Review

A comprehensive guide to
managing astigmatism in the
cataract patient
Expert Rev. Ophthalmol. Early online, 1–6 (2014)
Expert Review of Ophthalmology Downloaded from informahealthcare.com by Nyu Medical Center on 10/15/14

Michael J Coleman, Improvements in cataract surgery and ophthalmic lens technology have turned cataract surgery
Walter J Stark and into a refractive procedure. Patients are expecting that they will no longer require contact lens
Yassine J Daoud* or glasses for excellent vision. In order to meet the patient’s expectations, the surgeon must be
meticulous with preoperative measurements and precise with the intraoperative alignment of
The Wilmer Eye Institute, Johns Hopkins
University, Maumenee 327, 600 North
the implanted toric lens. Technological advances in intraoperative aberrometry and image
Wolfe Street, Baltimore, MD 21287, guidance software will improve intraoperative alignment of astigmatism correcting lens.
USA Despite the improvements in measurements, unforeseen refractive outcomes will occur and it
*Author for correspondence: is critical that the cataract surgeon is equipped to correct any problems. A systematic
Tel.: +1 410 910 2330
Fax: +1 410 910 2393 evaluation should be undertaken to find the source of the error. Complete ocular exam with
ydaoud1@jhmi.edu lens axis measurement, manifest refraction and repeat corneal measurements should be done.
Treatment options to correct residual refractive error include toric lens rotation, laser vision
For personal use only.

correction with photorefractive keratectomy or laser in-situ keratomileusis, piggyback lens

placement or intraocular lens (IOL) exchange. Prior to selecting a treatment option, it is
important to compare pre- and post-operative calculations. If preoperative calculations are
correct, a vector analysis can be performed to determine suggested IOL adjustment to correct
the refractive error. If toric lens rotation does not provide a satisfactory refractive outcome,
laser vision correction is recommended as a first option. If the patient is not a good refractive
candidate, an IOL exchange with a monofocal lens or with the appropriate toric lens, if the
loops can be safely placed in the bag, is advocated.

KEYWORDS: astigmatism • astigmatism correction • astigmatism management • cataract surgery • misaligned toric
lens • toric intraocular lens

decreased patient satisfaction after cataract

Background
Cataract affects nearly 22 million Americans
age 40 and over. By age 80, more than half of
all Americans have cataract [1]. As ophthalmic
technology has improved, there has been an
increased expectation of glass and contact lens
independence after cataract surgery.
The lower order refractive errors include
sphere and cylinder. Corneal astigmatism is a
significant contributor to preoperative ametro-
pia, and it is estimated that approximately
40% of patients having cataract surgery have
astigmatism of more than 1.0 diopter (D) [2].
Levels of corneal astigmatism greater than
1.50D are prevalent in 19–22% of the popula-
tion and levels of astigmatism greater than
3.5D are present in 1.7–2.7% [3–6]. Uncor-
rected astigmatism is a significant cause of
extraction. Postoperative residual astigmatism
greater than 0.75D may reduce patient visual
acuity as well as reduce their visual quality [7].
Common symptoms of uncorrected astigma-
tism include glare, ghosting, blur and halos [8].
Managing preexisting corneal astigmatism at
the time of cataract surgery is essential to
achieving optimum refractive outcomes.
Corneal astigmatism is the summation of the
power of the anterior and posterior cornea.
Corneal astigmatism is broadly divided into
regular and irregular astigmatism. Irregular
astigmatism can be defined as astigmatism
where the principal meridians are not 90˚ apart
that prevents it from being improved with
cylindrical spectacles alone. Regular astigma-
tism can be corrected with cylindrical spectacles
because the primary meridians are 90˚ apart.

informahealthcare.com 10.1586/17469899.2014.967217 Ó 2014 Informa UK Ltd ISSN 1746-9899 1

