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Accuracy of biometry in pediatric cataract

extraction with primary intraocular lens
Daniel B. Moore, MD, Itay Ben Zion, MD, Daniel E. Neely, MD, David A. Plager, MD,
Susan Ofner, MS, Derek T. Sprunger, MD, Gavin J. Roberts, MD

PURPOSE: To determine the accuracy of predicted postoperative refractive outcomes in pediatric

patients having cataract surgery with intraocular lens (IOL) implantation and to compare them
with other variables historically considered important in cataract surgery.
SETTING: Tertiary care referral hospital.
METHODS: This retrospective review comprised 203 eyes of 153 consecutive pediatric patients
(%18 years old) having cataract extraction with primary posterior chamber IOL implantation in
the capsular bag. All cases were performed by 1 of 2 surgeons, and all refractions were performed
manually by an experienced pediatric ophthalmologist using a retinoscope.
RESULTS: In all patients, the mean absolute value (MAE) of the prediction error was 1.08 diopters
(D) G 0.93 (SD). Age at time of surgery and corneal (K) mean curvature were significantly correlated with the absolute value of the prediction error (P Z .0006 and P Z .0088, respectively). A
multiple regression model showed that age at time of surgery and K mean curvature were the
only 2 variables significantly associated with MAE; axial length, formula, surgeon, and A-scan
type were not significantly associated with prediction error.
CONCLUSIONS: Data from 203 consecutive primary pediatric IOL implantations showed the heterogeneous nature of the variables involved in predictions of refractive outcomes in this population.
The complexities of this issue support the need for specific methods of measurement and an
IOL calculation formula for the pediatric population.
J Cataract Refract Surg 2008; 34:19401947 Q 2008 ASCRS and ESCRS

Cataract extraction has become the most common pediatric intraocular surgery performed in the United
States. Recent advances in instrumentation and technique have led to a significant decrease in complication
rates, resulting in a greater emphasis on refractive

Accepted for publication July 11, 2008.

From the Indiana University School of Medicine, Riley Hospital for
Children, Indianapolis, Indiana, USA.
No author has a financial or proprietary interest in any material or
method mentioned.
Supported by an unrestricted grant from Research to Prevent Blindness, New York, New York, USA.
Corresponding author: Daniel E. Neely, MD, Indiana University
School of Medicine, Department of Ophthalmology, 702 Rotary Circle, Indianapolis, Indiana 46202, USA. E-mail:


Q 2008 ASCRS and ESCRS

Published by Elsevier Inc.

outcomes.1,2 This has also resulted in widespread implantation of a posterior chamber intraocular lens
(IOL) in the capsular bag at the time of initial cataract
extraction,3,4 a procedure with low rates of complications such as pupil capture, fibrinous uveitis, and capsule fibrosis.2,46 The trend of expanded IOL use has
been observed in all pediatric ages; however, the most
significant increases are in the very youngest children.
A 2001 survey of members of the American Association
for Pediatric Ophthalmology and Strabismus and the
American Society of Cataract and Refractive Surgery1
indicate a 13-fold increase in the number of respondents
implanting IOLs in children 2 years of age and younger
over an 8-year period between 1993 and 2001.
Implantation of IOLs in children involves several
unique challenges not present in adult cataract surgery.
Childrens eyes continue to undergo significant growth
and change during postoperative years, resulting in refractive changes that complicate the prediction of
0886-3350/08/$dsee front matter


postoperative refraction and IOL power.79 Most surgeons thus aim for an age-dependent degree of postoperative hyperopia to allow for myopic shift as the eye
grows.6,1012 Furthermore, pediatric cataract surgery
is usually performed under general anesthesia and frequently requires axial length (AL) and keratometry
measurements in eyes that cannot fixate or centrate.10
Finally, available IOL calculation formulas are designed for adult eyes and may not be accurate in younger patients, who have steeper, narrower corneas,
shorter ALs, and shallower anterior chambers.13,14
This study was designed to determine the accuracy
of postoperative predicted refractive outcomes in pediatric patients having cataract surgery with primary
placement of an IOL in the posterior capsular bag.
Comparisons were made with other variables historically considered important in cataract surgery to determine whether any of them significantly correlate
to predictions of refractive outcomes. These data are
intended to aid surgeons in their predictions of desired
power of an IOL during pediatric cataract surgery.


