REVIEW

CURRENT
OPINION Update on astigmatism management
Ehsan Mozayan and Jimmy K. Lee

Purpose of review
Astigmatism is a common refractive error that affects a significant portion of the population. This is a
review of the most salient topics on assessing astigmatism as well as a discussion of the latest developments
in surgical options and newest technologies to improve outcomes.
Recent findings
Laser corneal ablation continues to be highly effective for correcting low-to-moderate levels of astigmatism
and may be the best option for the younger patient population. For eyes with astigmatism and cataracts,
both peripheral corneal-relaxing incisions and cataract extraction with toric intraocular lenses have proven
to be effective. Improved assessment of astigmatism, methods to select more accurate lens power, and new
technologies to confirm proper axis alignment have all contributed to minimizing postoperative residual
astigmatism.
Summary
Cataract surgery has evolved into a refractive procedure, in which not only the sphere but also cylinder
errors can now be confidently corrected. Careful assessment and surgical planning of astigmatism should
not be an option, but essential components of cataract surgery.
Keywords
astigmatism, peripheral corneal-relaxing incisions, topography, toric intraocular lens

INTRODUCTION caveat to consider is that wavefront maps are

Astigmatic refractive error is highly prevalent across
all ethnicities. A recent survey of refractive errors
in the European adult population of over 15 000
participants found that 32.3% had astigmatism
[1]. A similar large-scale study of a multiethnic Asian
population of over 10 000 adults found that 58.8%
had astigmatism [2]. Numerous family and twin
studies have alluded to a heritability of up to 60%
[3,4], and recently a candidate gene has been ident-
&
ified [5 ]. This review will provide an update in
assessing astigmatism, and review the current cor-
neal and intraocular surgical options to address this
refractive error.
ASTIGMATISM ASSESSMENT
Seminal to accurately measuring the magnitude and
axis of astigmatism is an optimized ocular surface.
Often, patients with regular or irregular astigmatism
are soft or hard contact lens wearers and a period of
contact lens holiday is recommended prior to assess-
ment. A stable tear film and cornea devoid of epi-
theliopathy is critical for accurate measurements.
Important especially for corneal laser vision correc-
tion is wavefront analysis, which measures higher
order aberrations of the entire optical system. One
dependent on pupil size and accommodation; there-
fore, in instances of corneal opacity or irregularity,
data may not be adequately captured or the line of
sight (pupil center) and the visual axis (corneal
vertex) may not be aligned.
Whereas manifest refraction and wavefront
analysis takes into account the entire optical system,
there are various modalities that measure corneal
astigmatism: automated keratometry, manual
keratometry, Placido-based corneal topography,
Scheimpflug elevation mapping, and partial coher-
ence interferometry (IOLMaster; Carl Zeiss Meditec,
Jena, Germany). The advantages and disadvantages
are that corneal curvature can be directly measured
with Placido-disc technology, but must be calcu-
lated from the Scheimpflug data. Elevation mapping
can be directly measured with Scheimpflug, but
Montefiore Medical Center, New York, New York, USA
Correspondence to Jimmy K. Lee, MD, Director of Refractive Surgery,
Department of Ophthalmology and Visual Sciences, Assistant Professor,
Albert Einstein College of Medicine, 3332 Rochambeau Avenue, 3rd
Floor, Bronx, NY 10467, USA. Tel: +1 646 342 5546; e-mail: jimmylee
@montefiore.org
Curr Opin Ophthalmol 2014, 25:286–290
DOI:10.1097/ICU.0000000000000068

www.co-ophthalmology.com Volume 25
Number 4
July 2014

Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

KEY POINTS

Corneal laser vision correction remains highly effective,
especially for the treatment of moderate amounts of
astigmatism (between 1 and 3 diopters).

Peripheral corneal-relaxing incisions are becoming
increasingly popular, with the latest improvements
being femtosecond intrastromal incisions.

