ARTICLE

Intraocular lens power calculation in eyes with

previous hyperopic laser in situ keratomileusis
H. John Shammas, MD, Maya C. Shammas, MD, Warren E. Hill, MD

PURPOSE: To establish a corneal correction equation for the Shammas post-hyperopic laser in situ
keratomileusis (LASIK) (Shammas-PHL) formula and to evaluate its accuracy in cases with and
without available pre-LASIK data.
SETTING: Private practices, Lynwood, California, and Mesa, Arizona, USA.
DESIGN: Retrospective comparative observational study.
METHODS: The corrected corneal power (Kc) was calculated in each eye by adding the refractive
change at the corneal level to the pre-LASIK keratometric (K) readings. By comparing Kc with
the measured post-LASIK K readings (Kpost), the following equation was derived: Kc Z 1.0457
Kpost
1.9538. This equation was combined with the Shammas original formula to obtain the
Shammas-PHL formula.
RESULTS: The new formula was evaluated in 18 eyes with previous LASIK data and in 24 eyes with
no previous LASIK data. Using the Shammas-PHL formula, the mean arithmetic prediction error
was
0.03 diopter (D) G 0.72 (SD) (range
1.57 to C1.54 D) and the median absolute error was
0.38 D in 18 eyes with available pre-LASIK data and 0.05 G 0.58 D (range
0.56 to C1.40 D) and
0.43 D, respectively, in the 24 eyes with no pre-LASIK data.
CONCLUSION: The Shammas-PHL formula can be used in post-hyperopic LASIK cases whether or
not the pre-LASIK data are available.
Financial Disclosure: No author has a financial or proprietary interest in any material or method
mentioned.
J Cataract Refract Surg 2013; 39:739–744 Q 2013 ASCRS and ESCRS

Corneal refractive surgery is gaining in popularity as
the method of choice for the correction of refractive
errors. Although myopic laser in situ keratomileusis
(LASIK) represents the majority of refractive surgery,
more patients in their 40s, 50s, and 60s are now having
hyperopic LASIK. As these patients develop cataract,
Submitted: August 23, 2012.
Final revision submitted: November 5, 2012.
Accepted: November 28, 2012.
From the Department of Ophthalmology (H.J. Shammas), the Keck
School of Medicine of the University of Southern California, Los An-
geles, and the Shammas Eye Medical Center (H.J. Shammas,
M.C. Shammas), Lynwood, California, and East Valley Ophthalmology
(W.E. Hill), Mesa, Arizona, USA.
Corresponding author: H. John Shammas, MD, 3510 Martin Luther
King Jr. Boulevard, Lynwood, California 90262, USA. E-mail:
jshammas@shammaseye.com.
they will likely expect excellent uncorrected postoper-
ative visual acuity, just like after their refractive
surgery.
We used a small group of eyes for which pre-LASIK
data were available to evaluate the corneal refractive
changes after hyperopic LASIK, to incorporate these
changes into the Shammas post-hyperopic LASIK
(Shammas-PHL) formula, and to compare the results
of the new formula with the ones calculated by the in-
traocular lens (IOL) calculator on the American Society
of Cataract and Refractive Surgery (ASCRS) web site.A
The ASCRS online calculator has a module that allows
IOL power calculation in eyes with previous hyper-
opic LASIK or photorefractive keratectomy (PRK).
This module includes 5 methods based on pre-
LASIK or pre-PRK keratometry (K) values and/or
the surgically induced change in refraction; they are
the clinical history,1 Feiz-Mannis,2 corneal bypass,3
Masket,4 and modified Masket5 formulas. The only
formula that does not require pre-LASIK data is the

