Arq Bras Oftalmol.

2009;72(2):189-93
Resultados clnicos na facoemulsificao utilizando a frmula SRK/T
Trabalho realizado no Departamento de Oftalmologia
da Universidade Federal de So Paulo - UNIFESP - So
Paulo (SP) - Brazil.
1
Department of Ophthalmology - Universidade Federal
de So Paulo - UNIFESP - So Paulo (SP) - Brazil.
2
Substitute Adjunct Professor, Posgraduation Profes-
sor at the Department of Ophthalmology of UNIFESP -
So Paulo (SP) - Brazil.
3
Department of Ophthalmology of UNIFESP - So Paulo
(SP) - Brazil.
4
Department of Ophthalmology of UNIFESP - So Paulo
(SP) - Brazil.
5
Department of Ophthalmology of UNIFESP - So Paulo
(SP) - Brazil.
6
Department of Ophthalmology of UNIFESP - So Paulo
(SP) - Brazil.
7
Department of Ophthalmology of UNIFESP - So Paulo
(SP) - Brazil.
8
Department of Ophthalmology of UNIFESP - So Paulo
(SP) - Brazil.
Address for correspondence: Juliana M. S. Lagrasta.
Rua Botucatu, 822 - So Paulo (SP) CEP 04023-062
E-mail: [email protected]
Recebido para publicao em 23.04.2008
ltima verso recebida em 16.12.2008
Aprovao em 28.01.2009
Nota Editorial: Depois de concluda a anlise do artigo
sob sigilo editorial e com a anuncia do Dr. Wagner
Zacharias sobre a divulgao de seu nome como revisor,
agradecemos sua participao neste processo.
Juliana Marques de Souza Lagrasta
1
Norma Allemann
2
Luciana Scapucin
3
Cecilia Tobias de Aguiar Moeller
4
Lilian Emi Ohkawara
5
Luiz Alberto Soares Melo Jr.
6
Eduardo Sone Soriano
7
Fabio Henrique Casanova
8
Clinical results in phacoemulsification using
the SRK/T formula
Keywords: Biometry; Cataract extraction; Lens implantation, Intraocular/methods; Lens
diseases; Phacoemulsification; Refractive errors/surgery; Refraction, ocular
Purpose: To evaluate the prediction of refraction using the SRK/T
formula for intraocular lens (IOL) calculation in eyes with medium axial
length after phacoemulsification. Methods: This prospective study
enrolled 33 eyes with nuclear cataract that underwent phacoemulsi-
fication. All procedures were performed by one surgeon with the
intraocular lens placed within the capsular bag. The same technician who
was unaware of the purpose of the study made all the measurements. The
achieved refractive error one month after surgery was compared to the
predicted postoperative refractive error by the SRK/T formula. Results:
The ocular axial length varied between 22.2 mm and 24.5 mm. The mean
predicted refraction was -0.431 0.181 D and the mean achieved
postoperative spherical equivalent was -0.220 0.732 D. Eighteen eyes
(55%) had a refractive error between 0.50 D and thirty eyes (91%)
between 1.00 D of the predicted refraction. There was a tendency
toward hyperopic shift (mean SD: 0.211 0.708 D, p=0.009). Conclusion:
The SRK/T formula demonstrated a satisfactory accuracy to calculate
the error of refraction in eyes with medium axial length.
ABSTRACT
INTRODUCTION
Intraocular lens (IOL) power calculation formulas have evolved over the
past 25 years. The most recent formulas (third and fourth generation) are
the most useful and precise
(1-6)
. These formulas vary with anterior chamber
depth (ACD), axial length (AL) and corneal curvature. Third-generation
formulas such as Holladay 1, Hoffer Q and SRK/T use constants associated
with the expected position of the IOL. Holladay uses the surgeon factor,
the distance from the iris plane to the IOLs plane; Haigis uses 3 constants
for better Effective Lens Position (ELP) prediction; Hoffer Q uses the ACD
constant, average distance between the power plane of the cornea and that
of the IOL; and SRK/T uses the A-constant to calculate the ACD, using the
retinal thickness and corneal refractive index
(1,3,5,7)
.
Prediction accuracy depends on three factors: accuracy of the biometric
data (axial length and keratometry readings), accuracy of manufactured IOL
power quality control and accuracy of the IOL power formulas
(1,8-9)
.
Several previous published studies reported accuracy of 1.00 diopter
(D) after cataract surgery using phacoemulsification technique that varies
from 80 to 94.8%, depending on the AL and the IOL power calculation
formula
(1-4,10-11)
.
