537
FROM THE EDITOR
Management of astigmatism
during cataract surgery
Nick Mamalis, MD
Salt Lake City, Utah, USA
Trouble with the curve
dWarner Bros. Pictures
Refractive outcome is one of the critical factors in the suc-
cessful treatment of patients with cataracts. Astigmatism is
commonly associated with patients undergoing cataract
surgery and correcting corneal astigmatism is an important
step in obtaining optimal results.1,2
The correction of astigmatism is one of the vexing prob-
lems in the treatment of patients with cataracts. There are
several methods that have been evaluated for the intraoper-
ative treatment of astigmatism in patients undergoing cata-
ract surgery. Corneal astigmatic incisions (CAIs), including
limbal relaxing incisions (LRIs) utilizing either a blade or a
femtosecond laser, are used for the correction of lower
levels of corneal astigmatism whereas toric intraocular
lenses (IOLs) are used for moderate or higher levels of
corneal astigmatism. Kessel et al. performed a large meta-
analysis evaluating toric IOLs in the correction of astigma-
tism and found that these lenses were more effective in
lowering astigmatism than CAIs.3
There is also the issue of utilizing manual LRIs versus
femtosecond laser–assisted astigmatic keratotomy for the
treatment of astigmatism. Roberts et al. found that there
were statistically significant differences favoring femto-
second laser astigmatic keratometry over manual LRIs in
a randomized controlled trial.4
In spite of currently available treatments, significant
corneal astigmatism can still be noted in patients following
cataract surgery. Accurate measurements for the power of
an IOL as well as the amount and axis of astigmatism are
critical. There are several instruments available that allow
precise measurement of corneal astigmatism in patients un-
dergoing cataract surgery. These include various laser inter-
ferometers such as the IOLMaster 500/700 (Carl Zeiss
Meditech AG) and the Lenstar LS 900 biometer (Haag-
Streit AG). In addition, there is the VERION Image Guided
System (Alcon Laboratories, Inc.). These measuring devices
along with a modern generation IOL calculation of formula
allow for more precise preoperative measurements of the
intended correction necessary for a patient with cataracts
and astigmatism. Other methods of decreasing the amount
of residual astigmatism during cataract surgery include the
use of intraoperative aberrometry. This technology not only
can measure the refractive error in an eye following the
Q 2019 ASCRS and ESCRS
Published by Elsevier Inc.
removal of the cataract but can also measure the degree
of astigmatism as well as the axis of astigmatism. This tech-
nology can allow intraoperative measurements following
placement of a toric IOL.
In this issue, Solomon et al. (page 569) present results of a
randomized study utilizing both eyes of patients with cata-
racts and astigmatism who underwent surgery. These pa-
tients were randomly assigned to two separate groups.
Group A included patients who received “the surgeon's
preferred standard of care.” This method utilized blue
marks denoting the astigmatic axis on the cornea. Patients
with low levels of astigmatism received manually created
LRIs. Those patients with higher levels of astigmatism
received toric IOLs. The IOL spherical power was selected
in this group using the Barrett Universal IIA formula and
biometry utilizing the IOLMaster as well as the Lenstar
LS 900 biometer. Astigmatic corrections were planned using
the keratometry method and the calculator/nomogram to
determine toric IOL power as well as orientation.
The opposite eye in this randomized group of patients
then were placed in Group B. These patients underwent
laser-assisted phacoemulsification utilizing a femtosecond
laser to also create corneal arcuate incisions in those with
lower levels of astigmatism. The patients with higher
levels of astigmatism underwent similar laser-assisted
phacoemulsification with placement of a toric IOL. The
second group of patients had their preoperative measure-
ments made using the VERION Image Guided System
with a surgeon-optimized Holladay 2 formula.B Patients
who underwent both CAIs and toric IOLs had calculations
made with the VERION plantar utilizing the Lenstar axial
length. The VERION digital markers were then used for
access placement. Intraoperative aberrometry was then
performed in this group of patients using the ORA System
with VerifEyeC Technology (Alcon Laboratories, Inc.) to
evaluate the need for any changes to both spherical power
as well as IOL orientation.
All patients were then evaluated postoperatively at
1 month and 3 months, at which time measurements
were made for the corrected distance visual acuity, using
the Early Treatment Diabetic Retinopathy Study system,
as well as manifest refraction, automated refractor keratot-
omy, and corneal topographic data. The primary end point
of the study was the amount of residual refractive astigma-
tism at 3 months. However, the authors also looked at
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https://doi.org/10.1016/j.jcrs.2019.03.022
538 FROM THE EDITOR
several secondary end points including the spherical equiv-
alent refraction and the uncorrected and corrected distance
visual acuity at both 1 month and 3 months. The actual axis
of the IOL was then compared to the intended axis. In addi-
tion, corneal incision stability at 3 months after surgery was
also evaluated based on manifest astigmatism and keratom-
etry comparing the 1-month to the 3-month data.