Q 2013 ASCRS and ESCRS 0886-3350/$ - see front matter 739

Published by Elsevier Inc. http://dx.doi.org/10.1016/j.jcrs.2012.11.031
740 IOL POWER CALCULATION IN EYES WITH PREVIOUS HYPEROPIC LASIK
Haigis-L formula,6 which uses a specific algorithm
for the adjustment of central corneal power after
refractive surgery for hyperopia. The module also in-
cludes an average IOL power7 that represents the
mean of all predicted IOL powers with the available
methods.
The results of the Shammas-PHL formula were also
evaluated retrospectively in eyes for which the refrac-
tive data were not available.
PATIENTS AND METHODS
In this retrospective study, all patients had pre-cataract sur-
gery measurements performed in Lynwood, California
(H.J.S.), or in Mesa, Arizona (W.E.H.). The pre-LASIK data
included the K readings (Kpre) and spectacle correction.
The post-LASIK data included the measured K readings
(Kpost) and spectacle correction. Biometry was obtained
with the Lenstar LS900 device (Haag-Streit AG) and in-
cluded measurement of the axial length (AL), central corneal
thickness (CCT), aqueous depth, and lens thickness. The bio-
meter also displays the anterior chamber depth (ACD) by
adding the CCT to the aqueous depth. Keratometry was ob-
tained by the same instrument using a 1.3375 index of refrac-
tion and included measurements at the flattest and steepest
meridians.
In this study, the mean K values and spherical equivalent
spectacle corrections were used in the presence of astigma-
tism. In each case, the pre-LASIK (Rc.pre) and post-LASIK
(Rc.post) refractive errors were calculated at the corneal
plane using a formula that assumes a vertex distance of
12 mm as follows:
Rc Z RsOð1
0:012RsÞ
The amount of hyperopia corrected at the corneal plane
(CRc) was also measured for each case where
CRc Z Rc:pre
Rc:post
The corrected corneal power (Kc) was calculated in each
eye as
Kc Z Kpre þ CRc
The measured values of Kpost and the calculated correct
values of Kc were plotted on a scattergram (Figure 1). The
best-fit regression equation was y Z 1.0457x
1.9538. Using
this equation and based only on the post-hyperopic LASIK
keratometric readings (Kpost), the corrected keratometric
value (Kc) can be calculated as
Kc Z 1:0457 Kpost
1:9538
This equation was combined with the Shammas original
formula8 to create a post-hyperopic LASIK modification,
the Shammas-PHL formula (Appendix), in which the
mean corneal power, K, is replaced by the corrected mean
corneal power, Kc, where Kc Z 1.0457 Kpost
1.9538,
with Kpost being the post-hyperopic LASIK K readings in
diopters (D). No other modification was made to the orig-
inal formula. The estimated postoperative ACD is ex-
pressed as the C value in the formula. The conversion
equation from the A constant of a specific IOL to the C
value used in the Shammas-PHL formula reads as follows:
J CATARACT REFRACT SURG - VOL 39, MAY 2013
Figure 1. Post-LASIK keratometric readings (Kpost) versus the cal-
culated values (Kc).
C Z (0.5835  A)
64.40 (Appendix). This conversion factor
is identical to the one in the Shammas-PL formula9 used in
the post-myopic LASIK cases.
All eyes with previous hyperopic LASIK had uneventful
cataract surgery between October 2010 and February 2012
by different surgeons, including the authors. The majority
of eyes had implantation of an Alcon SA60AT IOL (A con-
stant 118.4) or an Eyeonics Crystalens (A constant 118.6) be-
cause in general, hyperopic LASIK causes a reduction in the
naturally occurring positive spherical aberration of the cor-
nea. The other IOLs included the Alcon SN60WF (A con-
stant 118.9), Alcon SN6AD1 (A constant 118.9), and
Abbott Medical Optics Tecnis ZMA00 (A constant Z
119.4). The ASCRS web siteA was used to calculate the
IOL power.
In the cases in which pre-LASIK and post-LASIK data
were available, the prediction errors with the Shammas-
PHL formula were compared with the ones obtained with
the clinical history,1 Feiz-Mannis,2 corneal bypass3 (double-
K Holladay 1 formula used for all IOL power calculation pro-
cedures in these 3 formulas), Masket,4 modified Masket,5
Haigis-L,6 and the average formula7 from the ASCRS web
site.A The predicted refractive error is calculated as the diffe-
rence between the predicted refraction and the actual mea-
sured refraction. A positive value indicates the formula
would have left the eye more hyperopic than expected,
and a negative value indicates that the formula would
have left the eye more myopic than expected. For each oper-
ated eye, the following were evaluated: (1) mean arithmetic
prediction error with its standard deviation, (2) median
absolute prediction error, (3) number of eyes in which the
prediction error was within G0.50 D and within G1.00 D,
and (4) range of the prediction errors.
The results of the Shammas-PHL formula were also eval-
uated retrospectively in eyes for which the refractive data
were not available and compared with the results obtained
with the Haigis-L6 formula. To the authors' knowledge, these
are the only 2 formulas capable of calculating the IOL power
after hyperopic LASIK treatment when the pre-LASIK data
are not available.
Statistical analyses were performed using Microsoft Office
Excel (Microsoft Corp.) and SPSS for Windows software
(version 17.0, SPSS, Inc.). The prediction errors were com-
pared using a paired t test. The data followed a Gaussian
 IOL POWER CALCULATION IN EYES WITH PREVIOUS HYPEROPIC LASIK 741

Table 1. Prediction errors with the Shammas-PHL formula and the other formulas available on the ASCRS web site in the 18 eyes with avail-
able pre-hyperopic LASIK data.

