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SURGICAL MANAGEMENT OF
ASTIGMATISM
SURGICAL MANAGEMENT OF
ASTIGMATISM
Editors
Dimitri T Azar MD MBA
Senior Director, Ophthalmic Innovations
Clinical Lead, Ophthalmology Programs
Alphabet Verily Life Sciences
San Francisco, CA, USA
Distinguished University Professor
BA Field Chair of Ophthalmological Research and
Former Medical School Executive Dean
University of Illinois College of Medicine, Chicago, IL, USA

Jorge L Alió MD PhD FEBOphth

Professor and Chairman of Ophthalmology
VISSUM Instituto Oftalmológico, Alicante, Spain
Division of Ophthalmology
Universidad Miguel Hernández, Alicante, Spain

M Soledad Cortina MD
Associate Professor of Ophthalmology, Director
Comprehensive Ophthalmology Faculty Practice (COFP) and General Eye Clinic
University of Illinois College of Medicine
Department of Ophthalmology and Visual Sciences
University of Illinois at Chicago, Chicago, IL, USA

Joelle A Hallak MS PhD

Assistant Professor and Executive Director
Ophthalmic Clinical Trials and Translational Center
Director, Ophthalmic Data Science Laboratory
Department of Ophthalmology and Visual Sciences
University of Illinois at Chicago, Chicago, IL, USA

JAYPEE BROTHERS MEDICAL PUBLISHERS

The Health Sciences Publisher
New Delhi | London
 Jaypee Brothers Medical Publishers (P) Ltd
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© 2020, Jaypee Brothers Medical Publishers
The views and opinions expressed in this book are solely those of the original contributor(s)/author(s) and do not necessarily represent those
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All rights reserved. No part of this publication may be reproduced, stored or transmitted in any form or by any means, electronic, mechanical, photo­
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Inquiries for bulk sales may be solicited at: jaypee@jaypeebrothers.com
Surgical Management of Astigmatism
First Edition: 2020
ISBN: 978­93­89188­85­1
 Dedicated to
Our families. Without their constant support,
this book would not have been possible.
 Contributors

Afua Annor MD Arthur Cummings FRCS MD Daniel G Fernández-Pacheco PhD

Ophthalmologist Medical Director Faculty
University of California Davis Eye Center Wellington Eye Clinic Department of Graphical Expression
Sacramento, CA, USA Consultant Ophthalmologist Technical University of Cartagena
Head, Department of Ophthalmology Cartagena, Spain
Alanna S Nattis DO FAAO Beacon Hospital, Dublin, Ireland
Ophthalmologist Dimitri T Azar MD MBA
Department of Cornea and Asier Villanueva MSc Senior Director, Ophthalmic Innovations
Refractive Surgery Researcher Clinical Lead, Ophthalmology Programs
SightMD, NY, USA Department of Optical and Alphabet Verily Life Sciences
Visual Sciences San Francisco, CA, USA
Alexander Pleet MD University of Alicante, Alicante, Spain Distinguished University Professor
Glaucoma Fellow BA Field Chair of Ophthalmological
Department of Ophthalmology Brent A Kramer MD Research and
Feinberg School of Medicine Ophthalmology Resident Former Medical School Executive Dean
Northwestern University Department of Ophthalmology University of Illinois College of Medicine
Chicago, IL, USA University of North Carolina at Chapel Hill Chicago, IL, USA
Chapel Hill, NC, USA
Alfredo Vega-Estrada MD PhD Eric D Donnenfeld MD
Ophthalmologist Bryan S Lee MD JD Ophthalmologist
Department of Cornea and Ophthalmologist Long Island Cornea, LASIK and Cataract
Refractive Surgery Department of Cornea and Specialist
Vissum/Instituto Oftalmológico de Refractive Surgery Department of Ophthalmology
Alicante, Spain Altos Eye Physicians Ophthalmic Consultants of Long Island
Los Altos, CA, USA Garden City, NY, USA
Almutez M Gharaibeh MD
Associate Professor of Ophthalmology Damien Gatinel MD PhD Eric D Rosenberg DO MSE
Chief of Service Ophthalmologist
Faculty of Medicine
Department of Anterior Segment and Valhalla, NY, USA
The University of Jordan
Refractive Surgery
Amman, Jordan F Cavas Martínez
Rothschild Foundation PhD
Paris, France Faculty
Andrea Arteaga MD
Department of Graphical Expression
Ophthalmology Resident
David F Chang MD Technical University of Cartagena
Department of Ophthalmology and
Clinical Professor Cartagena, Spain
Visual Sciences
University of California San Francisco
University of Illinois FJ Fernández Cañavate
San Francisco, CA, USA PhD
Chicago, IL, USA Faculty
David R Hardten MD FACS Department of Graphical Expression
Andrzej Grzybowski MD PhD MBA
Ophthalmologist and Founding Partner Technical University of Cartagena
Professor Minnesota Eye Consultants Cartagena, Spain
Department of Ophthalmology Minnesota, USA
Chair of Ophthalmology George Stamatelatos BScOptom
University of Warmia and Mazury Debora E Garcia-Zalisnak MD Clinical Director
Olsztyn, Poland Cornea, Refractive Surgery and External ASSORT
Head, Institute for Research in Disease Specialist Senior Optometrist
Ophthalmology Clear Vision Ophthalmology New Vision Clinics
Poznan, Poland Tucson, Arizona, USA Melbourne, Australia
viii Surgical Management of Astigmatism

Gunther Grabner MD Jorge L Alió del Barrio MD PhD Noel Alpins AM FRANZCO FRCOphth FACS
Professor Surgeon, Cornea, Cataract, and Refractive Clinical Professor and Medical Director
Department of Ophthalmology Surgery Newvision Clinics
Paracelsus Medical University Division of Ophthalmology CEO of ASSORT
Salzburg, Austria Universidad Miguel Hernández Department of Ophthalmology
Alicante, Spain University of Melbourne
Joao Crispim MD Melbourne, Australia
Ophthalmologist Jose de la Cruz MD
Department of Ophthalmology and Assistant Professor
Piotr Kanclerz MD PhD
Visual Sciences Department of Ophthalmology and
Ophthalmologist
Federal University of São Paulo Visual Sciences
Department of Ophthalmology
São Paulo, Brazil University of Illinois at Chicago
Chicago, IL, USA Medical University of Gdansk
Gdansk, Poland
Joelle A Hallak MS PhD
Assistant Professor and Kai Kang MD
Assistant Professor Praneetha Thulasi MD
Executive Director
Department of Ophthalmology and Assistant Professor
Ophthalmic Clinical Trials and
Visual Sciences Department of Ophthalmology
Translational Center
University of Illinois at Chicago Emory Eye Center
Director
Ophthalmic Data Science Laboratory Chicago, IL, USA Atlanta, GA, USA
Department of Ophthalmology and Laurent Bataille
Visual Sciences
MSc Renan Ferreira Oliveira MD
Director Research and Development Ophthalmologist, Cataract and
University of Illinois at Chicago VISSUM Instituto Oftalmológico
Chicago, IL, USA Refractive Surgeon
Alicante, Spain Sadalla Amin Ghanem Eye Hospital
John SM Chang MD Leon Strauss MD PhD
Joinville, SC, Brazil
Director, Guy Hugh Chan Refractive Instructor
Surgery Centre Department of Ophthalmology Ricardo M Nosé MD
Hong Kong Sanatorium The Wilmer Eye Institute Research Fellow
and Hospital The Johns Hopkins University Department of Cornea, Cataract and
Happy Valley, Hong Kong School of Medicine Refractive Surgery
Baltimore, MD, USA Massachusetts Eye and Ear Infirmary
John P Berdahl MD Harvard Medical School
Ophthalmologist Surgeon M Soledad Cortina MD Boston, MA, USA
Vance Thompson Vision Associate Professor of Ophthalmology
Sioux Falls, SD, USA Director Roberto Fernández-Buenaga MD PhD
Comprehensive Ophthalmology Faculty Consultant Ophthalmologist
Jonathan Rubenstein MD Practice (COFP) and General Eye Clinic Department of Cornea, Cataract and
Professor University of Illinois College of Medicine Refractive Surgery
Department of Ophthalmology Department of Ophthalmology and Vissum Corporación
Rush University Medical Center Visual Sciences Madrid, Spain
Chicago, IL, USA University of Illinois at Chicago
Chicago, IL, USA Roberto Pineda II MD
Jorge L Alió MD PhD FEBOphth
Associate Professor
Professor and Chairman of Mauro C Tiveron Jr MD
Ophthalmology ICO Fellow Department of Ophthalmology
VISSUM Instituto Oftalmológico Department of Cornea, Cataract and Director
Alicante, Spain Refractive Surgery Department of Refractive Surgery
Division of Ophthalmology Massachusetts Eye and Ear Infirmary Massachusetts Eye and Ear Infirmary
Universidad Miguel Hernández Harvard Medical School Harvard Medical School
Alicante, Spain Boston, MA, USA Boston, MA, USA
 Contributors ix

Samantha Williamson MD Suphi Taneri MD Tomoaki Nakamura MD

Cornea and External Disease Specialist Director Ophthalmologist
Department of Ophthalmology Center for Refractive Surgery Department of Refractive Surgery
Kaiser Permanente Mid-Atlantic Medical Owner, Eye Department Nagoya Eye Clinic
Group St Franziskus Hospital, Munster Namiyose Atsuta-ward Nagoya, Japan
Baltimore, MD, USA Lecturer, Ruhr University
Bochum, Germany Verónica Vargas MD
Shilpa Gulati MD Refractive Surgery Fellow
Retina Fellow Susie Drake MD Department of Investigation,
Tufts New England Eye Center Cornea and External Disease Specialist Development and Innovation
Ophthalmic Consultants of Boston Center for Eye Care Vissum Alicante, Alicante, Spain
Boston, MA, USA Watertown Regional Medical Center
Watertown, WI, USA
 Preface

Astigmatism is one of the most frequent problems encountered in the surgical management of cataract, cornea, and
refractive conditions. In essence, the correction of astigmatism is part of the success of any anterior segment surgical
procedure.
Regardless of its types, astigmatism can be difficult to manage and may complicate surgical outcomes. In contrast
to myopia, there is no single focal point in astigmatism, which poses a challenge to the modern trends in refractive and
intraocular lens surgery.
The modern trend is to obtain a unique quality of retinal images, not distorted by astigmatism. This is why in this
book we present various solutions to the different types of astigmatism that the practical surgeon will find in today’s world
of refractive and cataract-lens surgical practices. The different chapters of this book are based on scientific evidence
and practice. Well-known authors, with extensive practice, offer what they consider to be pearls of their knowledge to
optimize and improve surgical outcomes for the correction of astigmatism with cornea or intraocular procedures.
We would like to thank all the authors and contributors of the book for sharing their knowledge and expertise through
comprehensive chapters. They have worked tirelessly on their chapters. Without their consistent efforts and dedication,
the book would lack the essence that we want to transmit to the readers, which is how to manage astigmatism from the
diagnostic stages, instrumental examinations, surgical plannings, surgical applications, and, last but not least, analysis
of outcomes.