 Review Coleman, Stark & Daoud
Since the introduction of toric intraocular lens (IOL) in
1992 by Shimizu, improvements in IOL design, IOL material,
surgical technique and toric calculators have made implanting a
toric lens a great option for correcting corneal astigmatism in
the cataract patient [9]. In this article, we will discuss preopera-
tive, intraoperative and postoperative considerations when deal-
ing with these patients as well as how to manage residual
astigmatism after toric lens insertion.
Preoperative evaluation
During preoperative evaluation for cataract surgery, it is essen-
tial to perform a thorough examination including refraction,
Expert Review of Ophthalmology Downloaded from informahealthcare.com by Nyu Medical Center on 10/15/14
slit-lamp biomicroscopy, tonometry, fundus examination, ocu-
lar biometry (corneal topography, keratometry, Scheimpflug
imaging) and IOL calculations. When considering astigmatism
correction at the time of cataract surgery, it is important that
the magnitude and axis of astigmatism be evaluated with at
least two instruments [10]. Corneal astigmatism can be corrected
with peripheral corneal relaxing incisions, paired clear corneal
incisions, toric IOL (monofocal or multifocal) or postoperative
laser vision correction [11–18]. During preoperative counseling
with the patient, it is very important to determine the patient’s
visual needs.
For personal use only.
Measurements
Optical biometry is critical for accurate correction of refractive
error after cataract surgery [19]. With trained staff, consistent and
reproducible measurements can be achieved with the available
ocular biometric instruments. Prior to performing corneal biom-
etry, patients who are soft contact lens wearers should remove
their contact lens 1–2 weeks prior to preoperative measure-
ments. Rigid gas-permeable contact lens wearers should remove
their contact lens at least 3 weeks prior to measurements.
At our institution, we use both IOL Master 500 (Carl Zeiss
Meditec, Jena, Germany) and Lenstar LS 900 (Haag Streit,
Mason, OH, USA) for keratometry, axial length and IOL
calculations [11–13,20]. When evaluating patients for possible
astigmatism correction, we also perform manual keratometry
(Bausch & Lomb, Rochester, NY, USA) and Pentacam (Ocu-
lus, Wetzlar, Germany) measurements [14]. While manual kera-
tometry only evaluates the central 3.2 mm optical zone, it does
provide useful information about the power and axis of astig-
matism in the visual axis. The Pentacam and Galilei (Ziemer,
Switzerland) accurately measure the global astigmatism of the
anterior and posterior cornea. We compare these measurements
to ensure that the magnitude and axis of astigmatism is repro-
ducible between machines. While all instruments may not be
available in every clinic location, using two keratometry meas-
urements of astigmatism will improve refractive outcomes with
toric lens correction [10].
Preoperative marking
Appropriate axis alignment is critical for successful astigmatism
correction. Upright marking is usually performed to avoid ocu-
lar cyclotorsion that may occur when the patient is placed in
doi: 10.1586/17469899.2014.967217
the supine position. Several techniques for marking the ocular
surface have been described. Patients can be marked at the slit
lamp or in their stretcher at the horizontal axis or at the 3, 6,
9 o’clock position. These marks can then be used for marking
the orientation axis of the toric lens [21].
Ocular cyclotorsion alone can result in a measurement error
of 2˚ between corneal markings when compared at two differ-
ent time points [22]. To minimize preoperative mark alignment
errors, digital photography is increasingly being used to aid in
alignment [21]. Preoperative digital photography using iris or
conjunctival vessels as landmarks can minimize marking errors
and improve postoperative alignment. The preoperative digital
images can be used in concert with software on the operative
microscope to allow precise alignment of the toric lens. Tech-
nologies, such as the Verion image guidance system (Alcon, Ft
Worth) or Guidance SG3000, can serve as axis alignment
markers or they can also perform intraoperative aberrometry to
confirm lens power as well as to align the lens axis (ORA,
Wavetec, Aliso Viejo, CA, USA) [22]. During the IOL position-
ing, the surgeon will see an overlay in the operating micro-
scope, which confirms the intended axis of alignment.
Operative technique
Once the desired marking system has been applied, the cataract
extraction will be performed with the surgeons’ preferred tech-
nique. As long as appropriate capsular support is in place, the
foldable IOL is then injected into the capsular bag. IOL posi-
tioning usually starts once the IOL is in the bag but prior to
completion of its unfolding. The IOL can be dialed approxi-
mately 5–10˚ counterclockwise to the axis of intent before the
ophthalmic viscosurgical device (OVD) is removed as the lens
may rotate during the OVD removal process. Alternatively, the
lens can be aligned on axis and held in place with either the
irrigation/aspiration hand piece or a second instrument during
OVD removal. After all OVD is removed, the IOL is centered
and aligned. It is easier to rotate the IOL clockwise rather than
counterclockwise after the viscoelastic is removed. The final
alignment is again checked once the incisions are watertight.
Postoperative evaluation
Postoperative day 1 exam is just a routine vision and intraocu-
lar pressure check. On the 1–2-week postoperative appoint-
ment, the patient is usually dilated to check for toric lens
alignment. The tolerance for lens misalignment depends on the
magnitude of cylindrical correction. The higher the cylinder
power, the more likely the patient will have clinically signifi-
cant uncorrected astigmatism. The astigmatism correcting
power of the IOL is reduced by 3.3% for each 1˚ the lens is
off its intended axis. If alignment is within 5˚ of the axis, a
final postoperative exam is performed within 4–6 weeks to
check for the final refraction. If the lens is more than 10˚ off
axis, an IOL repositioning, depending on the patient’s vision
and early refraction, may be considered. The toric IOL axis can
be determined by using the biomicroscope (slit lamp with
rotating slit) or digital photography against the red reflex.
Expert Rev. Ophthalmol.
 A comprehensive guide to managing astigmatism in the cataract patient