Arithmetic Error Absolute Range of Eyes Within Eyes Within

Formula (D) Mean G SD Error (D) Errors (D) G0.50 D, n (%) G1.00 D, n (%)

Shammas-PHL
0.03 G 0.72 0.38
1.79, 1.54 12 (66.7) 15 (83.3)

Clinical history 0.24 G 0.78 0.37
1.57, 1.84 10 (55.6) 14 (77.8)
Feiz-Mannis 0.18 G 0.76 0.34
1.68, 1.75 10 (55.6) 16 (88.9)
Corneal bypass 0.31 G 0.79 0.47
1.52, 1.88 9 (50.0) 12 (66.7)
Masket formula 0.12 G 0.72 0.41
1.87, 1.42 12 (66.7) 15 (83.3)
Modified Masket 0.31 G 0.74 0.40
1.66, 1.56 10 (55.6) 12 (66.7)
Haigis-L 0.21 G 0.80 0.62
1.93, 1.55 8 (44.4) 14 (77.8)
Average, ASCRS web site 0.23 G 0.72 0.43
1.71, 1.67 9 (50.0) 15 (83.3)

distribution according to the method of Kolmogorov and
Smirnov. A probability of less than 5% (P!.05) was consid-
ered statistically significant. The median values are reported
for the absolute prediction errors because these absolute
values did not fit a Gaussian distribution.
RESULTS
The study comprised 42 eyes (18 right, 24 left) of 30 pa-
tients between 59 years and 74 years of age. Thirteen
eyes received an SA60AT IOL, 16 eyes an Eyeonics
Crystalens IOL, 4 eyes an SN60WF IOL, 3 eyes an
SN6AD1 IOL, and 6 eyes a Tecnis ZMA00 IOL.
The mean AL was 23.44 mm G 0.80 (SD) (range
21.45 to 24.88 mm). The mean post-hyperopic LASIK
K reading (Kpost) was 45.08 G 1.82 D (range 42.27
to 48.32 D), and the mean corrected K reading (Kc)
was 45.19 G 1.91 D (range 42.25 to 48.58 D).
Pre-LASIK and post-LASIK data were available in
18 cases, with K readings and stable refractions. Using
the Shammas-PHL formula, the mean arithmetic pre-
diction error was
0.03 G 0.72 D (range
1.57 to C
1.54 D) and the median absolute error was 0.38 D.
Twelve eyes (66.7%) were within G0.50 D, and 15
eyes (83.3%) were within G1.00 D. Table 1 compares
the prediction errors obtained by the Shammas-PHL
formula with the clinical history (PZ.04), Feiz-
Mannis (PZ.08), corneal bypass (PZ.02), Masket
(PZ.02), modified Masket (PZ.001), and Haigis-L
(PZ.0003) formulas and the average calculation from
the ASCRS web site (PZ.004). Figure 2 shows a box-
plot of the prediction errors with each formula.
The Shammas-PHL formula was retrospectively
tested in 24 cases with no pre-LASIK data. The mean
arithmetic prediction error was 0.05 G 0.58 D (range

0.56 to C1.40 D), and the median absolute error
was 0.43 D. Sixteen eyes (66.7%) were within G0.50 D,
and 23 eyes (95.8%) were within G1.00 D. The predic-
tion errors obtained with the Shammas-PHL formula
were compared with the ones obtained with the
Haigis-L formula, where the mean arithmetic predic-
tion error was 0.20 G 0.48 D (range
0.61 to C1.59 D)
and the median absolute error was 0.24 D; 17 eyes
(70.8%) were within G0.50 D and 23 eyes (95.8%)
within G1.00 D. The difference between the mean
prediction errors obtained by both formulas was not
statistically significant (PZ.11).
The mean prediction error obtained with the
Shammas-PHL formula in all 42 eyes was 0.01 G
0.65 D, with a median absolute error of 0.41 D. These
values were compared with the prediction errors ob-
tained with the original Shammas formula, with
a mean prediction error of 0.06 G 0.66 D and a median
absolute error of 0.48 D. The difference between the 2
sets of errors was not statistically significant (PZ.85).