Dimitri T Azar
Jorge L Alió
M Soledad Cortina
Joelle A Hallak
 Acknowledgments

We would like to acknowledge and thank our students and mentors as well as our patients for trusting us in their care,
and for helping us in advancing the management of astigmatism.
Lastly, we would like to thank Shri Jitendar P Vij (Group Chairman), Mr Ankit Vij (Managing Director), Mr MS Mani
(Group President), Ms Chetna Malhotra Vohra (Associate Director—Content Strategy), Ms Pooja Bhandari (Production
Head) and Ms Prerna Bajaj (Development Editor) of M/s Jaypee Brothers Medical Publishers (P) Ltd, New Delhi, India,
for giving a go-ahead at the very beginning and helping us in every way possible to bring out this book.
 Contents

1. Etiology, Pathogenesis, and Epidemiology of Astigmatism and History

of its Surgical Management 1
Andrzej Grzybowski, Piotr Kanclerz

2. Optics of Regular Astigmatism 12

Leon Strauss

3. Optical Clinical Assessment of Astigmatism, Surgical Vector Planning,

and Analysis of Astigmatism for Refractive Surgery 22
Noel Alpins, George Stamatelatos

4. Keratometry and Placido‑based Topography: Techniques,

Advantages, and Limitations 25
Damien Gatinel

5. Scanning-slit, Scheimpflug, and Optical Coherence Tomography

in Regular and Irregular Astigmatism 36
Ricardo M Nosé, Mauro C Tiveron Jr, Roberto Pineda II

6. Morphogeometric Analysis of the Cornea and its Relation

to Corneal Astigmatism 53
F Cavas Martínez, Asier Villanueva, Laurent Bataille,
FJ Fernández Cañavate, DG Fernández-Pacheco

7. Corneal and Total Aberrometry: Orthogonal/Oblique and Secondary

Higher‑order Aberrations in Astigmatism 60
Andrea Arteaga, Jose de la Cruz

8. Aberrated Cornea–Irregular Astigmatism in Real-world Optics:

Topography, Aberrometry, and Applications in Refractive Surgery 66
Samantha Williamson, Joao Crispim, Dimitri Azar

9. Preoperative Evaluation of Astigmatism in Cataract Surgery 79

Debora E Garcia-Zalisnak, Joelle A Hallak, Soledad Cortina

10. Surgical Planning for the Correction of Astigmatism 85

Noel Alpins, George Stamatelatos

11. Posterior Corneal Astigmatism Measurement Techniques and

Preoperative Planning for Cataract Surgery 91
Kai Kang, Jose de la Cruz, Joelle A Hallak, Soledad Cortina, Dimitri Azar
xvi Surgical Management of Astigmatism

12. Toric Pseudophakic Intraocular Lenses: Materials/Characteristics of

Toric Monofocal, Toric Bifocal, and Toric Trifocal Intraocular Lenses 99
Roberto Fernández-Buenaga, Jorge L Alió

13. Surgical Techniques: Axis Marking, Toric Intraocular Lens

Positioning, and Incisional Approaches 117
Bryan S Lee, David F Chang

14. Intraoperative Alignment Techniques 128

Afua Annor, Jonathan Rubenstein

15. Induced and Residual Astigmatism after Cataract Surgery 136

Alexander Pleet, Soledad Cortina, Dimitri Azar

16. Correcting Astigmatic Surprises Following Toric Intraocular Lens Implantation 154
David R Hardten, John P Berdahl, Brent A Kramer

17. Cataract and Refractive Lens Exchange Surgery in Keratoconus 164

Jorge L Alió del Barrio, Roberto Fernández-Buenaga, Jorge L Alió

18. Astigmatic Keratotomy and Limbal Relaxing Incisions: Principles,

Indications, and Nomograms 173
Eric D Rosenberg, Alanna S Nattis, Eric D Donnenfeld

19. Femtosecond Arcuate Keratotomy: Principles, Indications, and Techniques 180

Gunther Grabner

20. Laser Profiles and Depths for Myopic, Hyperopic, and Mixed Astigmatism 186
Shilpa Gulati, Joelle A Hallak, Dimitri Azar

21. Photoastigmatic Refractive Keratectomy and Laser-assisted

in Situ Keratomileusis: Surgical Management of Astigmatism 195
Susie Drake, Soledad Cortina, Dimitri Azar, Joelle A Hallak

22. Small incision Lenticule Extraction versus Laser in Situ Keratomileusis in

Myopic Astigmatism 213
Suphi Taneri

23. Outcomes of Photorefractive Keratectomy, Laser in Situ Keratomileusis, and Small-

incision Lenticule Extraction for Myopic, Mixed, and Hyperopic Astigmatism 221
Jorge L Alió del Barrio, Verónica Vargas, Roberto Fernández-Buenaga, Jorge L Alió

24. Custom Treatment of Irregular Astigmatism 231

Arthur Cummings
 Contents xvii

25. Management of Postkeratoplasty Astigmatism 240

Praneetha Thulasi, Joelle A Hallak, Dimitri Azar, Soledad Cortina

26. Management of Astigmatism after Cataract Surgery: Excimer Laser, Astigmatic

Keratotomy, Piggyback IOL and IOL Exchange 249
Renan Ferreira Oliveira, Roberto Fernández-Buenaga, Jorge L Alió del Barrio, Jorge L Alió

27. Surgical Management of Corneal Ectatic Disorders Using Intracorneal Ring Segments,
Corneal Collagen Cross-linking, and Thermokeratoplasty Procedures 262
Alfredo Vega-Estrada, Renan Ferreira Oliveira, Jorge L Alio

28. Topography-guided Surgical Correction of Astigmatism: Indications, Techniques,

Limitations, and Complications 271
John SM Chang

29. Toric Implantable Collamer Lenses for the Correction of Astigmatism 283
Tomoaki Nakamura

30. Iris Clip Toric Phakic Intraocular Lenses for Keratoconus and Irregular Astigmatism 296
Almutez M Gharaibeh, Jorge L Alió

