial length, like anterior chamber depth and lens thickness, which provide a more customized lens power. Specifically, swept-source optical biometry and anterior segment OCT can evaluate lens position, tilt, and decentration pre-operatively to predict IOL positioning and refine the calculation. Considering these new parameters and technologies helps optimize outcomes for premium lens options and cataract patients' high expectations.

1. By A. Martinenghi
Eye exams evolutions for a better refractive
outcome after cataract surgery
PREMIUM CATARACT SURGERY

2. By A. Martinenghi
 Premium IOL: Monofocal Toric, multifocal e multifocal toric.
 Every IOL induce an optical aberration that is within the optical plate.
 Implanting Premium IOL is not only a defocus issue.
 That's why the needs to an finest IOL calculation.
PREMIUM IOL

3. By A. Martinenghi
 It was a revolution pass from the contact to the optical biometer.
 The opportunity to have in less time more values than only Ks and Axls give
us parameters to fit in advance Iol formula.
 New parameters lead to a new formulas and finest refractive outcome.
BIOMETRY

4. By A. Martinenghi
 Ks and Axls are the pillars in the Iol formulas.
 We understood that ACD (anterior chamber depth) and LT (lens thickness) are
important to enstabilish the Iol positioning after the surgery (ELP).
 Same Ks and Axl not corresponding at the same Iol power if the ACD and the LT
are different.
 So why the needs for new parameters.
Pillars

5. By A. Martinenghi
SAME VALUES EXCEPT LT…

6. By A. Martinenghi
 Corneal Ks
 Axial lenght
 Topography
 Pachimetry
 ACD
PARAMETERS
 LT
 Vitreous depht
 WTW
 Pupillometry

7. By A. Martinenghi
Which is the finest?
 Javal
 6 o 18 telecentric dot
 Topography
 Scheimpflug Camera
or anterior segment
OCT
CORNEAL Ks/ TOPOGRAPHY

8. By A. Martinenghi
In normal curvatures they
have same values.
The problem is in corneal
irregulaties:
 Asymmetric astigmatism
 Keratoconus
 Decentered corneal
laser surgery
 Dry eye
CORNEAL Ks/ TOPOGRAPHY

9. By A. Martinenghi
We do not forget that the corneal power is the 2/3 of the
total refractive eye power that is directly involved in the
calculation of the last 1/3 power.
We have to pay attention on that.
The real topography is, without any doubt, the best data
to make an accurate Premium IOL calculation.
CORNEAL Ks/ TOPOGRAPHY

10. By A. Martinenghi
The second pillar is the Axial lenght.
Before the 1999 the ophthalmologist were using the contact
ultrasound biometer after that with the optical one their lifes
became easier. Less time for the exam with better accuracy.
Now the Swept source technology has the benefit to pass
throught the worst cataract instead the previous technology.
AXIAL LENGHT

11. By A. Martinenghi
New needs for IOL calc means discovering new
parameters.
ACD is one of the more important value for that.
Know how far from the cornea the IOL is going to be is
an important "fine tuning" to determine the IOL power.
Another important parameter is the...
ACD: Anterior Chamber Depth

12. By A. Martinenghi
Evey eye has a different LT (Lens Thickness).
After the cataract removal the IOL fit into the capsular bag.
The real IOL distance from the cornea (ELP) is not only the ACD but
is the ACD + (somewhere in the LT).
That means that the LT is an important value to determine the IOL
power.
ELP: Effective Lens Position

13. By A. Martinenghi
A view on the parameters:
 Ks: most accurate with the Placido rings
 AXL: is a plus having an instrument that is able to pass
through opacity (swept source technology)
 ACD: good for ELP
 LT: fine tuning for the ELP with the newest formula (Olsen,
Kane Formula, etc.)
 WTW: good for the formul to understand how big is the
bulb eye
 Latest formulas: Barrett, Olsen, etc.
 That is the SWEPT SOURCE OA-2000 TOMEY
TOMEY OA-2000

14. By A. Martinenghi
These are some of the formulas that we can use:
• SRK T; Holladay 1; Hoffer Q
• Haigis
• Barrett II universal
• Olsen
• Evo
• RBF Hill
• Kane
But we saw that the last important value that must be
considered is the ELP and we will see not only for the
IOL power.
How would be in the capsular bag the IOL?
BIOMETRIC FORMULAS

15. By A. Martinenghi
Formula Axlen K ACD Lens Other
Fyodorov - X - - -
Binkhorst X - - -
SRK/T X X - - -
Hoffer Q X X - - -
Holladay I X X - -
Holladay II X X X X X
Haigis X - X - -
Olsen
(not ‘thin lens’)
- - X X -
HOW IS EXPECTED THE ELP?

16. By A. Martinenghi
More accuracy, more values and latest formula helps to do
not have refractive bad outcome.
Know the ELP is not enough.
Know how the IOL will be positioned in the capsular bag is
important to expect the quality of vision, because we are
talking about premium cataract surgery.
At the moment the Suite OA-2000/OCT Casia2 is the best
option.
SO?

