Seminars in Ophthalmology

ISSN: 0882-0538 (Print) 1744-5205 (Online) Journal homepage: https://www.tandfonline.com/loi/isio20

Accuracy of Intraocular Lens Power Calculation in

Eyes Filled with Silicone Oil

Piotr Kanclerz & Andrzej Grzybowski

To cite this article: Piotr Kanclerz & Andrzej Grzybowski (2019) Accuracy of Intraocular Lens
Power Calculation in Eyes Filled with Silicone Oil, Seminars in Ophthalmology, 34:5, 392-397, DOI:
10.1080/08820538.2019.1636097

To link to this article: https://doi.org/10.1080/08820538.2019.1636097

Published online: 01 Jul 2019.

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Seminars in Ophthalmology, 2019; 34(5): 392–397
© Taylor & Francis
ISSN: 0882-0538 print / 1744-5205 online
DOI: https://doi.org/10.1080/08820538.2019.1636097

REVIEW

Accuracy of Intraocular Lens Power Calculation in

Eyes Filled with Silicone Oil
1
Piotr Kanclerz and Andrzej Grzybowski2,3

1
Department of Ophthalmology, Hygeia Clinic, Gdańsk, Poland, 2Department of Ophthalmology, University
of Warmia and Mazury, Olsztyn, Poland, and 3Foundation for Ophthalmology Development, Institute for
Research in Ophthalmology, Poznan, Poland

ABSTRACT
Silicone oil (SO) is used mainly when managing complex retinal detachments, commonly with proliferative
vitreoretinopathy, as well as a hemostatic agent in proliferative diabetic retinopathy. Combined lens exchange
and pars plana vitrectomy remains preferred by many surgeons; however, sequential surgery might be
advantageous to minimize the postoperative anterior chamber inflammatory response, particularly in prolif-
erative diabetic retinopathy or retinal detachment. The aim of the study was to evaluate the optimal method of
intraocular lens (IOL) calculation in eyes filled with SO.
Different techniques are employed for axial length assessment in eyes filled with SO, including preoperative
A-scan applanation or immersion biometry, partial coherence interferometry (PCI), or less commonly com-
puted tomography, magnetic resonance imaging, or intraoperative retinoscopy/biometry after SO removal.
PCI might provide better refractive outcomes compared to ultrasound measurements, however, the quality of
presented evidence is low. Bias in calculation may be a result of limited vitreous base removal during
vitrectomy, partial filling of the vitreous chamber with SO and measurements in supine position, macular
edema or detachment, selection of an inappropriate IOL calculation formulas and sulcus IOL placement.
Clinicians should consider that even when employing optical biometry and correct calculation formulas only
a third of eyes filled with silicone oil might achieve ± 1.0 D of target refraction, compared to 97.2% of normal
eyes. We would recommend performing optical biometry before the application of SO; if this is impossible,
measurement of the second eye or biometry after SO removal is an alternative. Implantation of a convex-plano
monofocal polymethyl methacrylate or foldable hydrophobic acrylic IOL with large optic diameter is advised
in these patients.
Keywords: Cataract, intraocular lens, biometry, partial coherence interferometry, silicone oil

INTRODUCTION the postoperative anterior chamber inflammatory

response, this might be particularly advantageous in
Silicone oil (SO) is used when managing complex proliferative diabetic retinopathy or retinal
retinal detachments, commonly with proliferative detachment.
vitreoretinopathy, as well as a hemostatic agent in Cataract development is common after vitrectomy,
proliferative diabetic retinopathy.1 Combined cataract mainly due to inhibited diffusion of nutrients imped-
surgery and pars plana vitrectomy remains preferred ing proper lens metabolism.3 SO additionally acceler-
by many surgeons even if the cataract is not clinically ates cataract formation, which corresponds to the
significant. However, a recent study presented that in duration of contact between SO and the lens.3 SO
France combined surgeries accounted for only 15.8% causes refractive changes and hampers intraocular
vitreoretinal procedures performed in the years lens (IOL) power calculation. The aim of the study
2005–2014.2 With that, sequential surgery minimizes was to evaluate the optimal method of IOL power
calculation in eyes filled with SO.

Received 23 January 2019; accepted 18 June 2019; published online 1 July 2019.
Correspondence: Piotr Kanclerz, Hygeia Clinic, ul. Jaśkowa Dolina 57, 80-826, Gdańsk, Poland. E-mail: p.kanclerz@gumed.edu.pl
Color versions of one or more of the figures in the article can be found online at www.tandfonline.com/isio.