Index 309
CHAPTER 1
Etiology, Pathogenesis, and Epidemiology
of Astigmatism and History of its
Surgical Management
CORE MESSAGES
ll This chapter covers the etiology, pathogenesis, and
epidemiology of astigmatism, as well as the history of
surgical treatment.
ll The lack of standardized methods for population-
based studies on astigmatism make comparisons
challenging.
ll Visual impairment caused by astigmatism ranges from
2.2 to 34%.
ll The 19th century contributed greatly to our under­
standing and management of astigmatism, with the
first attempts to alter the refraction in astigmatic
patients by changing the shape of the cornea made
in the final two decades of the 19th century.
ll The occurrence of acquired astigmatism is an issue in
several ophthalmic procedures.
EPIDEMIOLOGY
According to the World Health Organization, in 2004, a
total of 153 million people (range of uncertainty: 123–184
million) were estimated to have visual impairment due
to uncorrected refractive errors, of whom 8 million were
blind.1 Other sources report that uncorrected refractive
errors and cataract are the principal causes of visual
impairment globally (43 and 33%, respectively).2-4 Naidoo
et al. put focus on the increase in vision impairment due
to uncorrected refractive errors: 15% in years 1990–2010.5
Visual impairment caused by astigmatism ranges from
2.2 to 34% depending on the region and the urban/rural
Andrzej Grzybowski, Piotr Kanclerz
setting.1 This gives an estimate of 2.7 up to 62.5 million
people with vision loss as a result of this disorder.2-5 In
some studies, the prevalence of astigmatism in people
aged over 50 years reaches 77%.6,7
Assessment of the prevalence of astigmatism
encounters a number of technical problems. Compa­
risons between studies might be problematic, as no
standardization has been introduced. Refractive error
measurements in population-based studies are usually
noncycloplegic. Commonly, stationary autorefractors
are used, however, home evaluation with handheld
autorefractors was employed in single studies. In children,
diagnostics of the refractive error are determined by
objective refraction under cycloplegia and subjective
refraction. In infants and preschool children, most
measurements are obtained by retinoscopy. Astigmatism
is usually defined as a refractive error of ≥1.00 cylindrical
diopter, less commonly as ≥0.75 cylindrical diopter.8 The
axis of the cylinder is classified as with-the-rule if the
minus cylinder axis is 0 ± 15°,8,9 against-the-rule if the
axis is 90 ± 15°, and oblique astigmatism when the axis
does not comply the preceding criteria. In some studies,
the range was 45° (0 ± 22.5° for with-the-rule, 90 ± 22.5°
for against-the-rule).10 Moreover, a range of 40° or 60° is
used in some papers.11 Several studies lacked information
regarding the preceding criteria.12,13 Furthermore, there
is a deficiency of cross-sectional reviews. Several studies
relate to a specific age group or are related to very limited
geographical areas.
2 Surgical Management of Astigmatism
Major Cross-sectional Studies
The European Eye Epidemiology Consortium conducted
a meta-analysis of data from 33 adult cohort and
cross-sectional studies. Refractive data were collected
between 1990 and 2013, mostly from Northern and
Western Europe. Fifteen population-based studies met
the eligibility criteria. In patients aged over 15 years,
the prevalence of astigmatism was 27.3% with an age-
standardized prevalence of 23.9%.12 Astigmatism rates
were fairly constant in the analyzed studies (15–25%), but
were higher after the age of 65. As data on ethnicity were
available for only 50% of participants with minimal ethnic
diversity, analysis of ethnicity was not carried out. Across
all age groups the prevalence of astigmatism was higher in
men than in women, and this difference was particularly
pronounced in middle aged individuals. As most of the
studies were conducted in Northern and Western Europe,
no conclusions regarding predominance in particular
regions could be drawn.11
The prevalence of astigmatism in the United States was
evaluated in the National Health and Nutrition Examination
Survey on 14,213 adult participants, which were examined in
the years 1999–2004.13 The reported rates varied by age; for age
groups of 20–39, 40–59, and ≥60 years, prevalence estimates
were 23.1, 27.6, and 50.1%, respectively. The prevalence of
astigmatism varied slightly by race–ethnicity category. In
those aged 60 years and older, astigmatism was more prevalent
among males (54.9%) than among females (46.1%).
The Blue Mountains Eye Study was a population-
based assessment of visual impairment of the
representative older Australian community sample. The
examinations were performed in years 1992–1994.8 The
prevalence of astigmatism (equal or higher than 0.75
cylindrical diopter) was 37%, and high cylinder values
(higher than 1.5 D) were reported in 13% of eyes. The
gender-adjusted mean cylinder increased with age: for
ages 49–59, 60–69, 70–79, and 80–97 years, it was −0.6 D,
−0.7 D, −1.0 D, and −1.2 D, respectively. There was no
statistically significant difference in the mean cylindrical
error between men and women. Furthermore, a trend
of increased cylindrical error with the spherical error
(either myopic or hyperopic) was found. There was no
difference in the axis of astigmatism by gender or age
group.
Most of the aforementioned population-based studies
on refractive errors correspond to European or European-
derived populations. Some large population-based studies
in Asian populations have been conducted in Singapore,
Nepal, Hong Kong, China, and Malaysia.14 The Singapore
Epidemiology of Eye Disease Study reported the prevalence
of astigmatism as 58.8% in a multiethnic cohort aged 40
years and over.15 The prevalence of astigmatism increased
with increasing age, while no sex difference was found. The
prevalence of astigmatism in the Chinese Singaporeans
was significantly higher in all age groups compared with
that in Singaporean Indians. Furthermore, the authors
observed that the prevalence of astigmatism increased
significantly during the 12 years of the study. The major
increase in the astigmatism rate was due to the increase
in the myopic astigmatism rate, which accounted for 72%
of the observed increase in the rate of astigmatism, while
hyperopic astigmatism accounted only for 16%. Therefore,
the authors postulated that the increase in myopic
astigmatism was due to the rise in environmental factors
such as a more competitive education environment.
The Baltimore Eye Study was a population-based
survey of ocular disorders among patients aged 40 years
and older living in East Baltimore, Maryland, United
States. It was conducted in the years 1985–1988. The rates
of astigmatism were higher for White people than for Black
people at all ages. In this study, astigmatism increased
with age in men and was more prevalent in men than in
women.16 These results were similar to the findings from
the European Eye Epidemiology Consortium. Most of the
studies found that the rates of astigmatism are higher in
men or revealed no differences between genders. However,
some reports from China and Bangladesh noted a higher
prevalence of astigmatism in women.17-19
A correlation between astigmatism and cataract
formation has been found, however, the mechanism by
which cataract induces astigmatism is not always clear. It is
argued that mainly cortical cataract can lead to astigmatic
shift and it might be caused by asymmetrical refractive
index changes within the parts of the cortex of the lens.20
Moreover, an association between nuclear cataract and
astigmatism was described.19
Other epidemiological risk factors for astigmatism
include lower educational background and living in an
urban population.11,17,19
 Etiology, Pathogenesis, and Epidemiology of Astigmatism and History of its Surgical Management
Relationship between Age and Astigmatism
Nearly half of 0- to 6-month-old infants have significant
astigmatism of one or more diopters. The prevalence found
in the first year of life is greatly reduced by the age of 4,
reaching <5% by the ages of 6–10 years.10 Before the age of
4½, years, most children have against-the-rule astigmatism,
and after that age, with-the-rule.9 After the age of 10, there
is an increased prevalence of astigmatism among those
children in whom it manifested earlier.10 Other studies put
forward a decline in astigmatism up to the age of 14 years.21
In adults there is a positive correlation between the
prevalence of astigmatism and age. The normal cornea
becomes steeper and shifts with age from with-the-rule
to against-the-rule astigmatism. Hayashi et al. noted that
the normal cornea gradually becomes steeper in virtual
proportion to age, leading to myopic shift.22 However, a
spherical equivalent often changes to hyperopia with aging
between ages 20 and 60, though a myopic shift occurs
after age of 60–70 years.23,24 Thus, other aging factors, such
as the increase in lens thickness and the decrease of its
maximum refractive index age, may have a greater impact
on the spherical equivalent.25
The alterations of shape of the cornea with age depend
on internal factors, such as aging of the cornea. It has been
reported that interfibrillar spacing of corneal collagen
decreases with age, and in particular, collagen bundles
become thicker.26 These structural changes may alter the
rigidity and elasticity of the cornea, thus leading to age-
related steepening and astigmatic shift. It has also been
investigated that corneal astigmatism shows an against-
the-rule shift of approximately 0.2–0.4 D within 10 years.27
ETIOLOGY, PATHOGENESIS, AND RISK
FACTORS
One possible explanation for the etiology of astigmatism
is that it may be genetically determined. The results of
twin,28-30 family,31 and genetic32,33 studies might support
this thesis.
In a study conducted on Norwegian twins, both
conditional and relative risks of developing astigmatism
were considerably higher in monozygotic twins than
in dizygotic twins. The autosomal dominant genetic
heritability was put forward with individual environmental
effects, partially explaining the contribution to astigmatism.
No differences in heritability of astigmatism between the
genders were found.28 Dirani et al. conducted a study
3
based on the Australian Twin Registry. In monozygotic
twin pairs, the risk of astigmatism was significantly higher
than that in dizygotic twins. Furthermore, the authors
claim that nonadditive genetic defects explain 50% of
variance in corneal astigmatism.29
Several studies have been conducted in an attempt to
find genes that influence the development of astigmatism.
Fan et al. described findings from a meta-analysis of five
genome-wide association studies in Asia. They revealed
that genetic variants in the PDGFRA gene on chromosome
4q12 are associated with corneal astigmatism. PDGFRA is
a receptor for platelet-derived growth factor. It is expressed
in several tissues within the eye and appears to contribute
to ocular development. The polymorphism in the PDGFRA
gene exhibited a strong and consistent effect over five
Asian cohorts.32,33 In a study by Lopes et al. conducted
on seven cohorts of 22,100 individuals in Europe and of
European descent, a susceptibility locus was identified
in the VAX2 gene on chromosome 2p13.3. The VAX2
gene plays an important role in the early stage of eye
development, particularly in forming the dorsal–ventral
axis of the eye.32,33 Another important study was conducted
by the CREAM consortium, which comprised researchers
from more than 30 research groups and performed a meta-
analysis of data for a total of 32 cohorts of White European
and Asian population. Their study revealed that refractive
astigmatism might be genetically codetermined with
the spherical equivalent refractive error. However, in the
meta-analysis of all cohorts, no marker was found to have
genome-wide significance. The most strongly associated
regions were NRXN1, TOX, and LINC00340.34
The incidence of astigmatism is associated with the
spherical equivalent refractive error. The Multi-ethnic
Pediatric Eye Disease and Baltimore Pediatric Eye Disease
Studies proved that children with myopia are 4.6 times
more likely to have astigmatism than children with no
refractive error. With hyperopia, the risk ratio is 1.6. 35
Fan et al. suggested that stable astigmatism in preschool
children is associated with greater progression of myopia
in subsequent years. An explanation for this issue would be
that astigmatism blurs vision and thus might influence the
development of myopia.36 On the other hand, astigmatism
might be a result of an even development of the eye,
including its axial length and corneal structure. This thesis
would be supported by the fact that astigmatism might be
genetically codetermined with the spherical equivalent
refractive error.34
4 Surgical Management of Astigmatism
External factors might also have an influence on the
development of astigmatism. The authors of the Multi-
ethnic Pediatric Eye Disease and Baltimore Pediatric Eye
Disease Studies report advised that maternal smoking
during pregnancy is associated with a higher risk of
having astigmatism.35 It has been hypothesized that
nicotine from tobacco may activate nicotinic acetylcholine
receptors, which are believed to be important in refractive
development.37,38 In animal models, drugs that block
nicotinic acetylcholine receptors are associated with the
development of myopia.39
Pressure on the cornea generated by the eyelids
might be a possible factor for the development of corneal
astigmatism. It was suggested that a band-like pressure
from the upper eyelid on the cornea could lead to with-the-
rule astigmatism. This mechanism would be significant
especially in the majority of young adults. Furthermore,
the typical shift in the astigmatic axis from with-the-rule to
against-the-rule with age could be explained by a decrease
of eyelid tension, leading to a reduction of with-the-rule
corneal astigmatism.40
Pressure induced by the orbit or eyelid tumor might also
influence the cornea, leading to astigmatism. Keratometric
evaluation of eyes with orbital tumors showed significantly
greater corneal astigmatism in the involved eye, compared
with the patient’s other eye.41 The astigmatism induced by
orbital tumors has been precisely described in capillary
hemangiomas and dermoids in children,42,43 as well as in
lacrimal and vascular tumors in adults.41 Extraconal tumors
had a significantly higher influence on astigmatism than
intraconal ones. Keratometric changes were not associated
with the amount of proptosis, duration of illness, visual
acuity, or fundus changes.41 It was found that despite the
removal of a long-standing cavernous hemangioma, there
was a persistent flattening of the posterior pole, which was
attributed to scleral remodeling. It is possible that a similar
mechanism may have a role in the corneal tissue, although,
in infants, a resolution of astigmatism has been described
after surgical resection of capillary hemangiomas.44
The presence of a pterygium is usually characterized
by with-the-rule corneal astigmatism resulting from
localized flattening of the central cornea.45 Alterations of
the shape or placement of the lens might lead to refractive
astigmatism. It can be a consequence of intraocular lens
tilt or decentration. Moreover, alterations of the posterior
sclera in optic nerve tilt or posterior staphylomas might
lead to refractive astigmatism.
Furthermore, astigmatism may occur in the course
of several hereditary diseases. Studies of the populations
suffering from these diseases tend to support the concept
that pressure from the eyelid might contribute to corneal
astigmatism. Additionally, in Down syndrome, corneal
morphology abnormalities have been observed. The
cornea in patients with trisomy 21 is found to be thinner
and steeper than that in healthy patients. Furthermore,
higher prevalences of keratoconus and astigmatism
have been described. Despite eyelid pressure, exhibited
upslanting palpebral fissures might also play a significant
role in the mechanic influence on the cornea.46 The early
incidence of astigmatism in Down syndrome might
deteriorate the visual acuity, as the typical decrease in
astigmatism in childhood is not exhibited. Patients with
Treacher Collins syndrome have an increased risk of
astigmatism, and the risk is correlated with the degree
of deformation of the upper face and cranium.47 In spina
bifida, upslanting of the palpebral fissure and increased
risk of astigmatism have been observed. 48 Moreover,
a higher risk of astigmatism has been associated with
Noonan,49 Turner,50 and other hereditary syndromes. The
occurrence of ocular findings in these patients seems to
be irrespective of their karyotype.50
Other proposed risk factors are extraocular muscle
tension, gestational age, and birth weight. Medical
conditions such as cerebral palsy may play a role in the
development of astigmatism.48,51-53
HISTORY OF SURGICAL TREATMENT
Thomas Young (1773–1829; Fig. 1.1) discovered
astigmatism in his own eye in 1801 and gave the first
description of astigmatism (Fig. 1.2) in his Bakerian
Lecture.54 Sir George Biddell Airy (1801–1892; Fig. 1.3),
a British Royal astronomer, was the first to correct
astigmatism. He had observed it in his left eye and instructed
an optician to make a cylindrical lens for its correction.
He read a paper on it in 1825 in front of the Cambridge
Philosophical Society, which was subsequently printed
in the Transactions of the Society 2 years later (Figs. 1.4A
and B).55,56 Young believed that it was due to asymmetry
of his crystalline lens and not of the cornea, and Airy did
 Etiology, Pathogenesis, and Epidemiology of Astigmatism and History of its Surgical Management
Fig. 1.1: Portrait of Thomas Young (1773–1829).
Source: Wellcome Library, London.
Fig. 1.3: Sir George Biddell Airy (1801–1892).
Source: Wellcome Library, London; photograph by Morgan and
Kidd, 1891.
not present any ideas on that concept. William Whewell
(1794–1866; Fig. 1.5), an English polymath and Master
of Trinity College in Cambridge, was the first to propose
the term “astigmatism” as it was described by Airy
(Fig. 1.6).57 Isaac Hays (1796–1879) reported the first case
of astigmatism in America, that of a Rev. Mr Goodrich, for
whom cylindrical lenses were made by the noted optical
firm from Philadelphia.58,59
The first literature descriptions of altering the refraction
by changing the shape of the cornea date back to the
19th century. At that time, the factor strongly influencing
5
Fig. 1.2: Original description of astigmatism by Thomas Young in 1801.
B
Figs. 1.4A and B: Original description of astigmatism
by George Biddell Airy in 1825.
cataract surgery outcome was the occurrence of
astigmatism related to a large incision size. The suggested
way to treat this condition was to perform a corneal full-
thickness incision perpendicular to the direction of the
steepest meridian of the cornea.60-62 The first reference to a
procedure for correcting astigmatism—keratotomy—was
made by Hjalmar Schiotz from Norway. He described a
case of a patient with astigmatism of 19.5 D after cataract
removal. Postoperatively, to correct the refractive error, he
made a 3.5-mm-long penetrating incision at the limbus
in the steep meridian, using a von Graefe knife. Following
this treatment, the astigmatism was reduced to 7.00 D.60
Lans proposed that a section of the superficial layers of
6 Surgical Management of Astigmatism
Fig. 1.5: William Whewell (1794–1866).
Source: Wellcome Library, London; photograph by Ernest
Edwards.
the cornea instead of a full-thickness incision could be
propitious.63 A Japanese ophthalmologist, Tsutomo Sato,
suggested performing posterior radial half-incisions of
the cornea to alter the optical properties of the cornea. He
carried out the first procedure in a keratoconic patient in
1939 and evaluated this method for treating astigmatism
in the 1940s.64,65 Unfortunately, this method caused severe
damage to the endothelium and resulted in significant
decompensation of the cornea in many patients; thus, this
technique was abandoned. Furthermore, there was strong
uncertainty regarding the results for all of the attempted
methods. Understandably, this discouraged further
enthusiasm for refractive surgery.
Another approach introduced by Wray was to change
the properties of the peripheral cornea with temperature.66
Radial intrastromal thermokeratoplasty was used to
shrink the peripheral and paracentral stromal collagen to
produce a peripheral flattening and central steepening of
the cornea. This treatment was used to treat keratoconus
and hyperopic astigmatism. A decrease in refractive error
was achieved, although low predictability and significant
regression were observed.66
In the 1960s, Russian ophthalmologists became
interested in the research initiated by Sato. Several studies
were conducted by Yenaleyev, Pureskin, Fyodorov, and
Durnev. The authors expressed concern about entering the
anterior chamber in Sato’s technique, as it was technically
difficult and increased the risk of complications. Therefore,
Fig. 1.6: Original description of the origin of term “astigmatism”
by George Biddell Airy in 1846.
they decided to develop anterior nonperforative radial
incisions. Several studies were performed regarding
modifications of the size of the optical zone and the number
and shape of the radial incisions. This allowed for various
magnitudes of correction to be achieved. Furthermore, it
enabled the development of nomograms to predict the
refraction obtained through the procedure. Fyodorov
strongly popularized this method. 67,68 It was serious
concern in radial keratotomy related to the depth of the
incision. Salz et al. performed histopathological evaluation
of human cadaver corneas after radial keratotomy and
revealed a considerable variation in incision depth. In
some cases, two adjacent incisions corresponded to 30
and 65% of the depth of corneal thickness, despite clinical
estimation of 80%. Some incisions were found to penetrate
more than 80%, with occasional incisions penetrating the
anterior chamber.69
Various locations and shapes of the keratotomy have
been described as appropriate in treating astigmatism.
The Ruiz procedure involved performing trapezoidal
cuts, four to five transverse cuts inside each pair of
two semiradial incisions.70 This method was indicated
for correcting astigmatism up to 10 D. Lindquist and
Lindstrom advocated for performing trapezoidal
incisions. In their study, they have achieved maximal
correction of astigmatism with a single set of tangential
incisions placed 5-mm apart between two sets of
semiradial incisions.71,72 Then Harto et al. reported that
 Etiology, Pathogenesis, and Epidemiology of Astigmatism and History of its Surgical Management
the use of trapezoidal cuts leads to a higher incidence of
polygonal and irregular patterns of the cornea compared
with transverse relaxing incisions. 73 Thus, trapezoidal
incisions were abandoned and reserved for only high
degrees of myopia. Further studies regarding the shape
of the corneal incisions revealed that any form of surgery
with intersecting incisions is not recommended, owing
to wound healing problems with the incision remaining
open.74
Nowadays, the preferable method of incisional
correction of astigmatism is transverse keratotomy. It can
be performed in a linear or arcuate (approximating the
curvature of the limbus) manner. Performing a transverse
straight or arcuate keratotomy transverse to the steep
meridian leads to flattening of the cornea in this axis. Most
transverse incisions have a coupling ratio of 1, meaning
that the degrees of flattening in the incisional meridian
and steepening in the perpendicular one are equal. This
results in an insignificant effect on the spherical refractive
error. Presently, the majority of incisions are performed at
an optical zone of 8–10 mm. Usually, a pair of symmetrical
partial-thickness corneal relaxing incisions are performed
in the peripheral area of the cornea or in the limbus.
The closer the incision is to the center of the cornea,
the higher is the astigmatic change. The procedure of
a limbal relaxing incision is used currently to correct
mild degrees of astigmatism in cataract surgery.73,75
Furthermore, arcuate incisions, although they are more
difficult to make than linear ones, induce less irregular
astigmatism. Generally, with an increasing incision width
and older patient age, a greater influence on the refraction
is expected. Currently, nomograms have been published
including the Lindstrom Arc-T nomogram.74,76 Despite the
preset nomograms, it is suggested that surgeons should
track their own results and adjust them according to
outcomes.77-79
Astigmatism induced by penetrating keratoplasty
is another clinically significant issue. In such a case,
performing a relaxing incision in the steep meridian of
the host–graft junction can be performed. Furthermore,
compression sutures in the flat axis can markedly
increase the net effect of the previously described
methods. Another technique is the wedge resection,
which is reserved for correction of postkeratoplasty
astigmatism of 10 D and more.80 The technique involves
removing a 1–1.5-mm-wide wedge of recipient corneal
7
tissue adjacent to the host–graft junction in the extent
of 90° in the flatter meridian, nearly to the level of
Descemet’s membrane. Subsequently, five to seven deep
10.0 nylon sutures are placed on the junction to achieve
the steepening effect. Each suture is tied with a slipknot,
and the sutures are then tightened under keratometric
control to achieve an overcorrection of one-third of the
existing astigmatism.
ASTIGMATISM INDUCED BY CATARACT
SURGERY
The potential induction of postoperative astigmatism
is important issue in several ophthalmic procedure. A
considerable change in the corneal curvature can result
from extraocular procedures such as surgery for squint,
ptosis, or scleral buckling/cerclage. It can be observed as a
result of cataract surgery, trabeculectomy, and vitrectomy.
The presence of a pterygium is usually characterized
by with-the-rule astigmatism resulting from localized
flattening of the central cornea, while its surgical removal
usually results in the opposite effect.45
Currently, most cataract surgery procedures performed
in Western countries involve phacoemulsification through
a clear corneal incision. It seems to be typical for this
type of approach that significant differences can exist
in the refractive outcome between surgeons. In a study
conducted by Ernest et al., although all of the surgeons
had performed the corneal incisions in the same manner
with the same incision width and same tools, the surgically
induced astigmatism differed by almost two-fold (mean
induced astigmatism ranged from 0.38 to 0.88 D depending
on the surgeon).81
The width of the incision correlates with the
surgically induced astigmatism. The introduction of
foldable intraocular lenses led to a decrease in incision
size from 5–6 to 2–3 mm. This was beneficial for the
magnitude of surgically induced astigmatism. Moreover,
the development of small- and microincisional cataract
surgery influenced outcomes. The surgically induced
astigmatism has been described as: 0.58–0.86 cylindrical
diopter for a 3.5-mm incision,82 0.6 for 3-mm, 0.46 for
2.8-mm,83 0.5–0.6 for 2.6-mm,83,84 0.57–0.6 for 2.5-mm,82
and 0.24–0.6 for 2.2-mm incision.83,84 For incisions smaller
than 2 mm, the astigmatism is lower than 0.5 cylindrical
diopter (i.e., 0.13 D for 1.4-mm incision).83
8 Surgical Management of Astigmatism
Furthermore, the location of the incision influences
the size of astigmatism. Incisions performed in the nasal
quadrant induce significantly higher astigmatism than
those in the temporal quadrant.85,86 Similarly, incisions
located in the superonasal quadrant induce higher
astigmatism than incisions in the superotemporal
quadrant.87 It was argued that inferotemporal incisions
induce lower astigmatism, compared with temporal
and superotemporal incisions.88 It is suggested for every
cataract surgeon to precisely evaluate the preoperative
astigmatism. If the corneal astigmatism is higher than 0.50
cylindrical diopter, the corneal incision should be placed
in the steep meridian.89
There is also a dynamic change in the magnitude
of astigmatism after the surgical procedure, and the
lowest postoperative astigmatism is present between 60
and 365 days after surgery.88,90 Although some studies
suggest that astigmatism can decrease up to 6 months
after surgery, 85,86 most authors agree that the most
substantial decline is observed up to 3 months after
surgery.82,91 These findings are significant as they suggest
an appropriate time of prescribing spectacles for the
patient. In a long-term analysis of the refractive change
in patients over 10 years after cataract surgery, a change
towards against-the-rule astigmatism of about 0.2–0.4 D
in a period of 10 years was observed. Such a change
occurred both in the cataract surgery group and the
control group with no statistically significant difference
between the groups.27
TAKE-HOME PEARLS
ll Myopic astigmatism contributes the most to increases
in astigmatism rates.
ll In adults, the prevalence of astigmatism significantly
increases with age.
ll There is a discrepancy between results concerning
gender and astigmatism.
ll Results of twin, family, and genetic studies may
support the role of genetic factors in the development
of astigmatism.
ll External factors, including pressure on the eye, smoking
during pregnancy, presence of pterygium, and optic
nerve tilt play significant roles in the development of
astigmatism.
ll Various locations and shapes of keratotomy have been
described as appropriate in treating astigmatism.
ll The preferred method for incisional correction of
astigmatism is transverse keratotomy.
ACKNOWLEDGMENTS
The authors thank Dr Rafael Iribarren from the Department
of Ophthalmology, Centro Médico San Luis, Buenos
Aires, Argentina, and Dr Akbar Fotouhi, Department of
Epidemiology and Biostatistics, School of Public Health,
Tehran University of Medical Sciences, Tehran, Iran, for
the critical discussion of our work.
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11
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87. Ozkurt Y, Erdog˘an G, Güveli AK, Oral Y, Ozbas¸ M, Cömez
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CHAPTER 2
Optics of Regular Astigmatism
CORE MESSAGES
ll This chapter covers the optics of regular astigmatism,
its classifications, and non-surgical correction.
ll An eye has regular astigmatism when spherical
wavefronts emanate from a point source and pass
through the ocular media towards the retina as a
conoid of Sturm with its toric wavefronts.
ll Regular ocular astigmatism is traditionally described
in two ways, according to the anterior and posterior
location of the conoid of Sturm, and according to the
meridian of the axes of astigmatism.
INTRODUCTION
In this chapter, we explain the basic concepts of
emmetorpia, myopia, hyperopia, and presbyopia. We
discuss refraction through spherical and toric interfaces
Fig. 2.1: Wavefronts expanding from a point source.
Leon Strauss
and we cover the causes and classification of regular
astigmatism. We also review the optical principles and
basic techniques of spectacle correction of regular
astigmatism and discuss the distortion created by
astigmatic spectacles.
EMMETROPIA
Spherical wavefronts expanding from a point source flatten,
as they become distant from their source. The wavefront
surface that meets the eye, coming from a distant source,
is nearly flat, and the rays we draw perpendicular to it
are nearly parallel (Fig. 2.1). The anterior segment of the
emmetropic eye has just the right power to focus pencils of
parallel rays coming through the pupil to distinct points on
the retina so that a real image of a distant object is formed
on the retina (Fig. 2.2).
 Optics of Regular Astigmatism 13