17. By A. Martinenghi
ELP: Effective Lens Position
Seeing before surgery how is the capsular bag helps.
Expecting how would be in the capsular bag the IOL will help us
on the IOL choice .
Know the equator diameter, the LT, the tilting between the visual
axis and the optical lens and the decenter may became really
important.
ELP E OCT

18. By A. Martinenghi
Casia2 can overlap the lens
pic (before surgery) with the
IOL pic (after the surgery).
We will see that the lens
parameters will be mostly
tha same of the IOL after
surgery, in normal
conditions.
That would be an important
assurance for the IOL
evaluation.
ELP: Effective Lens Position

19. By A. Martinenghi
ELP
ELP Effective Lens Position
Per essere più accurati nella scelte del tipo di IOL da
impiantare avere un OCT Swept source del segmento
anteriore aiuta.
Visualizzare alcuni dati utili che da solo un biometro ottico
non può dare ci orienta sul tipo di lente più adatta su cui
orientarci.
Misurare la lunghezza, il diametro, il tilting e la distanza del
centro ottico del cristallino rispetto all’asse visivo sono
oggetto di studio da parte di molti per predire oltre che un
ottimo risultato refrattivo anche una ottima qualità della
visione.

20. By A. Martinenghi
The IOL will keeps the tilting and decentartion of the natural lens.
The decentration is taken at the IOL plane (that would be the capsular bag
equator) and the tilting is taken between the optical axis IOL plane and the visual
axis.
That should be most accurate that an angle K or α for taking care about premium
IOLs parameters.
The optic axis plate must be more coaxial possible at the visual axis for a better
visual otucome.
ELP: Effective Lens Position

21. By A. Martinenghi
A IOL tilting means a toroid effect associated with a Coma aberration.
In a toric multifocal choice that must be something to take care about for a
residual toric error and/or a good quality of vision.
TILTING
As tigmatis m induc ed by intrao cular lens tilt e valuated via ray tracing
Weikert, Mitchell P. MD*; Golla, Abhinav MS, MPH; Wang, Li MD, PhD
Author Information
Journal of Cataract & Refractive Surgery: June 2018 - Volume 44 - Issue 6 - p 745-749

22. By A. Martinenghi
LENS ANALYSIS

23. By A. Martinenghi
 The IOL is not toric
 Good decent. value
 High tilting
 On the next slide we will
see the tilting effect in a
non-toric IOL
TILTING – CASE 1

24. By A. Martinenghi
 Internal
astigmatism (due
to the IOL)
 Along the tilting
line
 On the total OPD
we see also an
important Coma
TILTING – CASE 1

25. By A. Martinenghi
 Even the internal
COma is mostly on
the tilting line
 Even if the patient
has an Hyper prk
decentered treatment
the total Coma is..
 On the internal line
TILTING – CASE 1

26. By A. Martinenghi
 The IOL is not toric and internally
we have a cylinder.
 That must be taken care in an
evaluation on a Premium
cataract surgery
 The quality of vision is a must in
Premium cataract surgery
these parameters help you to
have the best outcome possible.
TILTING – CASE 1

27. CASE 2 – Hyper. Patient 47 aa + IOL SIMFONY

28. Pz. Ipermetrope OS
Tilting 7.6° - Decentr. 0.43mm
EDOF 29
Pz. Ipermetrope OD
Tilting 5.3° - Decentr. 0.23mm
EDOF 28
CASE 2 - Hyper. Patient 47 aa + IOL SIMFONY

29. OD EDOF 28 OS EDOF 29
CASE 2 – Hyper. patient 47 aa + IOL SIMFONY

30. EDOF 28
VISUS NATURALE10/10
NO SIDE EFFECTS
EDOF 29
VISUS NATURALE 9/10
NIGHT HALOS
OD OS
CASO 2 – Hyper. patient 47 aa + IOL SIMFONY

31. By A. Martinenghi
The Casia2 in the post
analyis measure the
IOL meridians.
That means we are
able to check the
effective implant of a
toric IOL with the pre-
op. planning
Rs = Steep Axis
Rf = Flat Axis
IOL ANALYSIS

32. By A. Martinenghi
 Toric IOL
 Well centered
 Low tilting
 Toric optic implant
at 176°
 Total toric value taking
care the tilting is 176°
 That because a low
tilting value
CASE 3 IOL ANALYSIS

33. By A. Martinenghi
 Same patient left eye
 Decent of 380µm
 Tilting of 5.2°
 Toric IOL implant at 6°
(planned to be at 7°)
 Total IOL toric value with
tilting at 12°
 5° difference with the
planned even if is almost a
perfect IOL orientation
CASE 3 IOL ANALYSIS

34. By A. Martinenghi
That make us thinking about the
influence of the Lens tilting and
decentration before surgery on
the refractive and quality of vision
outcome.
Something new to evaluate,
something that has not to scare
but has to give us the options for
a better IOL choice.
Premium surgeries with Premium
IOL deserve Premium diagnosis
to give us the options for a better
IOL choice.
IOL ANALYSIS

35. By A. Martinenghi
AT THE END
To be continued…...
We see how is evolved the technology in order to be more accurate on
the IOL calculations.
More parameters means a different approach and a better accuracy on
the refractive outcome.
Using Premium IOL means high expectations from the patient, having
new technology helps.
Helps to make the right choice or at list give us the best option for the
patient, and helps to understand the reason of a visual outcome.
These are my first experiences during the demo with a diagnostic
station like the suite Tomey for the anterior segment.
Different analysis will come on the next PPT