New preoperative, intraoperative, and postoperative
technologies are improving the outcomes of toric
intraocular lenses.
must be derived with Placido-disc. Recently, the
Galilei Dual Scheimpflug analyzer (Ziemer Ophthal-
mic Systems AG, Port, Switzerland), which combine
the two, have shown repeatability of corneal power
and wavefront aberration measurements [6].
Initial studies have reported similar measure-
ment of astigmatism when comparing the aforemen-
tioned modalities. One report found agreement of
mean corneal power, astigmatic power, and axis
when comparing IOLMaster to two manual keratom-
eters [7], and another found similar consistency
when comparing manual keratometer, IOLMaster,
Pentacam (Oculus, Wetzlar, Germany), and auto-
keratometer [8]. Although not a comparative study,
one prospective multicenter study of toric intraocular
lens (IOL) outcomes found that their 20/20 rates were
higher with Lenstar LS-900 dual-zone automated
keratometer (Haag-Streit AG, Koeniz, Switzerland)
than the manufacturers package insert, in which
manual keratometry was used for surgical planning
[9].
CORNEAL LASER VISION CORRECTION
If the patient is prepresbyopic or of precataractous
age, has no ocular disease, and the wavefront aber-
rometry is consistent with manifest refraction and
topography, corneal laser vision treatment is a
viable option. Laser-assisted in-situ keratomileusis
(LASIK) and photorefractive keratectomy (PRK) are
efficacious and popular for all types of refractive
errors including corneal astigmatism. For high
myopic [greater than 3 diopters (D)] astigmatism,
LASIK and PRK were found to be comparably well
tolerated, effective, and predictable with 39% of PRK
and 54% of LASIK patients achieving less than 1 D,
and 88% of PRK and 89% of LASIK eyes having
less than 2 D of residual astigmatism [10]. Similar
success with 65.3% within þ1.00 D was seen in those
with high preoperative mixed astigmatism (over
3.0 D) [11]. In comparing PRK with mitomycin-C
(MMC), without MMC, and trans-photorefractive
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Update on astigmatism management Mozayan and Lee
keratectomy (T-PRK) for the treatment of astigma-
tism with the Amaris 750s laser (Schwind eye-
tech-solutions, Kleinostheim, Germany), one group
found similar effectiveness and safety between
groups, with mean manifest refractive spherical
equivalent (MRSE) of within þ0.50 D in 100, 100,
and 93% of eyes, respectively [12]. Long-term find-
ings from one study found that for all types of
astigmatism (myopic, compound hyperopic, and
mixed), UCVA was 20/25 or better in over 90% of
eyes at 3 years [13]. Interestingly, recent findings
warrant caution when treating low amounts of astig-
matism. One study found that low myopic eyes with
preoperative cylinder or less 0.50 D were signifi-
cantly overcorrected with wavefront-optimized
&
LASIK [14 ]. In another study in which preoperative
astigmatism was minimal (less than 1.00 D), PRK
and LASIK were found to induce substantial astig-
matism, with surgically induced astigmatism posi-
tively correlated with greater levels of preoperative
astigmatism [15].
PERIPHERAL CORNEAL-RELAXING
INCISIONS
Introduced over 25 years ago, peripheral corneal-
relaxing incisions (PCRIs) continue to be effective
and popular today [16]. Critical to the success of
PCRIs are high-quality preoperative measurements,
accurate surgical reference marks, incision of suffi-
cient depth (90%), and fine-tuning of individual
nomograms. To compensate for cyclotorsion, it is
imperative to mark the patient’s horizontal (3 and
9 o’clock) meridians and 6 o’clock meridian if
possible. The lowest cost method is to use the slit
beam at the slit lamp oriented horizontally or a
commercially available bubble level marker in the
preoperative holding area. One group found that
placing reference marks on the limbus, identifying
the reference marks on the topographic image, and
performing the relaxing incision based on the image
were more accurate than basing the incisions with-
out topographic reference [17].
Online nomograms (www.LRIcalculator.com)
and smartphone apps have made the nomograms
very convenient for the surgeon, with basic data
required: patient’s age, keratometry, pachymetry,
and surgeon-induced astigmatism.
Several studies have compared PCRIs to toric IOLs
for correcting astigmatism during cataract surgery.
&
Although Hirnschall et al. [18 ] and Mingo-Botı́n et al.
[19] found that the latter was more effective and
predictable, Poll et al. [20] found both modalities to
be comparable for mild-to-moderate levels; toric IOLs
were more likely to achieve 20/40 UDVA in eyes
with higher degrees of astigmatism, at least 2.26 D.
www.co-ophthalmology.com 287
 Refractive surgery
Another group found that combining toric IOLs with
PCRIs in high astigmatism (>2.50 D) yielded an aver-
age reduction in cylindrical error from 3.90 D to
0.94 D and an average reduction in keratometric
cylinder from 3.46 D to 1.80 D [21].
Femtosecond PCRIs are gaining popularity with
precise axis placement and depth of incisions. The
true advantage over manual incisional PCRIs, how-