At the 3-month postoperative measurement, there was a
statistically significant difference when looking at the mean
residual astigmatism with toric IOLs resulting in a statisti-
cally significant less cylinder than CAIs. However, there
was no statistically significant difference when comparing
surgical methods. Furthermore, there was no statistically sig-
nificant difference in the mean spherical equivalent refrac-
tion in terms of surgical method or treatment. Lastly, there
was no statistically significant difference in uncorrected
visual acuity by treatment, surgical method, or over time.
Another important measurement was the axis of the toric
IOL, which was compared at 1 month and 3 months post-
operatively. At 3 months, 2 eyes in the standard group and 2
eyes in the automated group were found to have more than
10 degrees of absolute orientation away from the intended
axis. However, none of these eyes required a secondary sur-
gical intervention to reorient the IOL. Furthermore, only 1
eye had an absolute angle change of more than 5 degrees
between 1 month and 3 months.
The primary conclusion of this study was that the com-
bined use of the VERION Image Guided System and
ORA System with VerifEyeC intraoperative aberrometer
for correcting astigmatism in the form of a toric IOL or
arcuate incisions did not significantly improve outcomes
when compared to the surgeon's standard of care. A second
important outcome from this study was that the authors
found that toric IOLs resulted in almost 0.25 diopter less
cylinder than CAIs.
There were several limitations to this study that were
noted by the authors including a relatively small observed
difference between groups, which make it difficult to
demonstrate any clinically significant changes. In addition,
the authors looked at multiple different factors and did not
independently look at the effects of image alignment and
intraoperative aberrometry on the orientation and the po-
wer of the IOL. Lastly, the first group of patients (Group
A) received not only manual corneal incisions, but also
manual capsulorrhexis and phacoemulsification, while the
second group of patients (Group B) had femtosecond laser
corneal incisions as well as capsulotomies.
What can the cataract surgeon deduce from studies like
this evaluating the treatment of astigmatism during cataract
Volume 45 Issue 5 May 2019
surgery? First, no matter what method is used for the
correction of astigmatism, accurate measurements of the
eye preoperatively are critical. It is essential that accurate
axial length measurements be made and modern IOL
formulas be used to calculate the power of the IOL, and
accurate measurements regarding the degree of corneal
astigmatism as well as the axis of the astigmatism are
crucial. Second, CAIs either created manually or with a
femtosecond laser are a very good way of treating relatively
low levels of astigmatism. Last, toric IOLs are an excellent
method of treating moderate to higher levels of astigma-
tism. The use of high-tech methods utilizing intraoperative
aberrometry and an image guidance system did not
produce a significant difference in refractive outcomes
utilizing both CAIs and toric IOLs when compared with
manual methods utilized for the correction of astigmatism.
These results are reassuring in an era in which both patients
and surgeons demand excellent refractive outcomes
following cataract surgery at the same time there are
increased constraints to limit costs related to the treatment
of cataract surgical patients.
REFERENCES
1. Hoffmann PC, Hutz WW. Analysis of biometry and prevalence data from
corneal astigmatism in 23,239 eyes. J Cataract Refract Surg 2010;
36:1479–1485
2. Hayashi K, Hirata A, Manabe S-I, Hayashi H. Long-term change in corneal
astigmatism after sutureless cataract surgery. Am J Ophthalmol 2011;
151:858–865
3. Kessel L, Andresen J, Tendal B, Erngaard D, Flesner P, Hjortdal J. Toric
intraocular lenses in the correction of astigmatism during cataract surgery:
a systemic review and meta-analysis. Ophthalmology 2016; 123:
275–286
4. Roberts HW, Wagh VK, Sullivan DL, Archer TJ, O'Brart DPS. Refractive out-
comes after limbal relaxing incisions or femtosecond laser arcuate keratoto-
my to manage corneal astigmatism at the time of cataract surgery. J Cataract
Refract Surg 2018; 44:955–963
OTHER CITED MATERIAL
A. Barrett GD. Barrett Universal II Formula. Singapore, Asia-Pacific Association
of Cataract and Refractive Surgeons. Available at: http://www.apacrs
.org/barrett_universal2/. Accessed March 20, 2019
B. Holladay JT. Holladay IOL Consultant Software & Surgical Outcomes
Assessment. Bellaire, TX, Holladay Consulting. Available at: http:
//www.hicsoap.com. Accessed March 20, 2019
First author:
Nick Mamalis, MD
Department of Ophthalmology and Visual
Sciences, John A. Moran Eye Center,
University of Utah, Salt Lake City, USA