72(2)10.pmd 15/4/2009, 10:10 189
190 Clinical results in phacoemulsification using the SRK/T formula
Arq Bras Oftalmol. 2009;72(2):189-93
After introduction of phacoemulsification with small in-
cision techniques, minimizing cylindrical error
(12)
, and con-
tinuous curvilinear capsulorhexis technique, that allows better
IOL capsular fixation and more predictable ELP
(13)
, the correct
IOL power became a crucial step for good refractive outcome
in the preoperative examination of cataract surgery.
The purpose of this study was to evaluate the prediction
of postoperative refraction using the SRK/T formula in pha-
coemulsification in eyes with medium AL.
METHODS
This prospective non-comparative study comprised 33
eyes of 33 consecutive patients with senile cataract who un-
derwent phacoemulsification and in-the-bag IOL implantation
between August and October 2002. Informed consent was
obtained from all patients and the study protocol was appro-
ved by the Ethics and Research Committee of the Federal
University of So Paulo - Paulista School of Medicine.
Inclusion criteria were age between 50 and 90 years, nu-
clear cataract greater than 2.5 based on the Lens Opacities
Classification System III (LOCS III)
(14)
, and axial length
between 21.5 and 24.5 mm. Exclusion criteria were the pre-
sence of associated ocular pathologies, monocular patients,
and intraoperative or postoperative complications.
Before surgery, simulated keratometry was obtained from
corneal topography using axial map (EyeSys Technologies,
Houston, TX, USA), and the axial length was recorded as the
average of five readings taken using a 10 MHz A-scan ultra-
sound transducer (Zeiss Humphrey, Dublin, CA, USA) with
contact technique under topical anesthesia with 0.5% proxy-
metacaine chlorhydrate. SRK/T formula was chosen to predict
the IOL power. All examinations were performed by the same
examiner who was unaware of the purpose of the study.
All patients had standardized uneventful small-incision
phacoemulsification with in-the-bag IOL implantation perfor-
med by a single surgeon (FHC). Phacoemulsification was per-
formed using 20000 Legacy

(Alcon, Fort Worth, TX, USA).

The foldable IOL was implanted in the capsular bag, through a
3.0 mm incision, using a Monarch II

injector (Alcon, Fort

Worth, TX, USA). The sutureless incision was placed supero-
temporally for right eyes and superonasally for left eyes. All
IOLs used were Acrysof

(Alcon, Fort Worth, TX, USA) with

constants of 118.4, as follows: one (3%) SA60AT, 11 (33%)
SA30AT, and 21 (64%) SA30AL. The IOL requested for the
patients predicted a postoperative refractive error between
plano and -1.00 D.
Patients were examined 1, 7, 15, and 30 days after surgery.
Each visit included uncorrected visual acuity, slit lamp exami-
nation of the anterior segment, intraocular pressure measu-
rement by Goldmann applanation tonometry, and indirect oph-
thalmoscopy. Best spectacle-corrected visual acuity (BSCVA)
was taken between 30 and 40 days after surgery using a
Snellens chart.
The implanted IOL power was used to calculate the predicted
postoperative refractive error by SRK/T formula. The mean re-
fractive error was calculated from the difference between the
formula-predicted refractive error and the achieved postopera-
tive refractive error based on spherical equivalent (SE). Paired t
test was used to analyze statistical significance. P values of less
than 0.05 were considered statistically significant.
RESULTS
Of the 33 patients, 17 were female and 16 were male; AL
ranged between 22.2 mm and 24.5 mm. The right eye was
operated in 19 (57.6%) patients and the left eye in 14 (42.4%).
All surgeries were uneventful. All IOLs were implanted within
the capsular bag and the incisions were not sutured.
Between 30 and 40 days after surgery, BSCVA was 20/25 or
better in 23 (70%) eyes, between 20/30 and 20/50 in 10 (30%).
Mean IOL power used was 21.70 D 1.30 D (range, 19.0 D
to 24.5 D). The mean predicted SE was -0.431 0.181 D (range,
-0.02 to -0.72 D). The mean achieved SE was -0.220 0.732 D
(range, +1.75 to -1.625 D). At 1 month, the mean postopera-
tive spherical component of the refractive error was +0.227
0.756 D (range, +2.0 to -1.25 D), and the mean postoperative
cylindrical component was -0.894 0.625 D (range, 0 to -2.25 D).