Postoperative refractive surprise
Despite the improvements in measurements, unforeseen refrac-
tive outcomes will occur, with approximately 9% of patients
having more than 5˚ of misalignment, and it is critical that the
cataract surgeon is equipped to correct any problems [13].
A systematic evaluation should be undertaken to find the
source of the error [19,23,24]. Complete ocular exam with lens
axis measurement, manifest refraction and repeat corneal meas-
urements should be done. Every stage of the planning and exe-
cution of a toric IOL can serve as a source of error, which
could lead to toric misalignment or residual uncorrected
astigmatism.
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Preoperatively, measurement errors may occur including
measurements of the noncentral cornea from poor fixation,
poor ocular surface or failing to evaluate the posterior cor-
nea [19,23,24]. Preoperative errors can be minimized by having an
optimal corneal surface. Dry eye and blepharitis should be
appropriately treated, as this can adversely affect measurements.
Using Scheimpflug imaging (Pentacam or Galilei) allows for
assessment of the anterior and the posterior cornea astigmatism.
The use of at least two keratometry measurements will also
improve measurement accuracy.
Intraoperatively, cyclotorsion [25] can cause misalignment if
corneal marks are performed while the patient is in the supine
For personal use only.
position or if done after peribulbar anesthesia. Care should be
taken when performing preoperative markings. Success has
been documented using Nuijts–Lane toric marker, pendular
marker and slit lamp corneal markings [21]. The reference
marks are then used to align the IOL axis.
Postoperatively, the lens is more likely to decenter or mis-
align if viscoelastic is left behind the intraocular lens, the ante-
rior chamber shallows secondary to ocular trauma or a wound
leak or a silicone IOL is used [26]. To minimize this risk, all
OVD should be removed from the capsular bag and an acrylic
lens should be selected for astigmatism correction.
Treatment of residual refractive outcome
Treatment options to correct residual refractive error include
nonsurgical options (e.g., contact lens or glasses) or surgical
options. The treatment options depend on the patient’s satisfac-
tion with their visual acuity and their spectacle dependence. Sur-
gical treatment of residual refractive error include piggyback lens
placement, limbal relaxing incisions (LRI), IOL exchange, toric
lens rotation, laser vision correction with photorefractive kera-
tectomy (PRK) or laser in situ keratomileusis (LASIK). The goal
of any of the treatments is to get the patient to 0.5D or less of
residual astigmatism after the intervention is performed. Prior to
selecting a treatment option, it is important to compare pre-
and postoperative calculations. After verifying the correctness of
preoperative calculations, a vector analysis can be performed or
the treating physician can contact the IOL manufacturer to find
out the suggested IOL axis adjustment to correct the refractive
error [27,28]. If toric lens rotation does not provide a satisfactory
refractive outcome, laser vision correction is recommended as a
first option. If the patient is not a good refractive candidate,
informahealthcare.com
Review
then an IOL exchange with a monofocal lens or with the appro-
priate toric lens replacement is advocated [29,30].
Early interventions
Lens rotation
Once the source of the residual refractive error is identified, a
plan of action for treatment can be initiated. If the residual
refractive error can be treated by rotating the axis of alignment,
then this should be the first choice [31] if the patient is unhappy
with the refractive results. This is easier in the early postopera-
tive period, and this would be our first choice within the first
2 months of initial surgical implantation of the toric IOL.
We approach the lens rotation procedure in a similar fashion
to primary toric implantation. The patient should be marked
preoperatively in the upright position. Once the patient is
brought into the operating room, the axis of orientation is then
marked on the cornea. The previous clear corneal incision may
be opened or the procedure can be done through two paracent-
eses that give easy access to the optic haptic junction. The ante-
rior chamber is filled with a cohesive viscoelastic. A 27G
cannula on the viscoelastic syringe can be used to inject the
cohesive viscoelastic under the capsulorhexis edge to separate
the lens from the anterior capsule. Cohesive viscoelastic is then
injected posterior to the lens to dilate the capsular bag and sep-
arate the IOL from the capsule.
Once the lens is mobile, it is rotated to the correct axis. The
viscoelastic is then removed by bimanual irrigation and aspira-
tion. The lens axis is checked against the cornea markings to
ensure accurate alignment.
Refractive surgery
If IOL rotation is not adequate to address the residual refrac-
tive outcome, PRK and LASIK are safe and effective options
for correcting small-to-moderate refractive errors. Laser vision
correction addresses both residual spherical and cylindrical
errors. Currently, wavefront-guided and wavefront-optimized
lasers are not US FDA approved for refractive correction after
toric IOL implantation. There are no data showing superiority
of custom over conventional LASIK/PRK after toric lens place-
ment, but wavefront-guided laser ablations may be beneficial
after implantation of an aspheric toric IOL as this may mini-
mize higher order aberrations [32]. If a wavefront-guided plat-
form is unavailable, we recommend using the laser system that
is available to the surgeon.
IOL exchange
If a significant refractive error occurs after primary cataract sur-
gery (>3D), we recommend IOL exchange within the first
6–8 weeks after cataract surgery. Repeating all calculations is
advised to ensure accuracy.
Once the patient is brought into the operating room, the previ-
ous clear corneal incision may be opened or a new 3 mm corneal
incision is created. The anterior chamber is filled with a viscoelas-
tic. A 27G cannula on the viscoelastic syringe can be used to
inject the cohesive viscoelastic under the capsulorhexis edge to
doi: 10.1586/17469899.2014.967217
 Review Coleman, Stark & Daoud
separate the lens from the anterior capsule. Cohesive viscoelastic
is then injected posterior to the lens to dilate the capsular bag.