This retrospective review comprised all pediatric patients
(%18 years of age) having cataract extraction with primary
IOL implantation in the capsular bag at a single academic
center during an 8-year period (June 1998 to October 2006).
All cases were performed by 1 of 2 surgeons (D.A.P.,
D.E.N.) at the Indiana University School of Medicine, Riley
Hospital for Children, Indianapolis, Indiana.
Keratometry readings were generally obtained intraoperatively under general anesthesia with the patient supine; the
KM 500 handheld keratometer (Nidek) was used in all patients. Axial length measurements were also typically performed intraoperatively using a standard applanation or
immersion technique. From June 1998 to May 2004, 138
eyes were measured using the contact Compuscan LT
A-scan US (Storz Instruments). From June 2004 to October
2006, 65 eyes were measured using an immersion technique
with the OTI Scan 1000 (Ophthalmology Technologies).
Intraocular lens calculations were performed using the
SRK II, SRK T, or Holladay 1 formula at the surgeons
The standard surgical technique has been described.15 In
brief, all patients had cataract extraction using similar techniques depending on age at the time of surgery. Younger
patients (generally those !2 years of age) received a vitrector-type anterior capsulotomy of 5.0 mm, whereas older
children had a traditional continuous curvilinear teartype
anterior capsulorhexis using a cystotome needle and a capsular forceps under an ophthalmic viscosurgical device (OVD).
After thorough cortical and nuclear lens material removal,
the capsular bag was filled with OVD and a folded 5.5 or
6.0 mm optic acrylic IOL (AcrySof MA30BA, MA60AC,
SA30AL, or SA60AT, Alcon Laboratories) was implanted
in the bag by an injection or manual-folding technique. After
OVD removal, the incision was closed with a 10-0 absorbable
suture. In younger children, a primary posterior capsulotomy and limited anterior vitrectomy were performed via


a pars plana incision. The posterior capsulotomy size was

approximately equal to that of the anterior capsulotomy.

Data Collection
The patients date of birth, sex, date of surgery, type of cataract, affected eye, keratometry readings, AL, and corneal diameter were recorded. Target refraction was age dependent;
younger children were generally targeted for a higher
amount of residual hyperopia.
Outcome data were collected 4 to 8 weeks postoperatively
after the corneal suture had dissolved and a stable refraction
was obtained. All refractions were performed manually using the retinoscope by an experienced pediatric ophthalmologist. The spherical equivalent of the residual refractive error
was recorded in diopters (D). Prediction error (PE) for each
surgery was calculated as follows: PE (D) Z predicted postoperative refraction (D) actual postoperative refraction (D).

Statistical Analysis
Variables were summarized by the number of observations, mean and standard deviation, minimum, median,
and maximum. The Pearson correlation coefficient was
used to assess the strength of correlation between the absolute value of the prediction error and continuous measurements. The absolute value of the prediction error was
modeled using a mixed model with terms for age at time
of surgery, keratometry (K) mean, AL, formula used, surgeon, A-scan type, and random effect for patient. The random patient effect incorporates into the model the
correlation of repeated measurements from the same patient.
Residual plots were examined for possible violation of model
assumptions of normality and homogeneity of variance for
error terms.
Separate analyses for groups defined by age at the time of
surgery (%2 years, O2 years) were also performed. For each
age group, the absolute value of the prediction error was
modeled by a repeated-measures analysis of covariance
model. Terms in the model included K mean, AL, and
A-scan type.
An additional analysis of subgroups defined by AL was
conducted. Shorter length was defined as 20.0 mm or less,
normal length as 20.0 to 23.0 mm, and longer length as
greater than 23.0 mm. For each AL group, the absolute value
of the prediction error was modeled by a repeated-measures
analysis of covariance model. Terms in this model included
K mean, age at the time of surgery, and A-scan type.

Two hundred three eyes of 160 sequential patients between the ages of 18 days and 18 years were identified
in the study. Table 1 shows the patients characteristics. The mean absolute value of the prediction error
(MAE) was 1.08 D G 0.93 (SD) (Table 2), indicating
that this representative pediatric patient had roughly
a 1.00 D difference in actual versus predicted postoperative refraction (Figure 1).
Correlation of the continuous variables with the
absolute value of the prediction error resulted in 2
significant variables: age at time of surgery (r Z
0.24, P Z .0006) and corneal curvature (K mean)




Table 1. Patient characteristics (N Z 203 eyes).



Eye, n (%)
Sex, n (%)
Mean age (y) at surgery G SD
Mean AL (mm) G SD
Mean corneal diameter (mm) G SD
Surgeon, n (%)
IOL formula, n (%)
Holladay 1
A-scan, n (%)

108 (53.2)
95 (46.8)
113 (55.6)
90 (44.4)
5.52 G 4.19
21.54 G 2.19
11.34 G 0.71
128 (63.0)
75 (37.0)
85 (41.9)
92 (45.3)
26 (12.9)
138 (68.0)
65 (32.0)

AL Z axial length; IOL Z intraocular lens

Figure 1. Predicted postoperative refraction versus actual postoperative refraction.

showed a significant association between the absolute

value of the prediction error and age at surgery in patients with an AL greater than 20.0 mm and less than
23.0 mm (P Z .0207).

