Intraocular lens calculations status after corneal refractive surgery

With the increasing number of keratorefractive surgical procedures, an increasing number of cataract surgeries in eyes after keratorefractive surgery is anticipated within a few decades. Although cataract extraction seems to be feasible without major technical obstacles, intraocular lens (IOL) power calculation turned out to be problematic. Insertion of the measured average K-readings (= "central corneal power" = keratometric diopters) after myopic radial keratotomy (RK), photorefractive keratectomy (PRK), or laser in situ keratomileusis (LASIK) into standard IOL power-predictive formulas commonly results in substantial undercorrection and postoperative hyperopic refraction or anisometropia. In this article, the major reasons for IOL power miscalculations (which are different for RK versus RRK/LASIK) are discussed based on model calculations and based on case series of cataract surgeries, methods for improved assessment of keratometric diopters as the major underlying problem are exemplary illustrated, and finally a clinical step-by-step approach to minimize IOL power miscalculations status after corneal refractive surgery is suggested. The "clinical history method" (i.e., subtraction of the spherical equivalent [SEQ] change after refractive surgery from the original K-reading) should be applied whenever refraction and K-reading before the keratorefractive procedure are available to cataract surgeons. In addition, more than one modern third-generation formula (e.g., Haigis, Hoffer Q, Holladay 2, or SRK/T) but not a regression formula (e.g., SRK I or SRK II) should be applied and the highest resulting IOL power should be used for the implant.