Figure 2. Prediction errors (y-axis) with different IOL power calcula-
tion methods.
DISCUSSION
Most IOL power calculation formulas are based on
standard vergence equations, and the K readings in-
serted into these formulas represent the corneal power
measurement obtained by keratometry or by topogra-
phy. Most keratometers and topography units use
a conventional index of refraction of 1.3375 to convert
the measured radius of curvature of the anterior cor-
neal surface to a total corneal dioptric power. This in-
dex is based on an assumed fixed ratio between the
front and back curvatures of the cornea. After LASIK,
this ratio is altered, introducing an error in the

J CATARACT REFRACT SURG - VOL 39, MAY 2013

742 IOL POWER CALCULATION IN EYES WITH PREVIOUS HYPEROPIC LASIK
measurement of the corneal power. In other words, the
correct K values needed for accurate IOL power calcu-
lation are overestimated after myopic LASIK and
underestimated after hyperopic LASIK.
A second error is introduced when using 2-variable
third-generation IOL power formulas, namely the
Hoffer Q,10 Holladay 1,11 and SRK/T.12 The error is
caused by the manner in which these formulas inter-
nally calculate the estimated lens position (ELP),
which is the estimated postoperative distance between
the anterior corneal surface and the thin lens equiva-
lent of an IOL. These formulas use specific equations
based partly on the corneal curvature to measure
ELP. These equations will underestimate ELP after
myopic LASIK with a flatter cornea, and they will
overestimate it after hyperopic LASIK with a steeper
cornea. In an eye that had LASIK, the correct ELP
value should be calculated by entering the pre-
LASIK K values into the equation instead of contem-
porary post-LASIK measurements.13
After myopic LASIK, routine IOL power calcula-
tions with conventional third-generation formulas un-
derestimate the IOL power for emmetropia, resulting
in a high incidence of postoperative hyperopia. Theo-
retically, the same calculations in eyes that had hyper-
opic LASIK will result in postoperative myopia.
However, the magnitude of these errors is much lower
than in the post-myopic LASIK ones.6 Two reasons ac-
count for this discrepancy. First, the corneal steepen-
ing with hyperopic LASIK is relatively minimal
because less hyperopia than myopia is usually cor-
rected by LASIK. This, in turn, will decrease the im-
pact of any ELP miscalculation by the IOL power
formulas. In our study, the hyperopic LASIK correc-
tion averaged 2.10 G 1.88 D (range 0.25 to 5.72 D),
while in a previous study evaluating the corneal
changes after myopic LASIK,14 the myopic correction
was much higher, with a mean of 4.08 G 1.77 D (range
1.62 to 9.50 D). Second, our study has shown that the
change in the index of refraction secondary to the cor-
neal steepening from the hyperopic LASIK will induce
an error in the K readings of approximately 0.10 D in
a moderately steepened 45.00 D cornea and 0.30 D in
an extremely steepened 49.00 D cornea. Haigis and
Goes6 even found a lower error magnitude (0.01 and
0.05 D, respectively). This is in contrast to the errors in-
duced by myopic LASIK of 0.90 D in a moderately flat-
tened 42.00 D cornea and 1.50 D in an extremely
flattened 38.00 D cornea.14 This difference is due to
the way LASIK is applied in each case. In myopic
LASIK, the anterior corneal surface is flattened with a
major change in the conventional 1.3375 index of
refraction. In hyperopic LASIK, the corneal periphery
is thinned out to steepen the central cornea. The mini-
mal change in the required corneal power correction
J CATARACT REFRACT SURG - VOL 39, MAY 2013
after hyperopic LASIK in our study suggests that the
ratio between the anterior corneal radius and the pos-
terior corneal radius is not as altered as after myopic
LASIK. Further studies with Scheimpflug imaging of
the cornea are needed to evaluate and document the
post-hyperopic LASIK corneal changes.
In our series, many patients with bilateral hyperopia
had hyperopic LASIK to achieve emmetropia; how-
ever, a certain number opted for monovision, with 1
eye focused for distance and 1 eye focused for reading.
We also had emmetropic patients who had hyperopic
LASIK in the nondominant eye only to achieve monovi-
sion. We even had a small number of patients with low
myopia who opted for myopic LASIK in the dominant
eye to allow clear distance vision and for hyperopic
LASIK in the nondominant eye to allow reading
vision. This patient mix is reflected in the relatively
average AL of 23.44 mm (range 21.45 to 24.88 mm).
The Shammas-PHL formula is a modification of the
original Shammas formula8 coupled with the corneal
power correction equation. Contrary to the Hoffer Q,10
Holladay 1,11 and the SRK/T12 formulas, the ELP is
not altered after LASIK because the corneal power is
not used to calculate the estimated position of the