(r Z 0.18, P Z .0088). Using the multiple regression

model, age at time of surgery and K mean were the
only 2 variables significantly associated with MAE
(Figures 2 and 3); AL, IOL calculation formula, surgeon, and A-scan type were not significantly associated with prediction error outcomes (Table 3). The
Holladay 1 formula was used in 26 eyes, the SRK II formula in 85 eyes, and the SRK/T formula in 92 eyes.
The mean age at surgery was 5.3 G 3.6 years in the
Holliday 1 group, 5.2 G 4.1 years in the SRK II group,
and 5.9 G 4.5 years in the SRK/T group. The mean AL
was 22.2 G 2.1 mm, 21.1 G 2.0 mm, and 21.7 G 2.3
mm, respectively. Subgroup analyses (Table 4)

Refractive changes with age in normal phakic children

are influenced by 3 variables that ideally change in
concert to maintain emmetropia; the variables are
AL, corneal curvature, and lens growth. Axial length
rapidly increases during the first 2 years and continues
to grow at a declining rate until stabilization near age
10 years.16 Corneal curvature, however, tends to stabilize near the end of the first year of life,17 while lens
growth continues throughout childhood.7
Changing 1 of these variables in the developing eye,
for example removing the lens during pediatric cataract extraction, will likely alter normative refractive

Table 2. Overall summary of continuous variables (N Z 203).


Mean SD

Predicted postop
2.44 2.54
refraction (D)
Actual postop
2.44 2.84
refraction (D)
Prediction error
0.05 1.42
of refractive outcome (D)
Absolute value
1.08 0.93
of prediction error (D)
Age at surgery (y)
5.52 4.19
K mean (D)
44.53 1.99
Axial length (mm)
21.54 2.19
K Z keratometry


Median Max















Figure 2. Mean absolute value of the prediction error by age at time
of surgery.




Table 4. Subgroup multiple regression models for MAE.


Figure 3. Mean absolute value of the prediction error by K mean

(corneal curvature).

changes. A logarithmic decline in hyperopia (myopic

shift) with age has been established in aphakic children,18 and although it has been suggested that IOL
implantation may alter axial elongation,11,19,20 a similar logarithmic regression curve has been observed in
pseudophakic pediatric patients.7,9 Unfortunately,
the development of age-related regression curves has
not yielded precise individual refractive change predictions due to significant variability in the pediatric
population, with younger age groups having the
most unpredictable refractive changes.7,9
These theoretical impediments are further complicated by several technical considerations in pediatric
patients. Equipment used for AL and keratometry
measurements are intended and calibrated for adult
patients, who are generally awake and seated for the
ultrasound; most pediatric cataract surgery and AL

Table 3. Multiple regression model for MAE.

Age at surgery
K mean
Axial length
Formula used (SRK/T
is reference)
Holladay 1
Surgeon (D.A.P.
is reference)
A-scan type
(contact is reference)
K Z keratometry


Standard Error

P Value













%2 y (n Z 43)
K mean
Axial length
A-scan type (contact
is reference)
O2 y (n Z 160)
K mean
Axial length
A-scan type (contact
is reference)
Axial length
%20.0 mm (n Z 41)
K mean
Age at surgery
A-scan type (contact
is reference)
O20.0 to %23.0 mm
(n Z 114)
K mean
Age at surgery
A-scan type (contact
is reference)
O23.0 mm (n Z 48)
K mean
Age at surgery
A-scan type (contact
is reference)


































measurements are performed under general anesthesia.10 Furthermore, IOL calculations are not designed
for children, who have steeper narrower corneas,
shorter ALs, and shallower anterior chambers.13,14
Finally, the myopic shift and desired residual postoperative hyperopia in pediatric cataract patients are not
adequately predicted by commonly used IOL calculation formulas.15,21
Clearly, significant inherent and technical difficulties deter accurate calculations of appropriate IOL
power and desired postoperative refraction during
pediatric cataract surgery. This study was intended
to determine the accuracy of postoperative predicted




refractive outcomes in pediatric patients having cataract surgery with primary placement of an IOL. Comparisons were made with the IOL formula used, age at
the time of surgery, K mean, A-scan biometry technique, AL, and surgeon.