ever, may be in equal efficacy without irritation or
risk for infection [22,23] with intrastromal femto-
second PCRIs. One study of postkeratoplasty intra-
stromal PCRIs in eyes found a refractive cylinder
reduction from 6.8 D to 3.7 D and topographic
reduction from 9.5 D to 4.4 D [24]. Another inter-
ventional case series of 16 patients with naturally
occurring or postcataract surgery astigmatism who
were treated with femtosecond intrastromal PCRIs
demonstrated a reduction in refractive and topo-
graphic reduction of cylinder from 1.41 D to 0.33 D
and 1.50 D to 0.63 D, respectively [25].
TORIC INTRAOCULAR LENSES
There are currently more than 10 monofocal IOLs
&&
and 4 multifocal IOLs in the market today [26 ]. In a
randomized controlled trial, Holland et al. [27]
reported less than 1.0 D postoperative residual
refractive astigmatism in 88% of toric IOL eyes
versus 48% in the monofocal group; 60% of the
toric IOL group reported spectacle independence
compared with 36% in the monofocal group.
Although the success rates are impressive, there
has been much debate as to how outcomes may be
improved. At the heart are two concepts that did not
gain much attention in the past: posterior corneal
curvature and effective lens position (ELP). Koch
et al. [28] found that ignoring posterior corneal
astigmatism gave an incorrect estimation of total
corneal astigmatism, with overestimation of with-
the-rule (WTR) astigmatism and underestimation of
against-the-rule (ATR) astigmatism. A nomogram
has been proposed by the same group whereby for
toric IOL calculations, 0.5 D would be subtracted in
WTR astigmatism and 0.3 D would be added for
&&
ATR astigmatism [29 ]. The importance of posterior
topography and tomography in toric IOL calcu-
lations has also been confirmed by using ray tracing
software Okulix (Tedics, Dortmund, Germany) to
predict residual refraction [30].
Another crucial assumption by toric IOL manu-
facturers that has raised much attention is that the
ratio (1.46) of the IOL plane cylinder needed to
neutralize the corneal plane cylinder is constant.
In contrary, investigators have found that anterior
chamber depth (ACD) and axial length can strongly
&
influence the astigmatic power of toric IOLs [31 ].
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Savini et al. found that the ratio between toricity at
the IOL plane and the corneal plane depend on the
ACD; the highest ratio (1.86) was associated with
the steepest K (48.0 D) and longest axial length
(30.0 mm), whereas the lowest ratio (1.29) was
associated with the flattest K (38.0 D) and shortest
axial length (20.0 mm). When taking into consider-
ation the ACD and spheroequivalent power of the
IOL, Goggin et al. [32] also found that the manu-
facturer’s predicted fixed corneal plane cylinder
power was substantially different from the calcu-
lated corneal cylinder power. To address this issue,
Holladay [33] has proposed a table with different
ratios for IOL cylinder to corneal cylinder for various
ELPs and spheroequivalent powers.
After selecting the appropriate power of the toric
IOL, alignment of the IOL to the intended axis is
the next challenge. Currently, most surgeons are
manually marking reference 3, 6, and 9 o’clock
meridians as mentioned in the PCRI section. How-
ever, new systems which use a preoperative non-
contact reference unit to image the iris and limbal
and scleral vessels, and overlay the image with
the alignment axis onto the microscope during
surgery have emerged to more accurately aid proper
alignment. Currently available in the market are
Surgery Guidance SG3000 (Sensomotoric Instru-
ments GmbH, Teltow, Germany), Callisto (Carl Zeiss
Meditec AG, Jena, Germany), and Verion (Alcon,
Basel, Switzerland). Furthermore, intraoperative
aberrometers, such as ORA (WaveTec, Also Viejo,
California, USA) and HOLOS (Clarity Medical
Systems, Inc. Pleasanton, California, USA) have
been shown to be helpful in confirming the power
of the toric IOLs in the aphakic status and allow fine-
tuning of the axis alignment [34,35].
Rotational stability of the toric IOL is critical to
optimal refractive outcomes, as there may be up to
3.3% loss of astigmatic correction for every degree of
toric IOL misalignment. There are various methods
of measuring or calculating postoperative IOL
misalignment: slit lamp with a rotating slit, anterior
segment optical coherence tomography [36],
vector analysis [37], or using combined wavefront
aberrometer/topographers such as iTrace (Tracey
Technologies, Houston, Texas, USA), OPD-scan III
(Nidek Inc., Fremont, California, USA), KR-1W
(Topcon Medical Systems, Inc., Oakland, New
Jersey, USA), Keratron Onda (Optikon 2000 SpA,
Rome, Italy), or Discovery System (Innovative Visual
Systems, Elmhurst, Illinois, USA).
In the presence of significant residual refractive
error, several options are available for the dissatis-
fied patient. If the refractive error is because of
misalignment in the early postoperative phase
and zonular stability is not in question, the toric
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July 2014