The difference between predicted and achieved refractive
error presented a slight hyperopic shift (mean SD: 0.211
0.708 D, ranging from -1.07 D to + 2.33 D; p=0.09) as seen in
table 1. The majority of the eyes (18 eyes, 55%) had an error of
prediction within 0.50 D (Figure 1, Table 2 and 3) and thirty
eyes (91%) had a predicted refraction between 1.00 D.
DISCUSSION
Few studies in literature have shown refractive results after
phacoemulsification using SRK/T formula, but none of them
has been made following more restricted criteria in order to
avoid bias
(1,3-4,15-18)
. Our study showed a prediction accuracy of
55% for refractive errors of 0.50 D, using SRK/T formula in
eyes with medium AL, and a prediction accuracy of 91% in
errors of 1.00 D. This accuracy is very close to the results
presented in other studies using the same formula
(1,3-4,15-18)
.
SRK/T has been reported to present
(1)
a prediction error
of 1.00 D in 94.5% of 325 eyes with medium AL (from 22.0 to
Table 1. Mean attempted versus achieved spherical equivalent correc-
tion in medium axial length eyes using SRK/T formula (n=33 eyes).
SE (D) Mean SD (D)
Attempted -0.431 0.181
Achieved -0.220 0.732
Difference between attempted 0.211 0.708
and achieved (p=0.09)*
*= paired t test
SE= spherical equivalent; SD= standard deviation; D= diopters
72(2)10.pmd 15/4/2009, 10:10 190
191 Clinical results in phacoemulsification using the SRK/T formula
Arq Bras Oftalmol. 2009;72(2):189-93
24.5 mm) using the SRK/T formula. However, all IOLs used in
this study were unfoldable, made from polymethylmethacry-
late, with a 6.0 mm optic diameter, and had to be implanted
through a larger incision. Another study
(3)
, also studying this
formula, showed accuracy in 1.00 D prediction errors in 80%
of cases. This study comprised the development of the SRK/T
formula. Although the authors obtained the prediction of 80%
within 1.00 D, this study considered a large group of cases
with different axial length from different surgical centers using
different IOLs operated on by different surgeons. Besides,
this prediction of error is not only for eyes with medium axial
length. The same group of authors published a comparison
between SRK/T and other theoretical and regression formu-
las
(15)
. In this study, seven independent data sets were used
for comparison. Each data source consisted of one or more
surgeons series of cases using different IOLs and different
instruments to obtain biometric data. The authors reported
81% of cases within 1.00 D in 990 unselected patients.
Despite 76% of patients being average eyes, the authors did
not present results for this particular group, and only com-
pared separately SRK/T with other formulas in short, mode-
rately long, very long, and extremely long eyes
(15)
.
A study of 1993
(4)
found the error to be within 1.00 D in
87% of cases that included long and short eyes. The authors
included 11 different IOL types from 6 different companies
with different A-constants and IOL designs. Furthermore, the
axial length varied from 18.92 to 37.45 mm
(4)
. All these different
parameters make it more difficult to compare with our data and
increase the possibility for bias. Another study
(16)
used the
SRK/T formula and found the error between 1.25 D in 76.4%,
although they did not mention the preoperative AL of the
eyes and did not describe the presence or absence of corneal
suture. SRK/T has also been
(18)
reported with an error between
0.75 D in 78% of cases, however this study also did not
mention the AL of the eyes and the authors used both unfol-
dable and foldable lenses, referring that the best results were
obtained when using the latter (88% within 1.00 D). A study
comparing IOLs
(17)
reported differences in the predictability of
refractive outcomes between silicone and PMMA IOLs, con-
cluding that PMMA IOL showed better refractive results,
both using the SRK/T formula.
Some advantages of our study are the uniformity of the
biometric data collection (same technician) and the surgery
having been performed by a single surgeon, using sutureless
corneal incision with IOLs implanted within the capsular bag in
all cases, and also using the same IOL material type, decreasing
the variables that might confuse the analysis of the IOL power
prediction. One variable that we must comment is that, even in
experienced hands, the AL measured by immersion ultrasound
biometry can be more precise than the contact method, al-
though it is more critical in eyes with longer AL
(11,19)
.