patients experience refractive outcomes greater than

2.00 D from the predicted result.29,30 Some have even
suggested the standard of care for adults should be
a rate of 99.9% of postoperative refractions within
G2.00 D of the predicted refraction.31,32
Intraocular Lens Calculation Formula

Prediction Error of Refractive Outcome

The MAE in this study, 1.08 D, compares with findings in previous studies in its considerable difference
from that expected in adult populations. Tromans
et al.22 report an MAE of 1.40 D in a study of 52 pediatric eyes in patients aged 1.0 month to 15.5 years.
Another study by Andreo et al.23 of 47 pediatric eyes
from age 2 months to 16 years found an MAE ranging from 1.21 to 1.40 D. Similarly, Neely et al.15 observed an MAE of 1.16 D in 101 eyes of patients
between the ages of 22 days and 18 years; some of
these same patients are included in the present study.
A study by Mezer et al.24 of IOL implantation in 206
eyes in patients aged 2 to 17 years old found an MAE
between 1.06 D and 1.22 D at a 2- to 3-month followup and 1.35 D and 1.79 D at a 2- to 6-month followup. A recent study by Ashworth et al.25 reported an
MAE of 1.63 D in 33 eyes of patients younger than
12 months of age.
There are several possible reasons for the error observed in predicted refraction. Holladay26 showed
the effects of axial displacement if the effective IOL position of stronger IOLs is not accurate. Pediatric IOL
power is usually high due to the shorter length of
young eyes, which necessitates precise predictions of
axial position of the IOL. However, as stated, axial position is currently determined by assumptions of anterior chamber depth (ACD) and vaulting characteristics
of an IOL in the bag that are obtained from studies of
adult population. These data likely do not account for
the shallower anterior chamber in pediatric eyes or
postoperative dynamics of vitreous pressure, haptic
angulation, posterior capsule contraction, and the occasional proliferation of retained lens material that occurs in pediatric cataract surgery.26
The desired residual hyperopia required to compensate for myopic shift in pediatric patients further
complicates predicted refraction. Studies of IOL implantation in adults with eyes shorter than 22.0 mm
do not show the predictive variability found in pediatric eyes of similar size, which may reflect the influence
of refractive goals of up to C10.00 D residual hyperopia along with other factors unique to pediatric
eyes.27 It has been postulated that results of the IOL
power formulas would be significantly different if
desired postoperative refractions were closer to emmetropia, as they would be in adults.28 Indeed, it is
generally accepted that less than 5% of adult cataract

Controversy about the reliability of different IOL

power formulas in the pediatric population remains,
with some studies supporting differences in power
prediction between the formulas21,33 and others unable to find significance.15,23,24 The current study
found no significant association between the IOL formulas used (SRK II, SRK/T, and Holladay 1) and the
refractive prediction error (P Z .9341). In our study,
there was no randomization for which formula was
used; rather, the decision depended on surgeon preference. However, what formula to use and when remains conjecture and without standard guidelines
for IOL power prediction formulas in children, this
topic requires further study.
In an attempt to improve refractive outcomes in
unusual eyes, such as those of pediatric patients,
Holladay26 proposed the following 7 useful preoperative variables to better predict the effectiveness of
IOL position: AL, corneal power, horizontal corneal
diameter, phakic ACD, phakic lens thickness, preoperative refraction, and patient age. He incorporated
these factors into a new IOL calculation formula,
Holladay 2, available as part of a proprietary software package, the Holladay IOL Consultant (Holladay Consulting, Inc.). Recent reports indicate it is
as accurate as other commonly used formulas in
adult patients34 and may have increased accuracy
and decreased variability in extremely short
eyes.35,36 Prospective studies of pediatric patients
are needed to fully appreciate any significance in
this formula; however, the innovative approach to
IOL calculation is an appropriate measure to counter
some issues in pediatric IOL implantation.
Age at Time of Surgery
This study found age at time of surgery to be significantly and inversely correlated with MAE
(P!.0006); the MAE increased as age decreased,
showing the known difficulty in accurately obtaining
the desired postoperative refraction in younger infants. The inverse relationship between age at surgery and refractive accuracy is important because
modern techniques and instruments have generated
the ability to successfully implant IOLs in younger
and younger children, including infants. Previous
studies indicate greater variability in IOL calculation
errors in younger patients15,22; however, a series by