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 Seminars in Ophthalmology 393

METHODS FOR BIOMETRY IN EYES FILLED the IOL was implanted into the ciliary sulcus.6,8 As in
WITH SO AND THE REFRACTIVE sulcus IOL placement, the IOL is shifted anteriorly com-
OUTCOME pared to in-the-bag placement, surgeons empirically
subtract 0.5 to 1.5 diopters of IOL power. This was not
Optical biometry is the current standard for IOL clarified within the papers and could also be a con-
power calculations in clinical practice. Optical founding factor for IOL calculation.17 Interestingly,
biometers employ the principle of partial coherence some researchers employed intraoperative IOL calcula-
interferometry (PCI), low-coherence optical reflecto- tion after SO removal. In a study by El-Baha the AL was
metry (LCOR) or optical coherence tomography measured using a sterilized probe of the ultrasound
(OCT). In eyes filled with silicone oil, two studies unit after SO removal, with irrigating fluid running
reported higher accuracy of PCI compared to ultra- through the lower temporal cannula to maintain
sound biometry.4,5 Kunavisarut et al. noted that the globe configuration. The results did not differ from
when employing A-scan immersion biometry the those obtained preoperatively with IOL Master.15
postoperative refractive error (RE) had a higher Patwardhan proposed intraoperative retinoscopy for
standard deviation than with PCI, and a very wide IOL power calculation.13 Following phacoemulsifica-
range of −14.62 to +16.41 D.4 Studies presenting tion and SO removal through the pars plana, the ports
methods employed for IOL calculation in eyes filled were closed with scleral plugs and intraoperative reti-
with SO, while the refractive outcome has been noscopy was performed at the distance of 50 cm. IOL
presented in Table 1. power calculation was conducted using the Ianchulev
In one of the largest studies assessing the refractive formula (R x 2.01449) and all eyes had a postoperative
outcome in eyes filled with SO, even when employing RE within 1.00 D. A problem with intraoperative bio-
PCI, 33.7% of eyes achieved the desired refractive metry is that not all surgical centers have an IOL bank,
target of −2.0 to +0.25 D.9 In normal eyes it might be and this method requires immediate availability of var-
expected that 79.1% cases should reach ≤0.5 D of the ious IOLs. With that, retinoscopy is technically demand-
refractive target, while 97.2% should be within ≤1.0 ing procedure.
D.14 Importantly, PCI is not applicable in cases of
advanced cataracts, and SO-filled eyes might have
dense posterior subcapsular cataract or central cap-
sule opacification. In the study by Nepp et al.7 PCI INFLUENCE OF SILICONE OIL ON
could not be performed in 44 of 107 patients. In BIOMETRY
another investigation, six of 28 eyes were excluded,
as the PCI signal-to-noise ratio was less than 1.6.15 Most ultrasound biometers allow employing
LCOR or swept-source OCT devices employ longer a particular ultrasound velocity for SO filling the vitr-
wavelength than PCI, so they demonstrate better light eous compartment; it is significantly lower in SO
penetration through ocular tissues.16 Thus, it might be (987 m/s18,18 or 986 m/s11) than in the vitreous body
assumed that with LCOR or OCT biometers, the mea- or aqueous humor (1,532 m/s).18,19 Jackson Coleman20
surements could be obtained in a greater percentage claims that the viscosity of SO might alter the ultra-
of patients. sound velocity—with 972 m/s for 1000 cS SO and
As the refractive outcome of biometry in eyes filled 978.5 m/s for 5000 cS SO. Abu El Einen et al.5 suggested
with SO might be unsatisfactory, alternative methods a greater difference; 980 m/s for 1000 cS SO and
have been proposed. Takei et al. performed x-ray 1040 m/s for 5000 cS SO. If the biometer does not
computer tomography measurements with the SRK- allow to set a defined ultrasound velocity for the vitr-
T formula employed for IOL calculation.10 The post- eous chamber the Meldrum’s formula might be
operative RE was less than 1 D from goal refraction in employed (axial length (AL) = length of anterior cham-
six of 12 eyes (50%), and less than 2 D in nine eyes ber and lens + retrosilicone space + 0.63 x vitreous
(75%). Bencic et al.11 found that the outcome of mag- length).21
netic resonance imaging biometry does not differ The velocity of light is significantly lower in SO,
from results obtained with A-scan biometry. and the refractive index of SO (1.4035–1.405) is higher
However, in patients with AL over 26 mm the mean than that of the vitreous body (1.33–1.336).18,19
deviation was significantly greater in the A-scan Currently, available PCI biometers allow adjusting
group. of calculations to SO after selecting a particular pro-
In most of the analyzed studies SO was removed just gram. However, Wang et al. presented that AL mea-
after cataract surgery,4,7,10 and less commonly prior to surements obtained with the IOL Master after
cataract removal.6 In most of the articles, cataract was removal of SO were lower than the values obtained
removed by phacoemulsification.4,5,7–9,11–13 In two stu- preoperatively, and applying an adjustment formula
dies the lens was removed with phacofragmentation was advised.22 These findings are contentious, as it is
through the pars plana approach, and subsequently, known that the true AL does not change after SO