Fig. 2.2: Image formation in an emmetropic eye. When rays emanating from two distant point sources reach the eye, the rays coming
from each point are parallel to each other, and each parallel bundle of rays is focused to its own distinct point on the retina.

Fig. 2.3: In myopia, the eye is often longer than an emmetropic eye. In hyperopia, it is often shorter.

MYOPIA, HYPEROPIA, ACCOMMODATION,

PRESBYOPIA, FAR AND NEAR POINTS
If we keep the same anterior segment, the cornea, pupil,
and lens as that of the emmetropic eye we discussed
in the preceding paragraph, but make the eye longer,
creating a myopic eye, the rays cross and spread out
(Fig. 2.3). Individual points on the retina receive light from
many point sources, so the image on the retina is blurred
(Fig. 2.3). Similarly, if we shorten the eye to make it
hyperopic, again the pencils of light fall on overlapping areas
of the retina, and the image is blurred. A young hyperope
eye can accommodate, making the lens of the eye more
convex, refracting the pencils of light to focus on the retina
for a clear image (Fig. 2.4). If we move a point source close
to the emmetropic eye, the wavefronts reaching the cornea
are not flat; they are concave with respect to their origin.
The rays are diverging, but accommodation can make Fig 2.4: Accommodation in a hyperopic eye improves the focus
them converge to focus on the retina (Fig. 2.5). How close on the retina.
14 Surgical Management of Astigmatism

Fig. 2.5: Accommodation adds converging power to the rays that diverge from a near object, bringing them to focus on the retina.

Fig. 2.6: The far point of a myopic eye.

to the eye can we bring the source, before the eye cannot
accommodate enough to focus the image? This is the eye’s
near point. For the myopic eye, a distant object is out of focus.
If we begin far away and bring an object closer and closer to
the myopic eye, there will be a point where the divergence
of rays reaching the cornea is exactly enough for the
relaxed, non-accommodating myopic eye to focus its image
on the retina. This is the myopic eye’s far point (Fig. 2.6).
Indeed, the fact that the myope can see clearly at some
distance nearer to the eye is the origin of the name “near-
sighted.” If the myope is young enough to accommodate,
we can bring the object even closer until we reach that eye’s
near point, beyond which he can’t accommodate enough
to focus the image. For instance, a −2.00 myope capable of 3
diopters of accommodation will read effortlessly at ½ m, and
be able to keep a clear image until the object reaches 1/5 m.

Unfortunately for the hyperope, her far-point is virtual,
behind the retina, so without accommodating, distant
objects are out of focus, and near objects are even more out
of focus; hence the name “far-sighted.” The gradual loss of
the ability to accommodate with aging, presbyopia, causes
first near and then far vision to become difficult for the
uncorrected hyperope.
TORUS
A torus is formed by rotating a circle around a line that is in
its plane but does not pass through the center of the circle.
Depending on how close the line is to the center of the
circle, the shape may look like a tire or a barrel (Fig. 2.7).
Putting your hand around a bicycle tire and then along it,
you find the two curves lying on the toric surface that have
the greatest and least curvature, meeting under your hand,
perpendicular to each other (Fig. 2.8).
Refraction through Spherical and Toric
Interfaces
Suppose that light beginning at a point source passes
through a circular aperture, creating a cone-shaped pencil
of rays, we draw perpendicular to spherical wavefronts.
If we place a sufficiently convex spherical lens in its path
and fill the room with smoke, we will see a cone of light
coming through the aperture, then the second cone of
light exiting the lens, focusing at a point on the axis, and
Fig. 2.7: A torus is the surface formed by rotating a circle around a line lying in its plane. Depending on the location of the line, we see
here the shape of a bicycle tire or a barrel.
Fig. 2.8: Curves lying on a torus with the most and least curvature, meeting perpendicularly at a point.
Optics of Regular Astigmatism 15
then spreading out again, forming a third cone (Fig. 2.9).
(We are assuming the rays are sufficiently paraxial, so that
spherical aberration isn’t noticeable.) The wavefronts
traveling through the cones have spherical shapes. If
instead, we place a toric-surfaced, circular-bordered lens
in the path of the light, the second cone of light is replaced
by the “conoid of Sturm.” It is squashed to a first focal line
(Fig. 2.10) and then spreads out in that direction, while it is
squashed to a second focal line (Fig. 2.11), perpendicular
to the first. Its cross-sections are ovals that gradually
collapse to the first line and then become circular at the
“circle of least confusion,” before becoming oval in the
perpendicular direction until they collapse to the second
focal line (Fig. 2.12). The conoid then gradually spreads
out in all directions, like the third cone in the spherical
case, but deformed. The wavefronts exiting the spherical
lens have spherical shape; in the conoid of Sturm, between
its two focal lines, they all have saddle shapes. To imagine
the wavefront at the circle of least confusion, we show a
picture of a saddle-shaped potato chip that just fits into a
circular can (Fig. 2.13). A screen placed at the position of
this circle of least confusion would show an illuminated
disc. Looking at the inverse of distances from the refracting
surface, rather than distances, we find the location of the
circle of least confusion midway between the two focal
lines. For instance, if the power of the lens is +4 D in the
30° meridian and +2 D in the 120° meridian, the focal lines
16 Surgical Management of Astigmatism

Fig. 2.9: A point source emits spherical waves in a homogeneous medium. A cone-shaped pencil of the light passes through a circular
aperture and is focused by a spherical lens, so that the rays meet at a single spot, where they cross and form a third cone as they diverge.
The all wavefronts have spherical shape.

