REVIEW ARTICLe
IOL Power Calculation in Short and Long Eyes
Kenneth J. Hoffer, MD, FACS,*† and Giacomo Savini, MD‡
Abstract: An analysis of the studies published in the past 50 years
reveals that the Haigis, Hoffer Q, and Holladay 2 formulas are the best
options for intraocular lens power prediction in short eyes (<22 mm). In
long eyes (>26 mm), the Barrett Universal II, Haigis (with optimized
constants), Olsen, and SRK/T formulas provide the most accurate out-
comes for intraocular lens power prediction.
Key Words: axial length, IOL power calculation, refractive error
(Asia-Pac J Ophthalmol 2017;6:330–331)
F or almost a half a century obtaining accuracy in intraocular
lens (IOL) power calculation has been relatively easy in eyes
with an axial length (AL) between 22 and 26 mm with normal
range (unoperated) corneas. That even includes the early methods
of adjusting an 18-diopter (D) IOL based on the patient’s previous
refractive error through the development of many formulas based
on theoretical optics and even regression formulas developed in
the 1980s. However, the vexing problems that have arisen over
the years have been in eyes that are very short (<22 mm) or very
long (>26 mm). Thus, let us look at these 2 particular situations
separately.
Short Eyes
The major problem with short eyes is due to the higher opti-
cal power of the required IOL that gives more weight to any error
in the predicted IOL position. Other sources of error in short eyes
are related to the higher probability of having a steep corneal and
a shallow anterior chamber depth (ACD, distance between the
corneal epithelium and the anterior lens surface).1 Another cause
is the fact that IOLs over 30 D are only required to be within
±1.00 D of the labeled power compared with ±0.50 D for IOLs
less than 30 D.
The first evaluation of the accuracy of formulas for IOL
power calculation in eyes of various AL ranges was 24 years ago.2
From the *Stein Eye Institute, University of California, Los Angeles, CA; †St.
Mary’s Eye Center, Santa Monica, CA; and ‡G.B. Bietti Foundation IRCCS,
Rome, Italy.
Received for publication July 24, 2017; accepted July 28, 2017.
K.J.H. licenses the registered trademark name Hoffer® to Carl Zeiss-Meditec
(IOLMasters), Haag-Streit (LenStar), Oculus (Pentacam AXL), Nidek (AL-
Scan), Tomey (OA-2000), Topcon EU/Visia Imaging (Aladdin), Ziemer (Galilei
G6), and all A-scan biometer manufacturers to assure accurate programming of
the Hoffer Q formula. This has not been established with the Alcon Verion.
The contribution of the G.B. Bietti Foundation was supported by the Italian
Ministry of Health and Fondazione Roma.
The authors have no other funding or conflicts of interest to declare.
Reprints: Kenneth J Hoffer, MD, FACS, St. Mary’s Eye Center, 411 Lincoln Blvd,
Santa Monica, CA 90402. E‑mail: KHofferMD@aol.com.
Copyright © 2017 by Asia Pacific Academy of Ophthalmology
ISSN: 2162-0989
DOI: 10.22608/APO.2017338
330 | www.apjo.org
Copyright © 2017 Asia-Pacific Academy of Ophthalmology. Unauthorized reproduction of this article is prohibited.
In that study, one of us (K.J.H.) showed a greater accuracy in pre-
diction with the Hoffer Q formula in eyes shorter than 22 mm (us-
ing immersion ultrasound biometry). Later on, this difference was
confirmed statistically in a series of 984 eyes shorter than 22 mm
(provided by James Gills, MD), which unfortunately was never
published. The greater accuracy of the Hoffer Q formula in short
eyes was conclusively and statistically proven by Aristidemou et
al3 in 2011, using optical biometry in 8108 eyes. However, the
comparison was only with the other 2 third-generation formulas
(ie, the Holladay 1 and the SRK/T formulas).4,5 The difference
among these formulas lies in the use of the tangent of the corneal
power to predict the IOL position with Hoffer Q, rather than the
corneal height formula of Fyodorov.6
Over the past several decades there have been many publica-
tions showing different results with different formulas. In 1996,
Holladay debuted the unpublished Holladay 2 formula, which
uses 7 biometric variables and was designed to get the best accu-
racy in all ranges of AL. There are few published studies report-
ing the results with the Holladay 2; however, Hoffer7 showed in
2000 that the Holladay 2 was equally as accurate as the Hoffer Q
in eyes shorter than 22 mm, and that it was less accurate than the
Holladay 1 in eyes between 22 and 26 mm.