Ashworth et al.25 determined that age at the time of

surgery was not influential in IOL power accuracy
calculations or in myopic shifts in children younger
than 12 months.
When the patients were subdivided into age
groups of less than and greater than 2 years, no significant associations were found with the other studied variables. The decision to use 2 years as the age
of stratification was made because most ocular
growth occurs during the first 2 years of life. Furthermore, a study by Neely et al.15 found that 81% of
children older than 2 years at the time of surgery
had a refractive result that was G2.0 D compared
with 61% of patients 2 years and younger. Our results indicate that MAE varies inversely with age;
however, when we separated patients into discrete
groups of younger and older than 2 years of age,
we found no correlation with the observed variables
and the prediction error.
This finding points to the need for further investigation to determine the earliest appropriate age to consider IOL implantation in young children. In the face
of the highly dynamic ocular changes in growing
children, more data are needed to determine how
age at the time of surgery should influence IOL calculations. The Infant Aphakia Treatment Study is doing
ongoing research of infants 7 months or younger with
unilateral cataract to determine whether IOL implantation is better than surgical aphakia and refractive
correction with a contact lens. Although the highly
anticipated results will aid ophthalmologists in postsurgical management decisions, more studies are
needed to provide accurate age-specific IOL calculation formulas for younger patients.
Mean Keratometry
The other significant factor correlated with refractive prediction error in this study was K mean
(P!.0088), which seems reasonable because steeper
corneas are associated with a higher MAE. Gordon
and Donzis16 have demonstrated the mean K value
is 51.2 G 1.1 D in normal newborns, 45.2 G 1.3 D
in 0 to 1 year olds, 44.9 G 0.9 D in 1 to 2 year
olds, and 44.1 G 0.3 D in the 2 to 3 year olds. Although K values are an important variable in IOL
power formulas and have been shown to vary in pediatric eyes and decrease with age,21 the clinical
significance of this finding is limited. As stated, K
measurements are standardized for adult patients
who are awake and able to fixate while seated. Without known documentation on the reliability of readings on sedated pediatric patients in the supine
position, the accuracy and practical application of
this result are unknown.


A-Scan Biometry
We also found immersion A-scan biometry to be
slightly more accurate than contact biometry in relation to MAE, although the difference did not reach statistical significance (P Z .7794). This is the only known
comparison of the 2 techniques in pediatric patients
and contrasts with most studies in adults, which
show significantly increased accuracy of the immersion A-scan in terms of the targeted postoperative refraction.3739 The decreased accuracy of the contact
technique has been attributed to inadvertent indentation of the cornea by the ultrasound probe, thus shortening the actual AL.38 The supine and sedated state of
patients measured in our study is a limitation; nonetheless, the data support the multifaceted differences
between adult and pediatric cataract surgery.
Axial Length
Axial length was not found to be significantly associated with prediction error, which is consistent with
results in a previous study of infants younger than
12 months.25 However, Tromans et al.22 found prediction error to be significantly greater in eyes with an AL
less than 20.0 mm. A recent study by Trivedi and Wilson40 reported that eyes with an AL than shorter than
that in the fellow eye had a postoperative rate of axial
growth exceeding the growth rate in the eye with the
longer AL, resulting in a trend toward AL differences
toward zero. These results were independent of age at
time of surgery and, taken as a whole, suggest that differences in AL equilibrate over time.
We subdivided ALs into short, normal, and long
lengths (Table 4) to further define significant comparisons. However, the only association was between prediction error and age at time of surgery in patients
with a normal AL (O20.0 mm and %23.0 mm). Because younger age is largely associated with a shorter
AL and MAE was found to increase with decreased
age, one would expect a correlation between age at
time of surgery and MAE in patients with an AL less
than 20.0 mm. However, these results show the complexity of the variables analyzed in this study and
point to the multifaceted nature of pediatric cataract
patients and IOL calculations.
There were no significant differences in prediction
error between the 2 primary surgeons, which is consistent with findings in previous studies of the same physicians.15 Both share a similar surgical technique with
some minor individual preferences; however, this
did not affect the postoperative prediction error. Future studies with a larger number of surgeons and




multiple centers are needed before definitive conclusions can be drawn.

As techniques continue to improve and cataract extraction becomes more common in young children, it is
critical that surgeons have the ability to predict postoperative refraction and implant an accurately powered IOL in pediatric eyes. Our data from 203
consecutive primary pediatric IOL implantations
show the heterogeneous nature of the complications
surrounding predictions of refractive outcomes in
this population. Developing eyes undergo continuous
anatomical and physiological changes, and the
methods currently used to calculate desired IOL
power in pediatric patients fail to accurately account
for all these variations. This is especially evident in
younger children, in whom developmental change is
at a peak and consequent predictive variability is
greatest. The complexities of this issue support the
need for developing specific methods of measurement
and an IOL calculation formula that is designed for the
pediatric population.
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