Fig. 2.10: A cylindrical lens focuses light from a point source to a focal line.

Fig. 2.11: Perpendicular cylinders of different plus powers focus light from the point source first along one line, and then along another.
 Optics of Regular Astigmatism 17

Fig. 2.12: A toric lens has powers +5 and +3. Light diverges 1 m before meeting the lens after passing through a circular aperture, and
leaves the lens with convergence +4 and +2. The two focal lines are therefore ¼ and ½ m from the lens. The interval of Sturm is therefore
½ − ¼ = ¼-m long. The circle of least confusion is found 1/3 m from the lens, as 3 D is half-way between 4 D and 2 D.

two focal lines). If we wanted to correct an eye’s astigmatic

refractive error as well as possible, using only a spherical
corrective lens, we would choose the spherical power
aiming to place the disc of least confusion on the retina.
In this case, we would expect vision to be equally blurred
in all meridia. Otherwise, with uncorrected astigmatism,
we expect vision to be more blurred in one meridian than
another—for instance, the cross-bars of a letter E might
appear more blurred than its vertical line.

Fig. 2.13: In the conoid of Sturm, where the cross-section of the
conoid is outlined by the circle of least confusion, the wavefront
has the shape of a saddle, as we have passed one focal line, and not
yet reached the other focal line.
bounding the interval of Sturm would be at 1/4 and 1/2 m
along the axis, and the circle of least confusion would be
found at 1/3 m, because 3 is half-way between 2 and 4.
(Saying the same thing, some accounts describe the circle
of least confusion as “midway in diopters” between the
REGULAR ASTIGMATISM
If spherical wavefronts that emanate from a point source
and pass through the ocular media come towards the
retina as a conoid of Sturm with its toric wavefronts, we say
the eye has regular astigmatism, and expect that a “sphero-
cylindrical” spectacle lens can provide a focused image on
the retina. If the wavefronts approaching the retina are not
close enough to being toric, we say the eye’s astigmatism
is irregular.
Causes of Ocular Astigmatism
Let’s review from the front to the back of the eye the reasons
that we would find a conoid of Sturm with toric wavefronts,
18 Surgical Management of Astigmatism
B
Figs. 2.14A and B: In compound hyperopic astigmatism, the two focal lines of the conoid of Sturm lie behind the retina in the absence
of accommodation (A). One of the two focal lines of the conoid of Sturm lies on the retina in a simple hyperopic astigmatism (B).
or something even more aberrant, rather than a cone of
spherical wavefronts, approaching the retina. Suppose the
eye and its correcting eyeglass lens have no astigmatism.
Astigmatism can be “induced” in this situation, if the
eyeglass lens is tilted, or if the eye is turned to view off-
axis through the lens. We usually think of the shape of the
anterior corneal surface, where refraction occurs between
air and tear film, as the major source of astigmatism. Other
sources of astigmatism are the posterior cornea, both
surfaces and a non-homogeneous interior of the lens, as
well as tilting of the natural or implant lens. Fortunately,
the best acuity of many eyes can be achieved with sphero-
cylindrical spectacle lenses.
Classifications of Regular Astigmatism
Regular ocular astigmatism is traditionally described in
two ways, according to the anterior-posterior location of
the conoid of Sturm, and according to the meridia of the
axes of astigmatism.
There are five obvious locations of the non-
accommodating eye’s retina with respect to the two focal
lines of the conoid of Sturm that is created when the
eye gazes at a distant point source. Hence, the following
names, depending on whether the retina is: (Figs. 2.14 to
2.16) anterior to both focal lines—compound hyperopic
astigmatism (correction +3.00 + 2.00 × 50) (Fig. 2.14A) at
the more anterior line—simple hyperopic astigmatism
(correction 0.00 + 2.00 × 50) (Fig. 2.14B) between the two
lines—mixed astigmatism (correction −2.00 + 3.00 × 50)
(Figs. 2.15A and B) at the posterior line—simple myopic
astigmatism (correction −3.00 + 3.00 × 50) (Fig. 2.16A)
behind both lines—compound myopic astigmatism
(correction −3.00 + 2.00 × 50) (Fig. 2.16B).
Describing Regular Astigmatism by the
Approximate Location of the Meridia
With the rule: The more anterior focal line is nearly
horizontal.

B
Figs. 2.15A and B: One focal line lies within the vitreous while the other focal line of the conoid of Sturm lies behind the retina in mixed
astigmatism (A). Best focus occurs when the circle of least confusion lies on the retina (B).
(Glasses would have plus cylinder near 90° or minus
cylinder near 180°, greater keratometry reading at 90°,
tight limbal suture near 90°).
Against the rule: The more anterior focal line is nearly
vertical.
Oblique: The focal lines are not close to the horizontal and
vertical meridian, for instance, cylinder with axis at 43°.
NOTATION FOR DESCRIPTION OF A
SPHEROCYLINDRICAL LENS
+1.00 + 2.00 × 120 with plus cylinder axis notation or the
same lens, “transposing”
+3.00−2.00 × 30 with minus cylinder axis notation.
A power cross description of the same lens shows +1.00
power acting at the 30° meridian and +3.00 power at the
120° meridian.
Optics of Regular Astigmatism 19
SPECTACLE CORRECTION OF REGULAR
ASTIGMATISM
Jackson's Cross Cylinder
We assume the reader is familiar with this technique, and
mention only that if the vision is poor, a hand-held higher
power Jackson cross cylinder may be useful for further
refinement, for example, ± 0.75 instead of ± 0.25.
The astigmatic dial and stenopeic slit may prove useful
when other methods are not productive.
Astigmatic Dial
To use the dial, for the patient with plus sphere, and ask
the patient for the clock-hour of the line on the dial that
looks sharpest. For minus cylinder technique, multiply
that clock-hour by 30 to obtain an axis for minus cylinder,
which is added until the lines appear equally blurred.
20 Surgical Management of Astigmatism
B
Figs. 2.16A and B: In a simple myopic astigmatism, the posterior line of the conoid of Sturm falls on the retina (A). Both focal lines lie
within the vitreous in compound myopic astigmatism (B).
Then remove the fogging plus sphere. For plus cylinder
technique, multiply the clock-hour by 30 and add 90.
As you then add plus cylinder at this axis, add an equal
amount of minus sphere. For example, if the line running
from 2 to 8 o’clock looks sharp, then the axis of the minus
cylinder is 60°, and the axis for plus cylinder would be 150°.
Stenopaic Slit
This has the effect of a pinhole, reducing blur in the
meridian perpendicular to it. Having found a rough
spherical correction, rotate the slit, asking the patient to
tell you when the vision is clearest (We don’t want the best
sphere at first, as this would put the circle of least confusion
on the retina, and make it difficult to find an axis). Next, find
the best sphere with the slit at this meridian and then turn
the axis 90°. Determine how much plus or minus sphere
needs to be added for best vision at this axis; that will be
the amount of cylinder. The result is then the first sphere
with the plus or minus cylinder whose axis will be where
the slit pointed before you turned it 90°. For example, if
we find +3.00 sphere with the slit horizontal at 180°, turn
the axis to 90° and find the best acuity when we add +2.00
sphere to reach +5.00, then our result is +3.00 + 2.00 × 180.
Spherical Equivalent
The circle of least confusion of the conoid of Sturm is
placed on the retina by the spherical corrective lens whose
power is the “spherical equivalent” of the corrective
spherocylindrical lens: To find this, add half the amount
of cylinder with its plus or minus sign to the amount of
sphere.
For example, for corrective lens −5.00 + 2.00 × 50, the
spherical equivalent is −4.00.
Accommodation with Uncorrected
Astigmatism
When the eye accommodates, both lines of a conoid of
Sturm in the vitreous are pulled anteriorly, towards the

lens. For example, suppose that a hyperopic eye, when
not accommodating, is corrected for distance vision
by a lens which is +2.00 + 1.00 × 90. The two focal lines
of the conoid of Sturm are behind the retina, and this is
compound hyperopic astigmatism. Without glasses, when
the eye accommodates two diopters, the refractive error
becomes 0.00 + 1.00 × 90 (simple hyperopic astigmatism)
and the vertical lines of a distant letter H will be focused on
the retina. If the eye accommodates another diopter, the
refractive error becomes—1.00 + 1.00 × 90 (simple myopic
astigmatism), and only the horizontal lines of the letter H
will be clearly focused on the retina.
Distortion Created by Spectacle Correction of
Astigmatism
Correcting astigmatism in the spectacle lens plane, rather
than correcting it at the cornea, provides stigmatic, clear
imaging, but the image is distorted, as there is unequal
magnification or minification along meridia of greater
and lesser curvature. When both eyes have oblique
astigmatism with their axes of corrective spectacle lenses
in differing meridia, the brain processes the two distorted
images with a false three-dimensional perception of tilt,
so that a vertical pole appears tilted towards or away from
the viewer. Some patients are more comfortable, although
with less clear vision when the axes of the correcting lenses
are moved close to 90 or 180°, and the best amounts of
cylinder and sphere powers determined at those axes.
COMBINATIONS OF SPHERO-CYLINDRIC
LENSES
Thinking approximately in terms of “thin lenses,” suppose
we put one toric lens just behind another on the optical
axis. If their axes of astigmatism are the same or at right
angles, we can easily add the powers. A lens described
as +2.00 + 1.00 × 37 in front of a lens described as
+1.00 + 2.00 × 37 will have the same effect on a pencil of light
as +3.00 + 3.00 × 37. If we place the lens +2.00 + 1.00 × 37 in
front of a lens which is +1.00 + 2.00 × 127, the combined
effect will be +4.00 + 1.00 × 127. We can consider any
toric lens to be a sphere combined with a cylinder:
−3.00−2.00 × 47 is the same as −3.00 sphere combined
with 0.00−2.00 × 47. On the other hand, when the axes
Optics of Regular Astigmatism 21
are not at right angles to each other, and when refracting
interfaces have space between them, summing the vectors
to calculate the result of combinations of refracting
elements is not so simple. Two spherocylindrical lenses
can be placed, one on top of the other, in the lensmeter for
an easy measurement of their combined power, which will
be a third spherocylindrical lens. Suitable computational
tools are made available, as they are needed, for surgical
techniques such as those described in this book.
CONTACT LENS CORRECTION OF
ASTIGMATISM
Spherical soft contact lenses “mask” small amounts of
corneal astigmatism. Toric-shaped soft lenses, designed to
maintain a stable rotational position on the cornea, may be
fitted to correct astigmatism. Rigid gas permeable lenses,
either corneal or scleral, have a spherical anterior surface
and form a tear lens that fills in the space between them
and the cornea, correcting corneal astigmatism. A rigid
gas permeable corneal lens may also be designed with the
toric posterior surface to maintain rotational position and
toric anterior surface to correct “residual” astigmatism
caused by the lens or posterior cornea.
TAKE-HOME PEARLS
ll The shape of the anterior corneal surface, where
refraction occurs between the air and tear film, is
considered the major source of astigmatism.
ll The astigmatic dial and stenopaic slit may prove useful
when other methods are not productive.
ll Correcting astigmatism in the spectacle lens plane,
rather than correcting it at the cornea, provides
stigmatic, clear imaging, but the image is distorted, as
there is unequal magnification or minification along
meridia of greater and lesser curvature.
ll Spherical soft contact lenses “mask” small amounts of
corneal astigmatism.
ACKNOWLEDGMENT
Illustrations for this chapter were digitally drawn by Lauren
Kalinoski, MS, CMI, Biomedical Illustrator, Department of
Ophthalmology & Visual Sciences, University of Illinois at
Chicago.
CHAPTER 3
Optical Clinical Assessment of
Astigmatism, Surgical Vector Planning,
and Analysis of Astigmatism for
Refractive Surgery
Noel Alpins, George Stamatelatos