IOL may be repositioned [38]. In the latter scenario,
the IOL may need to be exchanged with a capsular
stabilizing ring or a three-piece monofocal IOL may
need to be iris or scleral fixated. If repositioning or
exchange of the IOL is not an option because of
fibrosis of the capsular bag, the residual refractive
error can be managed with excimer laser corneal
ablation.
CONCLUSION
In younger patients without cataracts, laser corneal
surgery remains the mainstay of astigmatism cor-
rection. However, recent improvements in techno-
logies that allow better assessment of astigmatism,
more accurate IOL selection, and improved intra-
ocular alignment are popularizing the use of toric
IOLs as an effective option for concurrently address-
ing both astigmatism and cataracts. Conceptually,
the new technologies are promising. However,
future comparative studies will reveal whether they
confer a true advantage. An encouraging trend is
that these new technologies are merging into com-
bination platforms, so that fewer scans from fewer
modalities will be necessary.
Acknowledgements
Supported by an unrestricted grant from Research to
Prevent Blindness to the Albert Einstein College of Medi-
cine Department of Ophthalmology and Visual Sciences.
Conflicts of interest
The authors do not have any financial interests relevant
to this article.
REFERENCES AND RECOMMENDED
READING
Papers of particular interest, published within the annual period of review, have
been highlighted as:
& of special interest
&& of outstanding interest
1. Pan CW, Zheng YF, Anuar AR, et al. Prevalence of refractive errors in a
multiethnic Asian population: the Singapore Epidemiology of Eye Disease
Study. Invest Ophthalmol Vis Sci 2013; 54:2590–2598.
2. Wolfram C, Höhn R, Kottler U, et al. Prevalence of refractive errors in the
European adult population: the Gutenberg Health Study (GHS). Br J Ophthal-
mol 2014. [Epub ahead of print]
3. Grjibovski AM, Magnus P, Midelfart A, Harris JR. Epidemiology and heritability
of astigmatism in Norwegian twins: an analysis of self-reported data. Ophthal-
mic Epidemiol 2006; 13:245–252.
4. Hammond CJ, Snieder H, Gilbert CE, Spector TD. Genes and environment in
refractive error: the twin eye study. Invest Ophthalmol Vis Sci 2001;
42:1232–1236.
5. Lopes MC, Hysi PG, Verhoeven VJ, et al. Identification of a candidate gene for
& astigmatism. Invest Ophthalmol Vis Sci 2013; 54:1260–1267.
This meta-analysis of seven Caucasian populations is the first to identify a
candidate gene associated with astigmatism in the VAX2 gene region.
6. Wang L, Shirayama M, Koch DD. Repeatability of corneal power and
wavefront aberration measurements with a dual-Scheimpflug Placido corneal
topographer. J Cataract Refract Surg 2010; 36:425–430.
7. Bullimore MA, Buehren T, Bissmann W. Agreement between a partial co-
herence interferometer and 2 manual keratometers. J Cataract Refract Surg
2013; 39:1550–1560.
1040-8738 ß 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Update on astigmatism management Mozayan and Lee
8. Chang M, Kang SY, Kim HM. Which keratometer is most reliable for