In 2000, Haigis originated his formula using AL and the pre-
operatively measured ACD to predict the IOL position based on
3 constants.8 Many studies have shown excellent accuracy of the
Haigis formula in all ranges of eyes, including short eyes. Eom et
al9 showed that the Haigis formula becomes more accurate than the
Hoffer Q in short eyes as the ACD gets shallower than 2.40 mm.
Olsen10 has consistently shown the Hoffer Q and Haigis for-
mulas to be the least accurate formulas in short eyes versus his
formula.
In the past several years the Barrett Universal II formula
has received much attention, without any major published study
showing it to be more accurate in any specific AL range than the
basic 3 third-generation formulas. However, in 2016, Kane et al11
published a series of 3241 eyes and showed statistically—when
comparing the Barrett Universal II with the Haigis, Hoffer Q,
Holladay 1 and 2, SRK/T, and T2 formulas—no superiority of
any of these 7 formulas in short eyes.11
The radial basis function (RBF), which uses pattern recogni-
tion and data interpolation to predict postoperative refraction, has
more recently become available and the only published study so
far on its accuracy is by Kane,12 who did not find any statistical
improvement of this method over the other formulas.
Our conclusion, from looking at these 50 years of analysis,
is that one can reliably depend on the Haigis, Hoffer Q, and Hol-
laday 2 formulas for IOL prediction in short eyes.
Long Eyes
In the same regard, long eyes have created problems. We
are dealing with eyes that have long ALs, flatter corneas, thinner
Asia-Pacific Journal of Ophthalmology • Volume 6, Number 4, July/August 2017
Asia-Pacific Journal of Ophthalmology • Volume 6, Number 4, July/August 2017
crystalline lenses, and deeper ACDs.1 Obtaining correct AL mea-
surements had been difficult until the introduction of optical bi-
ometry in 1999, due to the common presence of staphyloma. On
the other hand, the low power of the IOL makes the effect of IOL
position less significant on the final refraction of the eye. How-
ever, importantly, Haigis13 has shown that constant optimization
in these eyes leads to bizarre constants for theoretical formulas,
with negative and positive IOLs between −5 and +5 D, mandating
that personalization of constants be used in such unusual cases.
With these constants, the Haigis formula has produced accurate
results. We support this method for long eyes, as described by
Haigis, over the Koch and Wang14 adjustment of AL.
As an aside, it is interesting that Hoffer2 showed in 1993 that
the Holladay 1 formula gave the very best results in medium-long
eyes (24.5‒26 mm) and the best results one can obtain perform-
ing IOL power calculation. In 2000, Hoffer7 then showed that the
Holladay 1 was superior to the Holladay 2 in this medium AL
range.
Historically, as noted above with short eyes, Hoffer showed
in 1993 that the SRK/T formula would provide more accurate
IOL power prediction in eyes over 26 mm compared with the
Hoffer Q and the Holladay 1 formulas.2 In 2000 he showed that
the Holladay 2 was comparable to the SRK/T in these eyes.7 The
accuracy of the SRK/T has since been confirmed statistically by
Aristodemou et al.3 More recently, Olsen reported that his C-con-
stant formula provided the best outcomes in long eyes.10 In a small
sample of 54 eyes, Cooke et al15 reported that the Olsen, Haigis,
and Barrett formulas (in this order) gave the most accurate results
in these long eyes. The good outcomes of the Barrett Universal
II formula have also been reported by Kane et al.11 Additionally,
regarding the RBF method, they reported that no statistically sig-
nificant difference was detected with respect to the Barrett and
SRK/T formulas.12
Because, as of July 2017, the RBF method will not allow
calculations for eyes 30 mm or longer, our conclusion at this time
is that one can reliably depend on the Barrett Universal II, Haigis
(with optimized constants), Olsen, and the old stand-by SRK/T
formulas for IOL prediction in very long eyes.
© 2017 Asia-Pacific Academy of Ophthalmology
Copyright © 2017 Asia-Pacific Academy of Ophthalmology. Unauthorized reproduction of this article is prohibited.
IOL Power in Short/Long Eyes
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