CORE MESSAGES OPTICAL CLINICAL ASSESSMENT IN

ll With advances in technology, the measurement
of astigmatism now includes measurement of the
posterior corneal astigmatism as well as calculation of
ocular residual astigmatism.
ll The anterior corneal astigmatism can be measured
using a manual keratometer and a topographer.
ll The total corneal astigmatism, which includes the
posterior contribution, can be measured using a
tomographer, optical coherence interferometers, and an
auto keratometer.
ll Manifest, cycloplegic, and wavefront refractions are
used for measuring the refractive cylinder.
ASTIGMATISM SURGERY
With advances in technology, the measurement of
astigmatism has been elevated to a new level; this includes
measurement of the posterior corneal astigmatism as
well as calculation of ocular residual astigmatism (ORA).
The ORA is the vectorial difference between corneal
astigmatism and the refractive cylinder at the corneal
plane and is expressed in diopters (Fig. 3.1).1,2

INTRODUCTION
Astigmatism can occur at many different levels in the
human eye. This can include the anterior and posterior
cornea, the physiological lens inside the eye, retinal tilt at
the back of the eye, and processing in the visual cortex.
Correction of astigmatism can be performed in a number
of ways: spectacles, toric contact lenses (soft and gas
permeable), astigmatic keratotomy, excimer laser surgery,
toric intraocular lenses (IOLs), and limbal relaxing
incisions (LRIs). Accurate correction requires precise
measurement of both refractive and corneal astigmatism
Fig. 3.1: The ocular residual astigmatism is the vectorial difference
together with an understanding of what exactly is being between the corneal astigmatism and the refractive cylinder at the
measured. corneal plane. (Sim K: simulated keratometry).
Optical Clinical Assessment of Astigmatism, Surgical Vector Planning, and Analysis of Astigmatism for Refractive Surgery
Corneal Astigmatism
The anterior corneal astigmatism can be measured using:
i. A manual keratometer—measures at a corneal
diameter of 3.2 mm. Distorted mires can indicate a
dry corneal surface, in which case lubricating drops
before measurement may be advised for greater
accuracy. Furthermore, distorted mires on the manual
keratometer can indicate corneal irregularity and
detection of keratoconus. A skilled user can accurately
determine the corneal astigmatism magnitude and
meridian even for low amounts of astigmatism between
0.50 and 0.75 D.
ii. A topographer—measures the anterior corneal surface
and presents much more detail and information
than a manual keratometer. It calculates a simulated
keratometry (Sim K), which is comparable to the
manual keratometer measurement at a central 3-mm
region of the cornea. For accurate corneal topography
measurements, the eyelids must be outside the corneal
diameter and the tear film at an optimum. Many
topographers display the accuracy of the acquisition
using a tick or a cross and indicate why the acquisition
was not accurate. Simulated keratometry can vary,
particularly with the determination of the steep
meridian, and does not offer the technician any control
over the measurement apart from lubricating the eye
and keeping the eyelids clear of the cornea during
acquisition.
Many topographers such as the iTrace (TraceyTM
Technologies) and the Nidek OPD III (Nidek Co., Ltd)
calculate the internal astigmatism as well as the source
of ocular aberrations.
The total corneal astigmatism, which includes the
posterior cornea contribution, can be measured using:
iii. A tomographer—measures both the anterior and
posterior corneal shape as well as the thickness.
Calculations of total corneal astigmatism are displayed
and can be used for accurate toric IOL calculations of
how much and in what direction the astigmatism needs
to be neutralized. The total corneal astigmatism can
also be used in LRI surgery and excimer laser surgery
where the treatment plan incorporates the corneal
astigmatism.
It is important to note that the measure of corneal
astigmatism does not always fall within exactly 3–4 mm
23
of the central cornea as this varies depending on
whether the cornea is very flat or steep. With a steep
cornea, the measure of astigmatism will occur at a zone
<3 mm and for a flat cornea at a zone more than 4 mm.
iv. Optical coherence interferometers—measure axial
length using light instead of ultrasound.
a. IOLMaster 700—uses “telecentric keratometry,”
which is a distance-independent approach that
allows repeatable measurements. It uses six points
to measure keratometry within a diameter of
2.3 mm. At the same time, this biometry device
can acquire a reference image and data can be
transferred to the Zeiss Callisto eye (imaging)
system on the surgical microscope for markerless
alignment of toric IOLs in cataract surgery.
b. Lenstar LS 900—measures at two zones—at 2.3 and
1.65 mm—using two rings, each ring containing 16
lights.
v. Autokeratometer—can measure at corneal diameters
ranging from 2.5 to 3.3 mm and are both patient and
examiner objective.
Corneal Topographic Astigmatism
Instead of using measurements from a limited section
of the cornea to determine the corneal astigmatism, the
corneal topographic astigmatism (CorT) uses all the
acquired data and vectorially calculates the anterior
corneal astigmatism magnitude and meridian as well
as the total corneal astigmatism in cases in which the
posterior corneal measurement is included (Fig. 3.2).3,4
Use of all the acquired data reduces the possibility of
selecting an irregular section of the cornea and basing the
corneal astigmatism only on this one affected area. Using
tomographers such as the CSO Sirius, the Oculus Pentacam,
and the Ziemer Galilei, the total corneal astigmatism can
be measured and the CorT total can be calculated, which
includes the posterior corneal contribution.
Both CorT anterior and CorT total have been shown
to be more accurate measures of corneal astigmatism
compared with Sim K, manual keratometry, corneal
wavefront, and paraxial curvature matching. The CorT
parameters are calculated using the iAssort software,
which is compatible with the Keratron Scout, Humphrey
Zeiss Atlas, Nidek OPD III, Topcon CA-200, CSO Sirius,
Oculus Pentacam, and Ziemer Galilei.
24 Surgical Management of Astigmatism
Fig. 3.2: The CorT incorporates all the acquired data. The CorT
anterior is calculated using anterior corneal parameters alone
and the CorT total uses both the anterior and posterior corneal
curvatures. (CorT: corneal topographic astigmatism).
Refractive Cylinder
1. Manifest refraction—the gold standard for measuring
the refractive cylinder as it includes the optical system
of the eye as well as the cortical perception.
2. Cycloplegic refraction—in most cases this is the same
as the manifest refractive cylinder excluding the
perceptual component. The cycloplegic refraction
is useful in hyperopic excimer laser treatments to
manifest any latent hyperopia.
3. Wavefront refraction—the second-order sphero­
cylinder measurement here should always be
confirmed with the manifest refractive cylinder.
It is left to the surgeon’s discretion as to which measure
of astigmatism is used in planning for the surgical
correction of astigmatism. It is common to compare many
of the measures and remove outliers but ultimately one
must understand what part of the eye is being measured by
the method selected. Using the ORA as a guideline can be
helpful with the principle that a minimum ORA magnitude
will give you the best measure of corneal astigmatism
given the manifest refraction is the gold standard for the
total astigmatism of the eye and its perception. In some
surgical procedures, such as excimer laser surgery and
intracameral lens implantation, both the refractive and
corneal astigmatism parameters can be incorporated using
the method of “The symptoms of glare, ghosting, starbursts,
halos and reduced contrast sensitivity after refractive laser
surgery commonly termed GASH is prevalent in cases
where the ORA is greater than 1.00 D preoperatively and
the corneal astigmatism postoperatively is consequently
also greater than 1.00 D. Basing the treatment on refractive
parameters alone such as manifest or wavefront refraction,
can result in excess corneal astigmatism postoperatively.
The method of Vector Planning should be used to
systematically incorporate corneal parameters into the
refractive treatment plan so that for eyes at risk with
elevated ORA’s will be in “low astigmatism” mode with less
risk of developing what is collectively known as “PALS”
Syndrome: Predictable (by calculating the ORA pre-op),
Avoidable (by using Vector Planning to result in less overall
corneal astigmatism postop, LASIK, Surprise (unexpected
GASH). Many patients have written letters to the FDA and
more recently to the New York Times in response to their
article June 2018, complaining of astigmatism or one or
more of these distressing symptoms”.
TAKE-HOME PEARLS
ll It is important to note that the measure of corneal
astigmatism does not always fall within exactly 3–4 mm
of the central cornea as this varies depending on
whether the cornea is very flat or steep.
ll With a steep cornea, the measure of astigmatism will
occur at a zone <3 mm and for a flat cornea at a zone
more than 4 mm.
ll Use of all acquired data for astigmatism reduces the
possibility of selecting an irregular section of the
cornea and basing the corneal astigmatism only on the
affected area.
ll Comparison of several methods for measuring
astigmatism is recommended in planning the surgical
correction.
REFERENCES
1. Alpins NA. New method of targeting vectors to treat
astigmatism. J Cataract Refract Surg. 1997;23:65-75.
2. Alpins NA. Astigmatism analysis by the Alpins method. J
Cataract Refract Surg. 2001;27:31-49.
3. Alpins NA, Stamatelatos G. New method of quantifying
corneal topographic astigmatism that corresponds with
manifest refractive cylinder. J Cataract Refract Surg.
2012;38:1978-88.
4. Alpins NA, Stamatelatos G, Ong J. Corneal topographic
astigmatism (CorT) to quantify total corneal astigmatism. J
Refract Surg. 2015;31(3):182-6.
CHAPTER 4

Keratometry and Placido‑based

Topography: Techniques,
Advantages, and Limitations
Damien Gatinel

CORE MESSAGES
ll The production of keratometric, keratoscopic, and
videokeratoscopic devices is based on the simple idea
that the anterior surface of the cornea acts as a convex
mirror, allowing the deformation of reflected images to
deduce some of the properties of the reflective surface.
ll The types of curvature maps include: axial, tangential,
or mean curvatures.
ll The tangential (or instantaneous) curvature is defined
as the curvature measured at consecutive points along
the hemimeridians that extend from the vertex to each
Fig. 4.1: Virtual image.
of these points.
ll The sagittal (or axial) curvature is defined as the
curvature measured along the meridian which is From the deformation of the reflected images, it is possible
perpendicular to the meridian tangential to the to deduce some of the properties of the reflective surface:
measurement point. this simple idea has been implemented for the production
ll The “mean curvature” corresponds to the most accurate of keratometric, then keratoscopic, and videokeratoscopic
representation of the curvature variations of the devices, which have been improved and refined over the
corneal surface. This mean curvature corresponds to years, to provide the clinician with more repeatable and
the arithmetic mean between the minimum curvature comprehensive data about the anterior surface of the
and the maximum curvature at the point of interest. cornea. This technology is mandatory in most clinical
ll Unlike axial and instantaneous modes, the representa- situations which require a salient investigation of the
tion of the mean curvature is relatively independent of optical properties of the eye, including the determination
the direction of curvature measurement. of corneal astigmatism.

INTRODUCTION HISTORY OF KERATOMETRY AND

The anterior surface of the cornea is covered with a CORNEAL TOPOGRAPHY
lacrimal film whose reflective properties make it possible The first known manifestations of interest in corneal
to form the virtual image of light sources (Fig. 4.1). The topography date back to 1619, when Christopher Scheiner
anterior surface of the cornea then acts as a convex mirror. studied the images formed by reflection on the cornea.
26 Surgical Management of Astigmatism

Fig. 4.2: The radius of the convex surface assimilated as a sphere can be computed from the object side (O), its distance to the cornea
(D), and the size of the image of its reflection (I) with the formula: R = (2 D I)/O. F’ is the image foci of the spherical mirror. The focus is a
virtual image formed by incoming parallel rays which travel close to the optical axis. The keratometry (K) is equal to the reciprocal of the
radius of curvature (in m) multiplied by the difference between the keratometric or index (nk) and the index of refraction of the air. The
keratometric index is usually chosen as 1.3375, or 4/3. On the right, a photo of a Javal keratometer.