correcting astigmatism with toric intraocular lenses? Korean J Ophthalmol
2012; 26:10–14.
9. Potvin R, Gundersen KG, Masket S, et al. Prospective multicenter study of
toric IOL outcomes when dual zone automated keratometry is used for
astigmatism planning. J Refract Surg 2013; 29:804–809.
10. Katz T, Wagenfeld L, Galambos P, et al. LASIK versus photorefractive
keratectomy for high myopic (>3 diopter) astigmatism. J Refract Surg
2013; 29:824–831.
11. Alio JL, Pachkoria K, El Aswad A, Plaza-Puche AB. Laser-assisted in situ
keratomileusis in high mixed astigmatism with optimized, fast-repetition and
cyclotorsion control excimer laser. Am J Ophthalmol 2013; 155:829–836.
12. Baz O, Kara N, Bozkurt E, et al. Photorefractive keratectomy in the correction
of astigmatism using Schwind Amaris 750 s laser. Int J Ophthalmol 2013;
6:356–361.
13. Roszkowska AM, De Grazia L, Meduri A, et al. Long-term results of excimer
laser procedure to correct astigmatic refractive errors. Med Sci Monit 2013;
19:927–933.
14. Katz T, Frings A, Linke SJ, et al. Laser in situ keratomileusis for astigmatism
& 0.75 diopter combined with low myopia: a retrospective data analysis. BMC
Ophthalmol 2014; 14:1.
This report cautions against full-laser ablation correction in cases of low myopia
and compound astigmatism as it may result in overcorrection of cylinder.
15. Christiansen SM, Mifflin MD, Edmonds JN, et al. Astigmatism induced by
conventional spherical ablation after PRK and LASIK in myopia with astig-
matism < 1.00 D. Clin Ophthalmol 2012; 6:2109–2117.
16. Maguire LJ, Bourne WM. Corneal topography of transverse keratotomies for
astigmatism after penetrating keratoplasty. Am J Ophthalmol 1989; 107:323–
330.
17. Miyata K, Miyai T, Minami K, et al. Limbal relaxing incisions using a reference
point and corneal topography for intraoperative identification of the steepest
meridian. J Refract Surg 2011; 27:339–344.
18. Hirnschall N, Gangwani V, Crnej A, et al. Correction of moderate corneal
astigmatism during cataract surgery: toric intraocular lens versus peripheral
&
corneal relaxing incisions. J Cataract Refract Surg 2014; 40:354–361.
This is the only prospective bilateral study that compared toric IOLs versus PCRIs.
They found that the toric IOL Rayner-T (Rayner, East Sussex, UK) was more
effective and predictable than PCRIs.
19. Mingo-Botı́n D, Muñoz-Negrete FJ, Won Kim HR, et al. Comparison of toric
intraocular lenses and peripheral corneal relaxing incisions to treat astigma-
tism during cataract surgery. J Cataract Refract Surg 2010; 36:1700–1708.
20. Poll JT, Wang L, Koch DD, Weikert MP. Correction of astigmatism during
cataract surgery: toric intraocular lens compared to peripheral corneal relax-
ing incisions. J Refract Surg 2011; 27:165–171.
21. Ouchi M, Kinoshita S. AcrySof IQ toric IOL implantation combined with limbal
relaxing incision during cataract surgery for eyes with astigmatism >2.50 D. J
Refract Surg 2011; 27:643–647.
22. Haripriya A, Syeda TS. A case of endophthalmitis associated with limbal
relaxing incision. Indian J Ophthalmol 2012; 60:223–225.