SRK/T formula is a third-generation formula, as are Holladay
1 and Hoffer Q, that vary the ACD based on the patients axial
length and corneal curvature, and its accuracy of IOL power
prediction has very satisfactory clinical results. A comparative
study reported the accuracy of the Hoffer Q, Holladay 1 and 2,
SRK-I and II and SRK/T

formulas
(1-2)
, and found a substantial
better performance of the Holladay 1 and 2, Hoffer Q and SRK/
T formulas when comparing them to the SRK-I and II. In one
study
(1)
, the predicted error within 1.00 D in medium eyes was
94.8% for Holladay 1, 93.2% for Hoffer Q and 94.5% for SRK/T.
In a retrospective study with 317 eyes, Hoffer
(2)
published that
Hoffer Q and Holladay 2 formulas would be better in eyes
shorter than 22 mm (AL < 22 mm), Hoffer Q and Holladay 1 for
average eyes (AL between 22.0 to 24.5 mm), SRK/T and Hol-
laday 1 for medium-long eyes (AL between 24.5 and 26 mm) and
SRK/T in very long eyes (AL > 26 mm). In eyes with medium AL
(between 22 and 24.5 mm) the 3 Hoffer Q, SRK/T and Holladay 1
formulas showed equally high accuracy. Our data also confirm
that SRK-T presents satisfactory accuracy and predictability
for average axial length eyes.
Narvaez compared the 4 formulas (Hoffer Q, Holladay 1,
Holladay 2 and SRK/T) in 643 eyes and found no difference in
accuracy between them in 4 subgroups of axial length
(20)
. Fourth
generation formulas, like Holladay 2, did not outperform those
of third generation, especially in eyes with extreme AL
(2,21)
.
Figure 1 - Dispersion plot demonstrating attempted versus achieved
spherical equivalent (SE) correction in medium axial length eyes
underwent phacoemulsification using SRK/T formula
Table 2. Distribution of the prediction error (difference between
attempted and achieved spherical equivalent) in medium axial
length eyes using SRK/T formula (n=33 eyes)
Range of SE (D) n (%)
0.25 8 (24)
0.50 18 (55)
1.00 30 (91)
2.00 32 (97)
> 2.00 1 ( 3)
SE= spherical equivalent; n= number of operated eyes
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192 Clinical results in phacoemulsification using the SRK/T formula
Arq Bras Oftalmol. 2009;72(2):189-93
Table 3. Attempted and achieved refraction, final spherical equivalent, final visual acuity, IOL model, K and diopters. Error between attempted
and achieved refraction in medium axial length eyes using SRK/T formula (n=33 eyes)
Attempted Achieved Real SE VA IOL K Diopters Error
-0.58 +2.00 -0.50 x 130 1.750 20/40 SA30AL 118.4 24.5 2.330
-0.06 +0.25 -0.75 x 180 -0.125 20/30 SA30AL 118.4 22.5 0.065
-0.50 -0.50 -0.50 x 110 -0.750 20/20 SA30AL 118.4 22.5 -0.250
-0.52 +0.75 -1.00 x 30 0.250 20/25 SA30AL 118.4 21.5 0.770
-0.43 -1.00 -1.00 x 125 -1.500 20/20p SA30AL 118.4 20.5 -1.070
-0.60 -1.00 -0.50 x 55 -1.250 20/25 SA30AL 118.4 21.0 -0.650
-0.58 +1.50 -2.25 x 105 0.375 20/25 SA30AL 118.4 23.0 0.955
-0.55 +0.75 -1.00 x 100 0.250 20/20p SA30AL 118.4 23.0 0.800
-0.55 +0.75 -0.75 x 105 0.375 20/20p SA30AL 118.4 21.5 0.925
-0.35 +0.25 -0.75 x 105 -0.125 20/30 SA30AL 118.4 20.0 0.225
-0.55 -1.25 x 105 -0.625 20/20 SA30AL 118.4 21.5 0.075
-0.04 +0.75 -2.00 x 160 -0.250 20/40p SA30AL 118.4 23.0 -0.210
-0.42 +1.00 1.000 20/30 SA30AL 118.4 19.0 1.420
-0.21 -0.25 -0.50 x 105 -0.500 20/25 SA30AL 118.4 23.0 -0.290
-0.69 +0.50 -1.50 x 105 -0.250 20/20 SA30AL 118.4 22.0 0.440
-0.61 -1.25 -0.75 x 145 -1.625 20/25 SA30AL 118.4 23.5 1.015
-0.46 -1.75 x 130 -0.875 20/40p SA30AT 118.4 22.0 -0.415
-0.58 -0.75 -0.75 x 155 -1.125 20/20 SA30AT 118.4 22.5 -0.545
-0.55 -0.25 -0.250 20/20 SA30AL 118.4 21.5 0.300