This German Jesuit astronomer devised a method for
estimating the curvature of the cornea. He made a series
of marbles of which he knew the curvature of each. It was
then sufficient to find which of the marbles produced a
reflection comparable to that of the cornea studied. The
principle of keratometry was born.
At the end of the 18th century, the desire to elucidate
the mechanisms of accommodation and to objectify
possible corneal involvement led Jesse Ramsden to
develop an instrument designed to study the reflection
of two patterns on the cornea.1 If the use of the reflective
properties of the cornea seems to have been used for
clinical purposes by David Brewster, a Scottish physicist,
in 1898, the invention of the first instrument for the study
of the cornea (keratoscope) is credited to Henry Goode
of the University of Cambridge in 1847. This technique
of measuring the corneal curvature (keratometry) really
took off, thanks to the German physicist Hermann von
Helmholtz, who developed a keratometer based on the
study of corneal reflection of a circular pattern of known
diameter.2 Once the size of this reflection determined, it
was possible to estimate the radius of apical curvature of the
cornea, assimilated to a convex spherical mirror. Thanks to
a set of glass plates of known index and orientation, the
user could induce a splitting of the image of the circular
reflection until the edges of each of the generated images
would touch each other. This ingenious technique made it
possible to get rid of effects caused movements of the eye.
The distance necessary for each of the reflections to be just
tangent was equal to the size of the reflection. Other types
of keratometers, based on the same fundamental principle
(to determine the size of the reflection of a chart of known
dimensions on the cornea), were developed later by Javal
and Schiotz (Fig. 4.2).
If the determination of the curvature of the cornea was
valuable anatomical information, the exact determination
of the optical power of the cornea would have required
knowledge of the curvature of the posterior surface of the
cornea, which was not technically possible in the 19th
century. This difficulty is the root of potential inaccuracies,
which are leading to some persisting clinical issues for
today’s clinicians. This point will be emphasized in this
chapter.
In 1880, Placido designed a flat disk with a series
of concentric black and white circles, combined with a
camera called “photokeratoscope.” Photokeratoscopy can
be considered as the ancestor of today’s videokeratography.
The corneal reflections of the circles could also be
observed directly by a small central opening while the
disk was held along the line of sight. A regular oval profile
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jetzt als praktisch bewährte Einrichtungen erfand — bedeutende sind
und der unzählige Male mit Wort und Schrift für dasselbe begeistert
und viele Andere begeisternd eintrat und wahrhaft unermüdlich
wirkte. Es ist dies der Kaufmann und Turngeräthefabrikant Herr
Oswald Faber in Leipzig,[2] dessen Bild als Zugführer der
Turnerfeuerwehr wir auf dem Titelblatt und im Text unsres Heftes VI
bringen. In wahrhafter Bescheidenheit hat er sich stets allen
Ovationen für seine Thätigkeit entzogen, ihm gebührt ein Ehrenplatz
in dieser Chronik unsres Leipzigs.
[1] Nach Oswald Fabers »Die freiwilligen Feuerwehren,« 3.
Auflage.
[2] Mit seiner Concurrenzarbeit »Ueber Organisation von Dorf-
Feuerwehren« mit der großen silbernen Medaille der k. k.
österreich. Regierung prämirt im Juli 1870 auf dem 8. deutschen
Feuerwehrtag zu Linz.

C. Die Rettungscompagnie.
Die Leipziger freiwillige Rettungscompagnie, welche neben der
städtischen und der Turnerfeuerwehr bestand, rekrutirte sich aus
Leipziger Bürgern und Einwohnern von den besten
Gesellschaftsklassen herab bis zum Arbeiterstande. Ein sehr großer
Theil derselben waren ebenfalls noch aktive oder doch frühere
Turner. Die Compagnie, deren Zusammensetzung, Ziele u. s. w. so
ziemlich dieselben waren, wie die der Turnerfeuerwehr, wich an der
Bekleidung insofern von der Turnerfeuerwehr ab, als sie dunklere,
schwarzgraue Blousen mit dem auf die Brustseite angestepptem R.
C. trug. Obwohl die Mitglieder derselben ebenfalls zum Spritzen- und
Steigerdienst vollständig ausgebildet waren und ihre eigene vom
Rath beschaffte Spritze besaßen, war ihr Augenmerk doch in erster
Linie, wie schon ihr Name sagt, auf das Rettungswerk von Personen
und beweglichem Besitzthum gerichtet. Die Rettungscompagnie,
welche eine Stärke von etwa 100 Mann besaß, wechselte mit der
Turnerfeuerwehr behufs Besetzung der Wache im Brühl dergestalt
ab, daß sie, nachdem die 15 tägigen Wachtposten der
Turnerfeuerwehr beendet waren, ihrerseits nun während 9 Tagen die
Wache besetzte, worauf wieder der Turnus der ersteren begann.
Auch die Rettungscompagnie nahm an der Tilgung aller Brände
während der Zeit ihres Bestehens mit gleicher Bravour und großer
Pflichttreue und Erfolg Theil und hielt — kleine Häkeleien dann und
wann ausgenommen — mit der Turnerfeuerwehr treue
Kameradschaft. Aber dieselben Gründe, welche schon 1871 eine
freiwillige Auflösung der Turnerfeuerwehr herbeiführten, führten auch
obwohl mehr als ein Jahrzehnt später ihre freiwillige Auflösung
herbei. Dieselbe erfolgte am 31. Dezember 1886. Bei dem
Abschiedscommers im alten Schützenhause am Abend des 31.
December wurde die gesammte Mannschaft zur Tilgung eines
größeren Feuers nach Reudnitz commandirt. Commandanten der
Rettungscompagnie waren nach einander:
Kaufmann Rudolf Gruner (s. Bericht an den Rath vom
5. August 1842).
Advokat (späterer Stadtrath) Schilling vom 5. April 1851
(ausgetreten am 1. Februar 1862).
Eisengießereibesitzer Gustav Götz vom 12. Februar 1862
(ausgetreten am 17. Februar 1870).
Kaufmann Hermann Meister, vom 23. Februar 1870; (vom
1. Juni 1875 städt. Branddirektor).
Zimmermeister Aug. Kersten (vom 5. Juni 1875, gest. im
August 1883).
Baumeister W. Rob. Rost (vom 12. Oktober 1883 bis zur
Auflösung der Compagnie am 31. Dezember 1886).
Beide Corporationen wurden vielen Hunderten freiwilliger
Feuerwehren in ganz Deutschland zum Vorbild, sie nahmen unter
allen derselben den ältesten und berechtigsten Vorrang ein und
wenn jetzt noch das — namentlich für kleinere und mittlere
Gemeinden von so außerordentlich wichtigen, werthvollen und mit
verhältnißmäßig geringem Kostenaufwande verbunden — freiwillige
Feuerlöschwesen in so hoher Blüthe steht, so fällt ein guter Theil
des Bewußtseins, wesentlich hierzu beigetragen zu haben, auf die
ehemalige freiwillige Feuerwehr zu Leipzig.
 XXXIII.
Auf der Wache der Turnerfeuerwehr.
Das Wachtlokal der Turnerfeuerwehr und Rettungscompagnie
befand sich bis zur Auflösung beider Corporationen im Brühl, Ecke
der Göthestraße, damalige städt. Fleischhallen und zwar in
ursprünglich zum Verkaufsgewölbe eingerichteten Räumen. Groß
war dasselbe nicht und von übermäßigem Comfort war darin keine
Rede. Im Hintergrund des ziemlich tiefen, aber nicht sehr breiten
Lokals befanden sich nebeneinander die »Pfefferkuchen« vulgo
»Matratzen« auf den Holzpritschen, auf denen des Schlafes
bedürftige Wachtmannschaften sich ausstrecken und der Ruhe
pflegen konnten, falls sie nicht die »Wache« hatten oder gar die
Wache allarmirt wurde. Ein einfacher großer Holztisch und mehrere
Stühle, eine Stechuhr zur Controlle der Wachthabenden, an den
Wänden Pflöcke und Kleiderhalter und eine alte Wanduhr, dies war
die ganze Einrichtung der »freiwilligen Wache.« Das Allarmiren nun
ging früher, ehe die Wachtlokale mit der Polizeiwache telegraphisch
verbunden waren, allerdings nicht ohne wirklichen Allarm vor sich.
Da stürmten die Feuerglocken von den Thürmen, die Trommeln der
Communalgarden rasselten durch die Straßen und die Feuersignale
ertönten aus den Hörnern der Signalisten der Garnison und bei
Nacht erschollen in diesen Chaos von Tönen noch der dumpfe Ton
der Nachtwächterhörner, feuerrufende Menschen rannten durch die
Straßen und von allen Seiten jagten Spritzen und Zubringer,
Sturmfässer und Geräthewagen dem Ziele zu, welches von den
Thürmern durch Herausstecken von Fahnen oder bei Nacht von
Laternen als die Gegend, in welcher das Feuer ausgebrochen war,
angedeutet wurde. Die zuerst am Brandplatz ankommende Spritze
wurde prämiirt und diese Prämie haben sich die beiden freiwilligen
Corps oft genug errungen. Waren doch ihre Mannschaften mit Leib
und Seele bei der Sache und trotz des meist heiteren, geselligen
Lebens, welches sich stets auf diesen Wachen entwickelte, stand
dieselbe stets auf dem Sprunge, ihre übernommenen Pflichten auch
voll und ganz auszuführen. Daß hierbei einige Mal sogar ein
Uebereifer zu Tage trat, ist wohl entschuldbar. So hatten junge
Mannschaften des 2. Zuges, die sich Nummer und Farbe ihrer
Spritze noch nicht genau eingeprägt hatten, einst das Malheur, bei
Feuerlärm einst am hellen Tage, statt ihrer Spritze, die der
Rettungscompagnie aus dem gemeinschaftlichen Depôt an der
ersten Bürgerschule zu ziehen und mit Unterstützung einiger
hilfsbereiter Lehrbuben und Gesellen im vollen Lauf nach der
Brandstelle zu fahren und dort in Thätigkeit zu setzen. Und —
welche Freude! — ihre Spritze war die erste am Platze und erhielt
die Prämie! — Aber — welche Enttäuschung, welche Spötteleien
und gegenseitigen Vorwürfe, als das Versehen erkannt wurde und
nun die Prämie der Rettungscompagnie zufiel! —
Beim Commers, nach Legung des Grundsteines zum Denkmal
für die Völkerschlacht (Anno 1863 — Gott weiß, wann das Denkmal
selbst erbaut wird) sang die Turnerfeuerwehr:
Wir und die Rettungscompagnie —
Sahn oftmals uns kaum an
Und dennoch hatten wir uns nie
Etwas zu Leid gethan.
Woraus der Streit entstanden war,
Ist Keinem recht bekannt
Und doch verging so manches Jahr —
Eh’ er sein Ende fand etc. etc.