© 2019 Taylor & Francis

 394

TABLE 1. Studies presenting methods employed for IOL calculation in eyes filled with silicone oil and the refractive outcome.

IOL Group 1: Sample size and method of Group 2: Sample size and method of Eyes within ± 1.0
calculation measurement measurement Statistical D of target
Study Surgery formula Postoperative RE/Results Postoperative RE/Results significance refraction

Kunavisarut PCS SRK-T 34 eyes (34 patients) A-mode immersion 34 eyes (34 patients), PCI (Zeiss IOL Master V5.0) p = .049 Group 1: 30.0%
et al. 20124 biometry (Quantel Medical compact II Version 0.60 ± 0.23 D Group 2: 50.0%
1.03)
1.79 ± 1.04 D
Abu El Einen PCS/ECCE N/A 30 eyes, A-mode biometry 30 eyes, immersion B-guided biometry p= .024 Group 1: 46.6%
et al. 20115 -0.95 ± 1.157 D 0.15 ± 0.94 D Group 2: 83.3%
Suk et al. PF SRK-I 35 eyes, A-mode biometry 19 eyes, PCI (Zeiss IOL Master) p = .13 Group 1: 31.0%
20056 −1.34 ± 2.18 D −0.51 ± 2.03 D Group 2: 45.0%
Nepp et al. PCS SRK-II 117 eyes (107 patients) A-mode biometry in 73 patients, PCI (Zeiss IOL Master) p > .05. 85.0%
P. Kanclerz and A. Grzybowski

20057 supine position pre- vs postoperative AL measurement: 0.04 ±

pre- vs postoperative AL measurement: 0.4 ± 0.46 mm
2.6 mm
Ghoraba et al. PCS/PF SRK-T 10 eyes with AL>27mm A-mode biometry (SO 19 eyes with AL<27mm, A-mode biometry (SO p= .05 51.9%
20028 1000/5000 cS, Biovision Internation 10 MHz 1000/5000 cS, Biovision Internation 10 MHz
probe) probe)
3.04 ± 2.68 D 1.04 ± 1.04 D
Al Habboubi PCS SRK-T/ 98 eyes, measured with PCI (92.9%) or A-mode 33.7% of eyes RE
et al. 20189 Hoffer-Q/ biometry (7.1%) −2.0 to +0.25 D
Holladay 7.1% of eyes RE
higher
than −2.0 D
41.% of eyes RE
between +0.5 to
8.5 D
17.3% of eyes
cylinder over 2 D
Takei et al. PCS/ECCE SRK-T 12 eyes (12 patients) AL measured in CT scan 50.0%
200210 (supine)
−0.27 ± 1.59 D
Bencic et al. PCS SRT-T 33 eyes AL measured in MRI scan (upright 37 eyes A-mode biometry (upright position) p = .125 N/A
200911 position) -0.76 ± 1.73 D
-0.36 ± 1.26 D
El-Baha and PCS SRK-T 22 eyes (21 patients) intraoperative applanation 22 eyes (21 patients) preoperative PCI (Zeiss IOL p= .74 81.82%
Hemeida A-mode biometry after SO removal Master V1.1)
200912 AL = 24.56 ± 2.77 mm AL = 24.28 ± 2.84 mm
Patwardhan PCS Ianchulev 12 eyes (12 patients) after SO removal and 100.0%
et al. 200913 formula cataract surgery retinoscopy for IOL power
evaluation
-0.45 ± 0.63 D

Abbreviations: AL-axial length, CT-computed tomography, ECCE-extracapsular cataract extraction, IOL-intraocular lens, MRI-magnetic resonance imaging, N/A - not applicable,
PCI-Partial Coherence Interferometry, PCS-phacoemulsification cataract surgery, PF-phacofragmentation with sulcus placement of the IOL, RE-refractive error, SO-silicone oil.

