Accuracy of IOL power calculations in the very elderly



To analyze the refractive predictability and outcomes of cataract surgery in the very elderly (≥85 years old).


A retrospective case-series performed at the Shiley Eye Institute, University of California San Diego, USA. Electronically pulled data of 2444 surgeries revealed 147 surgeries on 133 very elderly patients. Chart review was conducted for all very elderly and corresponding control patients (75–84 years old). The first operated eyes of patients with final best-corrected visual acuity ≥20/40, axial length (AL) 22–26 mm, and implanted SN60WF IOL were included. Patients with ocular comorbidities and/or intra- or post-operative complications were excluded. Prediction errors of refractive outcome and percentage of eyes within ±0.50D and ±1.00D were compared between the groups for the Holladay 1 and Barrett Universal II (Barrett) formulas. Logistic regression analysis for achievement of ±1.00D was conducted.


Final analysis included 90 eyes (n = 44, very elderly, n = 46, control patients). Median absolute refractive error (MedAE) with Holladay 1, but not Barrett formula, was significantly higher in the older group (p = 0.02 and p = 0.07, respectively). The MedAE in the older group was lower using the Barrett compared to Holladay 1 (p = 0.02). Fewer older patients than younger patients achieved refraction within ±0.50D and ±1.00D from goal, using the Holladay 1 (p = 0.049 and p = 0.002 respectively). Logistic regression analysis supported the relationship between Holladay 1 predictive refractive error of >1.00D and patient’s age (p = 0.046).


Very elderly patients undergoing cataract surgery may be prone to reduced refractive precision, particularly with utilization of the Holladay 1 formula.

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Fig. 1: Summary of criteria for patient selection.
Fig. 2: Refractive outcomes within the range of ±0.50D and ±1.00D using the Holladay I formula and the Barrett Universal II formula among the age groups.


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All authors contributed to the study conception and design. Material preparation, data collection, and analysis were performed by RS, LC, AKS, and HEG. The first draft of the paper was written by RS and all authors commented on previous versions of the paper. All authors read and approved the final paper. The authors would like to acknowledge Saurabh Sawney and Ashima Aggrawal for the complimentary use of the online lens formula performance audit calculator, available online at


This project was partially supported by the National Institutes of Health, Grant T35 AG026757/AG/NIA, an unrestricted grant from Research to Prevent Blindness (New York, NY) and the University of California San Diego, Stein Institute for Research on Aging.

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Correspondence to Natalie A. Afshari.

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Financial disclosure(s): RS, LC, AKS, HEG, NAA—no relevant financial disclosures. RNW: Consultant: Aerie Pharmaceuticals, Alcon, Allergan, Bausch & Lomb, Eyenovia, Novartis, Sensimed, Unity, Valeant; Financial support: Heidelberg Engineering, Carl Zeiss Meditec, Genentech, Konan, Optovue, Topcon, Optos, Centervue. AKS: non-financial support: Heidelberg Engineering, grants: Bayer Vital, Novartis.

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Sella, R., Chou, L., Schuster, A.K. et al. Accuracy of IOL power calculations in the very elderly. Eye (2020).

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