Für alle Theilnehmer an diesen Wachen bildeten dieselben ein

Vergnügen, und den Werth und die Bedeutung derselben für das
kameradschaftliche Wesen lernte man eigentlich erst richtig
erkennen, als man in der letzten Kneiperei der Turnerfeuerwehr am
22. Juli 1871 unter anderen Schwanen-Gesängen auch den Vers
sang:
Nachdem zuvor im Tageblatt
Die Gründe dargelegt man hat —
Verschied zwar sanft — und dennoch schwer —
Die Leipz’ger Turnerfeuerwehr!
 Männer der besten Gesellschaftsklassen, aber auch einfache
Gesellen und Handwerker gehörten der Truppe an und alle verband
das Gefühl echter kameradschaftlicher Freundschaft. Daß natürlich
die Wachen der beiden Corps von den Wachen der berufsmäßigen
Feuerwehr insofern bedeutend abwichen, als dieselben eben von
den betreffenden Mannschaften mit Vergnügen bezogen und
»abgeschraubt« wurden, ist selbstverständlich, und nicht nur ein
geselliges, sondern auch oft genug ein feuchtfröhliches Treiben, so
weit solches mit den übernommenen Pflichten vereinbar war, machte
sich geltend. Scat und der solidere Schafkopf traten in ihr volles
Recht und wurden weidlich »gedroschen«, oft aber waren auch
Gäste »auf Wache«, die sich nicht »lumpen« ließen und zur
allgemeinen Erheiterung mit beitrugen. An Letzterer fehlte es aber
auch so nicht und so flog die Zeit von Abends 8 bis 2 Uhr vorüber.
Erst um diese Zeit, wo die sogenannte »Hundewache« (von 2—4)
begann, machte sich die Ermüdung geltend und die gefürchteten
»Pfefferkuchen« (Matratzen) wurden aufgesucht. Gefürchtet aber
waren diese Schmerzenslager wegen der Unmasse jener schwarzen
Eindringlinge, die sich sogar oft genug bis zu Quälgeistern unsrer
Damenwelt aufschwingen und also für den robusten Körper eines
Feuerwehrmannes nicht die Spur von Achtung oder Nachsicht
hatten. Das hopste und sprang lustig umher und zwickte und
zwackte, daß männiglich nicht die zartesten Redensarten den
Sprechwerkzeugen der also Gefolterten entquollen.
»Donnerwetter!« schrie einst, früh gegen 3 Uhr, als der
Wachtcommandant, noch allein munter, bei der Stechuhr saß und
las, ein Wehrmann und sprang mit gesträubtem Haar und einem
neuen Fluche vom »Pfefferkuchen« herab.
»Was ist denn los?« rief erschrocken der Lesende.
»Donnerwetter« rief der Andere, seines Zeichens ein biederer
Tanzlehrer, wieder und griff nach seinem Helm, als wollte er die
Wache verlassen, »e Scorpion — e Scorpion hat mich gebissen —
ich gehe heem!«
Der Wachtcommandant hatte alles Mögliche zu thun, ja mußte
zuletzt seine ganze Autorität aufbieten, um den Aufgeregten zu
beruhigen, der dabei blieb »e Scorpion« habe ihn gebissen.
Auch die anderen Mitglieder der Wache waren munter
geworden und eine allgemeine Durchsuchung der »Pfefferkuchen«
begann. Hei! wie das fröhlich hüpfte und sprang — und — man fand
zwar keinen Scorpion — aber ein so riesiges Exemplar der Familie
»Floh« wurde trotz der zu solchen Fängen nur wenig geschickten
Hände der tapferen Turner gefangen und hingerichtet, daß es auf
dem Tisch ordentlich »knallte« und es kein Wunder war, wenn der
Jünger Terpsichores an einen Scorpion gedacht hatte. — —
Jedem von denen, die als Gäste einen solchen Wachtabend mit
verleben durften, wird derselbe sicher unvergeßlich sein und
manche bethätigten ihre Dankbarkeit dafür, daß sie der Wache
»etwas stifteten«.
So hatte sich einst ein Meßfremder aus Nordhausen auf der
Wache so gut amüsirt, daß er versprach, der Wache ein Fäßchen
Nordhäuser — aber echten und alten — zu schicken. Aber als
dieselbe Mannschaft nach 15 Tagen wieder auf Wache kam, fragten
sie vergeblich nach dem Fäßchen und man lachte schließlich über
das windige Versprechen. Wie ward aber den Guten zu Muthe, als
sie bald darauf erfuhren, daß das Fäßchen allerdings richtig
angekommen war, aber an einem von der Rettungscompagnie
besetzten Abend, und da das Geschenk eben einfach an die
»freiwillige Wache« adressirt war, so hatten sich die von der
Rettungscompagnie nicht als Verächter der von einem »Pirnschen«
gegebenen edlen Gottesgabe bewiesen und den Inhalt des
Fäßchens zur allgemeinen, tiefgefühlten Entrüstung der Anderen —
bis auf die Nagelprobe geleert. Ja — ja:
Wir und die Rettungscompagnie u. s. w.

Und die — waren doch so unschuldig — so unschuldig. — Der

Nordhäuser wurde aber als »ausgezeichnet« von ihnen gepriesen —
nicht gerade zur Beruhigung der Anderen.
 Auf der Wache der Turnerfeuerwehr.
Manche alten Kämpen der Turnerfeuerwehr und
Rettungscompagnie werden frühere Mitglieder der beiden Corps auf
unserem Bilde erkennen. Viele — viele von ihnen sind längst
schlafen gegangen.
Es ist nicht zu leugnen, daß sich mit der Neuorganisation der
Leipziger Feuerwehr zu einem möglichst organischen Ganzen, sich
die Wache der freiwilligen Wehren allmälig als überflüssig — ja
vielleicht sogar der allgemeinen Verwaltung — hinderlich erwies und
so kam es denn, daß im Laufe der Zeit Zustände eintraten, bei
denen die freiwilligen Wehren fühlen mußten, daß sie — entbehrlich
waren und dies höheren Ortes längst anerkannt wurde. Das Beste
wäre nun wohl gewesen, wenn man dies einfach und offen den
Corps mitgetheilt hätte, statt dessen — und dies wohl wieder, weil
man ihre früheren großen Dienste eben ganz und voll anerkannte —
suchte man durch kleinliche Manöver mancher Art die Corps zu
veranlassen, selbst zu gehen, und als dies denn endlich geschah,
konnte man sich nicht wundern, daß Gefühle bitterer
Enttäuschungen und Zurücksetzungen mit zum Ausbruch kamen,
wenn auch nur innerhalb der letzten Versammlungen und geselligen
Feste der Corps selbst.
Der Rath schrieb auch »Ich danke schön,
Es ist schon gut — der Mohr kann geh’n —
Gebt möglichst bald — am liebsten gleich,
Die Blousen ab — und Euer Zeug!«

D’rauf streckten alle das Gewehr —

Mit Gurten, Flechen, Beilen schwer,
Beladen sah man Manchen hin —
Zu Brutus — unserm Hausmann zieh’n! u. s. w.

sangen sie wehmüthig im letzten Commers am 22. Juli 1871 und

daß man sie zwang freiwillig zu gehen, kam in den Versen eines
anderen Liedes bei jenem Commers so recht schmerzlich zum
Ausdruck. Da hieß es unter Anderem:
Der junge Baum, den in die Erde —
Wir voller Hoffen einst gesenkt,
Daß er ein Waldeskönig werde —
Hat reiche Freude uns geschenkt.

Er bot dem Wetter Trotz, der Starke,

Und seine Krone brach kein Sturm —
Nun aber nagt an seinem Marke,
An seiner Lebenskraft der Wurm.

Und soll er lange kläglich siechen

Wehrlos des gier’gen Wurmes Raub —
Und endlich doch am Boden liegen
Mit dürrem Ast — und welkem Laub?
— Nein — dreimal Nein! Die letzte Liebe
Gewährt ihm noch und zaudert nicht —
Daß von der Axt und ihrem Hiebe
In voller Pracht er niederbricht!
 Mehr als zwanzig Jahre sind seitdem verflossen, aber die
Geschichte der freiwilligen Turnerfeuerwehr und der etwas später
ebenfalls aufgelösten Rettungscompagnie ist mit der Leipzigs eng
verflochten geblieben und den beiden Corps gebührt für immer ein
Ehrenblatt in der Chronik unserer Vaterstadt.
 Inhalts-Verzeichniß.

Heft 1.
Vorrede des Verfassers 3
Die alte innere Stadt anno 1840 5
Heiterer Rückblick auf die Steuerbeitreibung in früherer Zeit (mit Bild.) 12
Die Südvorstadt. — Ein Sonntagsausflug vor 50 Jahren 20
Das Gutenbergfest 1840 25
»Die Communalgarde rückt aus!« (mit Bild) 29

Heft 2.
Der »hohe Seeler!« 41
Kramerlehrling und Gehilfe (mit Bild) 47
Verschiedene Chronica’s von 1840—1845 58
Die letzte öffentliche Hinrichtung in Leipzig 64
Die Leipziger Sänftenträger-Compagnie (mit Bild) 71
D. L. M. 64

Heft 3.
Allerlei Chronica von 1846—49 81
Die innere Stadt zur Meßzeit vor 40 Jahren (mit Bild) 87
Der damalige Meßfremde 94
Wichsekrah (mit Bild) 98
Student und Verbindungströdeljude 108
Ein Abend bei den Harfenistinnen in Auerbachs Keller vor 40 Jahren
(mit Bild) 115

Heft 4.
Allerlei Chronica von 1850—1859 129
Die Hiersemusen! (mit Bild) 135
Der Judenbrühl 143
Unter den Buden (mit Bild) 150
Die Leipziger Meßmusikanten und das Tagebuch des Chorführers und
Leinewebers Gottfried Hahn aus Stollberg im sächs. Erzgebirge (mit
Bild) 156

Heft 5.
Allerlei Chronica von anno 1860 169
Eckensteher und Nachtwächter vor 40 Jahren (mit Bild) 171
Der alte Petersschießgraben (mit Bild) und Leipziger Originale: Dr. Ewald 180
Leipzigs Südosten vor 40 Jahren 186
In Wechselhaft (mit Bild) 193
Der Verbrechertisch in der »guten Quelle« (mit Bild) 206

Heft 6.
Allerlei Chronica 217
Die politische Lage Deutschlands zu Ende der fünfziger, bis Mitte der
sechziger Jahre des 19. Jahrhunderts 219
Das 3. deutsche Turnfest 1863 (mit Bild) 224
Feier der Völkerschlacht 1863 239
Leipzigs frühere Feuerwehrverhältnisse 241
Auf der Wache der Turnerfeuerwehr (mit Bild) 254
 Verlag von Otto Lenz in Leipzig.
Bibliothek niederdeutscher Werke:
Bd. 1. Frans Essink, sien Liäwen un Driewen äs aolt Mönstersk Kind. Von
Prof. Dr. H. Landois, 1. humor. Teil: Bi Liäwtieden. 7. Aufl., illustriert. brosch.
M. 3.—, elegant geb. M. 4.—
Bd. 2. Frans Essink. 2. satyr. Teil: Nao sienen Daud. 6. Aufl., illustriert, brosch.
M. 1.80, elegant geb. M. 2.70.
Bd. 3. Frans Essink. 3. romant. Teil: Up de Tuckesburg. Brosch. M. 4.—, geb. M.
5.—.
Bd. 4. Sappholt aus Westfalens Dichterhain oder Mirza Schaffy in Holsken.
Neue humor. plattdeutsche Gedichte von Tonius Happenklang. Mit
Illustrationen, brosch. M. 1.40, elegant geb. M. 2.25.
Bd. 5/6. De westfölsche Husfrönd. Allerlei Spinnstuowen­geschichten von Karl
Prümer. Bd. 1/2. brosch. à M. 1.80, geb. à M. 2.70.
Bd. 7. Rugge Wiäge. Aus dem westfälischen Bauernleben in niederdeutscher
Sprache erzählt von Ferdinand Krüger. 3. Ausgabe, brosch. M. 2.—, eleg.
geb. M. 2.80.
Bd. 8. Dä Chronika van Düöpm. Ernste und spassige Epistel mit allerlei schäune
Biller von Karl Prümer, brosch. M. 1.80, elegant geb. M. 2.70.
Bd. 9. Plattdütsche Lachpillen oder lustige Reimereien in der Mundart der
Kanonen- und Kohlenstadt Essen von Willem Täpper in Bochum. Bd. 1. 3.
Auflage. Brosch. M. 1.20, eleg. geb. M. 2.10.
Bd. 10/13. — — Band 2/5 erscheinen später.
Bd. 14/16. Hempelmann’s Smiede. Ein westfälischer Roman aus der »guten
alten Zeit« in münsterländisch-niederdeutscher Sprache von Ferdinand
Krüger. Bd. 1/3. brosch. à M. 3.—, geb. à M. 4.—

Weitere empfehlenswerthe Werke:

Frl. Paulinchen Huhn’s Briefe an ihre Freundin Frl. Laura Niedlich. brosch. Mk.
3.—, eleg. geb. Mk. 4.—
»Cabinetstücke psychol. Feinmalerei« (Lpzg. Tagebl.) — »erinnert an
Raabe’s Chronik der Sperlingsgasse« (Allg. Modenztg.) — »ergötzl. Bild
kleinstädt. Lebens« (National-Ztg.) »für die »Buchholzen« Schwärmende wird
das echten Berliner Humor enthaltende Buch sehr zusagen.« (Für’s Haus)
u. s. w.
Blumensprache nebst Liedern der Liebe. 15. Aufl., brosch. M. —.75, geb. 1.25.
Die Verlagshandlung Otto Lenz in Leipzig, Gellertstr. 16.
 Weitere Anmerkungen zur Transkription
Offensichtliche Fehler wurden stillschweigend korrigiert. Die Darstellung der
Ellipsen wurde vereinheitlicht.
Korrekturen:
Prinzipal → Principal (häufigere Verwendung)
S. 54: Da jeder Principal genau wußte
Peterstraße → Petersstraße (es gibt keine Peterstraße in Leipzig)
S. 7: links von der Petersstraße
S. 9: Die Petersstraße, damals noch
S. 80: Leinenwaarengeschäft der Petersstraße
S. 84: Petersthor und Petersstraße
S. 162: in der Petersstraße
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