Seminars in Ophthalmology
 Seminars in Ophthalmology 395

removal.22,23 The manufacturer of IOL Master claims CHOOSING THE IOL, CALCULATION
that the adjusted formula has been implemented in FORMULA AND TIME FOR BIOMETRY
the new version 700.
It is recommended that for eyes under 22 mm in AL
the Haigis formula should be applied for IOL calcula-
SURGERY-RELATED ISSUES tions, while the Hoffer Q formula for comparative
assessment.24 SRK-T is the recommended for eyes
Retinal surgeons might avoid excessive intravitreal with AL over 22 mm. In these eyes, the Haigis for-
injection of SO which can cause secondary glaucoma mula might be used alternatively, or the Holladay
in the early postoperative period. Thus, an interface formula for eyes with AL ranging 22–26 mm.24 In
between the SO and the vitreous humor might be some of the assessed studies the SRK-I6 or SRK-II7
observed, and the so-called retrosilicone space should formulas were applied, in other studies, the SRK-T
be taken into consideration for IOL calculation. The was employed in spite of the eye length.4,8,10,11,15
space is the largest when patients were in the supine Despite modern vitreoretinal techniques, in some
position, decreased when they were sitting upright, patients, it is unfeasible to remove the oil, which must
and absent when they were in the prone position.10 remain in situ indefinitely. This includes eyes with recur-
The mean dimension of this space was assessed as 1.9 rent vitreous hemorrhages or tractional retinal detach-
(±0.67) mm, and measurements in supine position ment secondary to proliferative diabetic retinopathy.25,26
with detection of oil-free fluid space behind the SO Another patient group includes those with proliferative
in with echography were suggested.7 Neglecting the vitreoretinopathy detachments who have undergone
retrosilicone space in IOL calculations might results in multiple operations, complicated by hypotony, with
a postoperative deviations.7 With that, it should be redetachment following previous oil removal or those
underlined that it is not possible to perform complete declining further surgery.27 Additionally, patients with
vitreous removal behind the lens without intraopera- limited mental capacity may be unable to cooperate with
tive cataract formation or progression. Importantly, their continued care and require long-term SO
biometers usually cannot automatically distinguish tamponade.27 In these cases, an additional IOL power
SO from fluid/vitreous present in the vitreous cham- between +3.0 and +3.5 D, depending on the AL of the
ber. (Figure 1). Thus, the presence of retrosilicone eye, would be recommended.25,28
space or residual vitreous may result in IOL miscal- When choosing the IOL a possible interaction with SO
culations, as the refractive index/ultrasound velocity should be considered, thus monofocal polymethyl
of these structures is interpreted by the biometer as methacrylate or foldable hydrophobic acrylic IOLs are
that of SO. recommended.25,29 Silicone IOLs should be unadvised as

FIGURE 1. Some sources of IOL calculation error in eyes filled with silicone oil (SO) include incomplete vitreous base (VB) removal
or partial filling of the vitreous chamber with SO resulting in a retrosilicone space (RSS).

© 2019 Taylor & Francis

396 P. Kanclerz and A. Grzybowski

they adhere strongly to SO; however, other lens bioma- financial support from Bayer, non-financial support from
terials are also susceptible to this complication.30 Novartis, non-financial support from Alcon, personal
Hydrophilic acrylic lenses are at risk for calcification,31 fees and non-financial support from Valeant, grants
and can be stained with trypan blue if another vitreor- from Zeiss, personal fees and non-financial support
etinal surgical intervention is required.32 The IOL should from Santen, outside the submitted work.
have a convex-plano configuration to prevents the
decrease in refraction on the posterior IOL surface due
to the similar refractive indexes of SO and the IOL mate- ORCID
rial. The optic diameter should be at least 6 mm, as
greater optics facilitate viewing the vitreous body and Piotr Kanclerz http://orcid.org/0000-0002-8036-
retina and are associated with less posterior capsule 7691
opacification.33
If possible, we recommend performing biometry
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