-0.39 0 0 20/20 SA30AT 118.4 22.5 0.390
-0.72 -0.25 -0.75 x 120 -0.625 20/20 SA30AT 118.4 19.0 0.095
-0.58 +0.25 -1.00 x 110 -0.250 20/20 SA30AT 118.4 21.5 0.330
-0.38 +1.00 -2.00 x 105 0 20/30p SA60AT 118.4 22.5 0.380
-0.36 0 0 20/20 SA30AT 118.4 20.0 0.360
-0.37 -0.50 -0.50 x 30 -0.750 20/20 SA30AT 118.4 21.0 -0.380
-0.15 +1.50 -1.50 x 90 0.750 20/50 SA30AL 118.4 23.0 0.900
-0.41 -1.25 x 95 -0.625 20/25 SA30AL 118.4 21.0 -0.215
-0.38 +0.25 0.250 20/20p SA30AL 118.4 21.0 0.630
-0.32 -0.25 -0.50 x 105 -0.500 20/20 SA30AL 118.4 21.5 -0.180
-0.63 -0.25 -2.00 x 135 -1.250 20/40 SA30AT 118.4 22.5 -0.620
-0.02 +0.75 -0.50 x 85 0.500 20/25 SA30AT 118.4 20.0 0.520
-0.35 +1.00 -1.00 x 150 0.500 20/30 SA30AT 118.4 22.5 0.850
-0.33 +0.50 -1.00 x 100 0 20/20 SA30AT 118.4 20.0 0.330
SE= spherical equivalent; VA= visual acuity; IOL= intraocular lens; K= IOL constant; n= number of operated eyes
For these cases, optic biometry is useful, with limitation of
needing good fixation and relative lens transparency
(11,22)
. Haigis
examined eyes after refractive surgery and found a 61% per-
centage of a correct refraction prediction between +/- 0.50 D
(6)
.
Due to restrictions of both methods (ultrasonic and optic), it is
necessary to use the best available formulas, to improve the
prediction error in postoperative refraction after phacoemul-
sification.
CONCLUSION
The results of this study support SRK/T formula as a good
option to predict the refractive error after cataract extraction
by phacoemulsification in eyes with medium axial length. To
our knowledge, this study is unique in reporting eyes with one
lens material from one manufacturer, implanted in the capsular
bag by the same surgeon, with preoperative measurements
obtained from the same instrumentation by the same method
and same technician, using SRK/T formula for IOL power
calculation in eyes with medium axial length that underwent
phacoemulsification with foldable IOL implantation.
ACKNOWLEDGEMENTS
The authors thank Yara Cristina Lopes from the Universi-
dade Federal de So Paulo for her help in performing all bio-
metric examinations.
RESUMO
Objetivo: Avaliar resultados refracionais utilizando a frmula
SRK/T no clculo de lentes intraoculares (LIO) em olhos com
comprimento axial mdio aps facoemulsificao. Mtodos:
Este estudo prospectivo envolveu 33 olhos com catarata nu-
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193 Clinical results in phacoemulsification using the SRK/T formula
Arq Bras Oftalmol. 2009;72(2):189-93
clear que foram submetidos a facoemulsificao. Todas as
cirurgias foram realizadas pelo mesmo cirurgio com lentes
intraoculares no saco capsular. O mesmo tecnlogo, o qual
no sabia o objetivo do estudo, realizou todas as medidas
biomtricas. O erro refracional atingido um ms aps a cirurgia
foi comparado ao erro refracional ps-operatrio previsto pela
frmula SRK/T. Resultados: O comprimento axial variou entre
22,2 mm e 24,5 mm. A refrao mdia prevista foi -0,431 0,181
dioptrias (D) e o equivalente esfrico ps-operatrio alcana-
do foi -0,220 0,732 D. Dezoito olhos (55%) obtiveram erro
refracional de 0,50 D e 30 olhos (91%) entre 1,00 D da
refrao prevista. Houve tendncia a um erro hipermetrpico
(mdiaSD: 0,211 0,708 D, p=0,009). Concluso: A frmula
SRK/T demonstrou acurcia satisfatria no clculo do erro
refracional em olhos de comprimento axial mdio.
Descritores: Biometria; Extrao de catarata; Implante de len-
te intraocular/mtodos; Doenas do cristalino; Facoemulsi-
ficao; Erros de refrao/cirurgia; Refrao ocular
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