Once the lens is mobile, the distal haptics are freed from the cap-
sule using gentle traction. Once the haptic is freed, it is pulled
out of the capsular bag. Once both haptics are freed, the lens is
elevated into the anterior chamber. An IOL fold in the anterior
chamber can be performed or the optic can be cut and the lens
can then be pulled out of the eye through the primary incision. If
the haptics are significantly fibrosed into the capsule and they
cannot be freed, amputation of the haptic at the optic haptic
junction can be performed [33]. Once the lens is removed, if the
posterior capsule is open (from prior YAG capsulotomy or from
Expert Review of Ophthalmology Downloaded from informahealthcare.com by Nyu Medical Center on 10/15/14
surgical trauma), anterior vitrectomy is performed. The three-
piece replacement lens can then be inserted into the ciliary sulcus.
LRI/astigmatic keratotomy
In patients who have mild residual astigmatism but may be
deterred by the cost of refractive surgery, LRIs can serve as a safe
and effective way to treat residual astigmatism [34]. LRIs have
fallen out of favor secondary to its less predictable outcomes
compared to toric IOLs. Currently, LRIs are having a resurgence
with the increasing popularity of femtosecond laser-assisted cata-
ract surgery. The newer femtosecond lasers create accurate inci-
sions of predictable depth and length. This appears to show some
For personal use only.
promise; however, nomograms are still being developed for this
treatment modality. Given the less predictable correction of LRIs
compared to refractive surgery, we recommend refractive surgery
as it corrects both spherical and astigmatic refractive error.
Late interventions
In our practice, this tends to be a self-referral for a second
opinion in a patient who has had a toric lens placed elsewhere
and is dissatisfied with the results. These patients tend to come
in for evaluation 6 months to a year after their primary cataract
surgery. When approaching these patients, the decision is more
nuanced. Again, repeat imaging is performed to assess the cor-
neal astigmatism, ocular surface and IOL position. The
patient’s old records should be requested. Once all the data are
collected, we determine if the implanted lens was correct. If so,
would a YAG capsulotomy resolve the patient’s symptoms or
would IOL rotation/exchange improve the refractive outcome?
If there is any consideration for an IOL exchange, then a cap-
sulotomy should not be performed, but many times this has
been done prior to the initial exam in this patient population.
Piggyback lens
Caution is advised if IOL rotation is to be performed in
referred patients because of uncertainty of capsular support. If
there is significant refractive error, PRK or LASIK can be used.
Rarely, a piggyback IOL may be inserted [35,36]. Even though
this will not address residual astigmatism, it has been proven to
successfully reduce spherical error and it can be combined with
astigmatic keratotomy.
To perform a piggyback IOL placement, the lens power is
determined. This can be done by using the Holliday R formula
doi: 10.1586/17469899.2014.967217
or the refractive vergence formula [29,30]. The patient is dilated
preoperatively. The incision is created. The anterior chamber is
filled with a dispersive viscoelastic to protect the endothelium.
A dispersive viscoelastic is then used to expand the ciliary sul-
cus. Once the lens is selected, it is easy to insert the lens
through a 3-mm clear corneal incision. The IOL is then
injected into the sulcus. The lead haptic is placed directly into
the ciliary sulcus. The trailing haptic can then be placed by
using McPherson forceps, Kuglen or Lester hook. If the lens
was initially delivered completely into the anterior chamber,
the haptics can be positioned posteriorly to the iris using a
Kuglen or Lester hook. The viscoelastic is then removed and
the wounds are checked for integrity.
Toric implantation in corneal disease
Implanting toric IOL is not FDA approved in patients with
corneal ectasia or those who have undergone penetrating kera-
toplasty. Thus, significant amount of care and extensive discus-
sion with the patient are imperative before such a procedure is
done. In patients with documented progression of corneal ecta-
sia or those at risk of graft rejection or failure, toric IOLs are
not recommended.
The predictability of astigmatism correction with toric IOLs
correction has allowed for successful astigmatism correction in
patients who have stable keratoconus and pellucid marginal
degeneration [37–40], as well as in patients with prior penetrating
keratoplasty [41–43]. Although the surgical technique has minimal
modifications, preoperative counseling is important. Issues
related to graft failure and rejection need to be discussed with
cornea transplant patients [43]. Loss of the ability to fully correct
astigmatism with the use of rigid contact lens needs to be thor-
oughly addressed with ectasia and post-keratoplasty patients [44].
If the patient might need a rigid gas-permeable contact lens to
correct irregular astigmatism, a toric IOL should not be used.
Prior to considering toric IOL implantation in patients with
corneal ectasia, it is imperative that refractive stability, for at
least 6 months, is documented [37]. The treating physician
should ensure that the patient is happy with glass correction,
because hard contact lenses will leave the astigmatism of the
toric IOL uncorrected [44]. If a toric rigid contact lens cannot
be used, then such patients will likely require the use of glasses
to correct this residual refractive error [44].
Prior to toric lens implantation in a post-penetrating kerato-
plasty patient, all sutures should be removed and the patient
should have regular astigmatism on topography [41–43]. A thor-
ough discussion about potential graft failure, induction of rejec-
tion and potential increase in astigmatism should be held with
the patient during the surgical consent.
Expert commentary
Preoperative corneal assessment with Scheimpflug imaging and
keratometry will provide the cataract surgeon with the informa-
tion necessary to perform successful astigmatism correction
with a toric lens. It is essential that the preoperative measure-
ments and intraoperative alignment are done with precision
Expert Rev. Ophthalmol.
 A comprehensive guide to managing astigmatism in the cataract patient Review