IOL. It was designed to calculate the IOL power after
hyperopic LASIK treatment whether or not the pre-
LASIK data are available. Our corneal correction equa-
tion can also be used with the Hoffer Q,10 Holladay 1,11
and SRK/T12 formulas if the ELP is also corrected with
the Aramberri double-K formula.13
In our study, we retrospectively used the Shammas-
PHL formula in 18 eyes for which the preoperative
LASIK data were available and we compared the re-
sults with the ones obtained by the 7 formulas avail-
able on the ASCRS web site.A Both the arithmetic
and the absolute errors with the Shammas-PHL for-
mula were among the lowest. In the second retrospec-
tive study in which the Shammas-PHL formula was
tested in 24 eyes with no previous data related to
LASIK, the final refraction was within G0.50 D in
66.7% of cases and within G1.00 D in 95.8% of cases.
These percentages are well within the benchmark stan-
dards for refractive outcomes after cataract surgery in
normal eyes (55% of cases within G0.50 D) established
by the National Health Service of the United King-
dom15 and by the Swedish National Cataract Register
Study.16 Although our results are on par with other
methods used for IOL power calculation, further re-
finement of the currently used formulas is needed to
improve the overall accuracy, especially in eyes that
had previous LASIK surgery.
The maximum amount of corneal power correction
needed for IOL power calculation after hyperopic
LASIK in our study was 0.26 D, and the mean value
was only 0.11 D. Such values are definitely on the level
 IOL POWER CALCULATION IN EYES WITH PREVIOUS HYPEROPIC LASIK
of measurement errors for corneal powers. In previous
studies in which different biometric parameters were
compared at a 1-month interval, the median absolute
difference between the 2 K readings was 0.14 D with
a maximum difference of 1.04 D in 1 study17 and a me-
dian absolute difference of 0.18 D with a maximum
difference of 0.54 D in the second study.18
To gauge the added value of the corneal correction
equation when performing IOL power calculation in
eyes that had hyperopic LASIK, we compared the re-
sults obtained in all 42 eyes using the Shammas for-
mula with and without said equation. Although the
difference between the 2 sets of results was not statis-
tically significant (PZ.85), the use of the corneal cor-
rection equation decreased the mean absolute error
from 0.48 to 0.42 D. The amount of hyperopic LASIK
corneal correction was known in 18 cases. In the 11
cases in which this correction was less than 1.50 D,
the addition of the corneal correction equation to the
Shammas formula decreased the median absolute
error from 0.37 to 0.35 D only. However, in the 7 cases
in which this correction exceeded 1.50 D, it decreased it
from 0.57 to 0.49 D. Although the number of these
cases is too small for statistical analysis, it leads us to
believe that the use of the corneal correction equation
is more beneficial when the amount of corrected
hyperopia by LASIK exceeds 1.50 D, while straight
uncorrected small zone autokeratometry is often
sufficient when the amount of corrected hyperopia
by LASIK is below 1.50 D. Further prospective studies
are needed to validate its value in post-hyperopic
LASIK eyes, whether or not the pre-LASIK data are
available.
WHAT WAS KNOWN
 The IOL power calculation with 2-variable third-
generation formulas (Hoffer Q, Holladay 1, SRK/T) in
eyes that had previous hyperopic LASIK will result in an
overestimation of the IOL power and the frequent occur-
rence of unanticipated postoperative myopia.
 Multiple formulas to improve the postoperative refractive
results are available from the IOL calculator on the ASCRS
web site.
WHAT THIS PAPER ADDS
 A new formula, the Shammas-PHL, is described to allow
IOL power calculation in eyes with previous hyperopic
LASIK, whether or not the pre-LASIK data are available.
 The Shammas-PHL formula was found to be accurate in
its predictions when compared with other available
formulas.
J CATARACT REFRACT SURG - VOL 39, MAY 2013
743
APPENDIX
The Shammas-PHL Formula
Calculations for an emmetropic IOL:
1336
IOLemm Z
L
0:1ðL
23Þ
ðC þ 0:05Þ
1


1:0125 C þ 0:05


Kc 1336
where L is the axial length in millimeters, C is the post-
operative anterior chamber depth (ACD) (estimated
postoperative ACD) in millimeters, and the corrected
K readings Kc is 1.0457 Kpost
1.9538, with the Kpost
being the post-LASIK K readings in diopters.
Calculations for an ametropic IOL:
1336
IOLam Z
L
0:1ðL
23Þ
ðC þ 0:05Þ
1


1:0125 C þ 0:05


Kc þ R 1336
where R is the desired refraction at the corneal plane.
For converting the A-constant of a specific IOL to the
Shammas pACD:
C Z pACD Z ð0:5835  AÞ
64:40
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First author:
H. John Shammas, MD
Department of Ophthalmology,
the Keck School of Medicine of the
University of Southern California,
Los Angeles, California, USA