and consistency for best outcomes. If an undesired refractive
outcome occurs, appropriate corrective action can be performed
by using a systematic approach to determine the source of
error. Measurements should be repeated. Vector analysis should
be performed to see if IOL rotation will correct the problem.
If toric lens rotation does not provide a satisfactory refractive
outcome, laser vision correction is recommended as a first
option. If the patient is not a good refractive candidate, then
an IOL exchange is recommended. If these steps are followed,
this will allow for prompt correction of the undesired refractive
outcome and reduce the number of subsequent patients who
will likely require additional surgical interventions.
Expert Review of Ophthalmology Downloaded from informahealthcare.com by Nyu Medical Center on 10/15/14
and toric calculators will continue to improve the accuracy of
IOL selection. There is potential for postoperative refraction
modification with the light adjustable lens or mechanically
adjustable lens [45]. Improved preoperative biometry coupled
with intraoperative aberrometry or image-guided systems will
minimize the number of refractive surprises after refractive
cataract surgery.
Financial & competing interests disclosure
The authors have no relevant affiliations or financial involvement with
any organization or entity with a financial interest in or financial
conflict with the subject matter or materials discussed in the

manuscript. This includes employment, consultancies, honoraria, stock

Five year view ownership or options, expert testimony, grants or patents received or
New technologies are on the horizon. Femtosecond laser- pending, or royalties.
assisted cataract extraction has allowed for improved lens cen- No writing assistance was utilized in the production of this
tration. Current improvements in preoperative measurements manuscript.

Key issues
• Greater patient expectation as well as out-of-pocket expense can make toric intraocular lens placement a high-stakes proposition.
• Despite meticulous preoperative toric calculations and intraoperative axis alignment, uncorrected residual astigmatism can occur.
• Postoperative management of residual refractive error with intraocular lens repositioning, laser vision correction or limbal relaxing
incisions can improve patient satisfaction.
For personal use only.

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