23. Moon SW, Yeom DJ, Chung SH. Neurotrophic corneal ulcer development
following cataract surgery with a limbal relaxing incision. Korean J Ophthalmol
2011; 25:210–213.
24. Wetterstrand O, Holopainen JM, Krootila K. Treatment of postoperative
keratoplasty astigmatism using femtosecond laser-assisted intrastromal
relaxing incisions. J Refract Surg 2013; 29:378–382.
25. Rückl T, Dexl AK, Bachernegg A, et al. Femtosecond laser-assisted intras-
tromal arcuate keratotomy to reduce corneal astigmatism. J Cataract Refract
Surg 2013; 39:528–538.
26. Visser N, Bauer NJ, Nuijts RM. Toric intraocular lenses: historical overview,
&& patient selection, IOL calculation, surgical techniques, clinical outcomes, and
complications. J Cataract Refract Surg 2013; 39:624–637.
A comprehensive review on toric intraocular lenses with comparative analysis of
currently available models.
27. Holland E, Lane S, Horn JD, et al. The AcrySof Toric intraocular lens in subjects
with cataracts and corneal astigmatism: a randomized, subject-masked, parallel-
group, 1-year study. Ophthalmology 2010; 117:2104–2111.
28. Koch DD, Ali SF, Weikert MP, et al. Contribution of posterior corneal
astigmatism to total corneal astigmatism. J Cataract Refract Surg 2012;
38:2080–2087.
29. Koch DD, Jenkins RB, Weikert MP, et al. Correcting astigmatism with toric
&& intraocular lenses: effect of posterior corneal astigmatism. J Cataract Refract
Surg 2013; 39:1803–1809.
The effect of posterior corneal astigmatism in addressing with toric intraocular
lenses is analyzed, and a new nomogram to adjust for overestimation of with-the-
rule astigmatism and underestimation of against-the-rule astigmatism is proposed.
30. Hoffmann PC, Wahl J, Hütz WW, Preußner PR. A ray tracing approach to
calculate toric intraocular lenses. J Refract Surg 2013; 29:402–408.
31. Savini G, Hoffer KJ, Carbonelli M, et al. Influence of axial length and corneal
& power on the astigmatic power of toric intraocular lenses. J Cataract Refract
Surg 2013; 39:1900–1903.
Anterior chamber depth influenced the ratio (a standard number used by the lens
manufacturer) between the cylinder power in the IOL plane and the corneal plane,
and should be accounted for when selecting the power of the toric IOL in eyes with
axial length and keratometry readings far from the average values.
www.co-ophthalmology.com 289
 Refractive surgery
32. Goggin M, Moore S, Esterman A. Outcome of toric intraocular lens
implantation after adjusting for anterior chamber depth and intraocular
lens sphere equivalent power effects. Arch Ophthalmol 2011; 129:998–
1003.
33. Holladay JT. Improving toric IOL outcomes. Ocular Surgery News. http://
www.osnsupersite.com/view.aspx?rid=83309. Published 25 May 2011 and
10 June 2011.
34. Ianchulev T, Hoffer KJ, Yoo SH, et al. Intraoperative refractive biometry for
predicting intraocular lens power calculation after prior myopic refractive
surgery. Ophthalmology 2014; 121:56–60.
290 www.co-ophthalmology.com
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
35. Krueger RR, Shea W, Zhou Y, et al. Intraoperative, real-time aberrometry
during refractive cataract surgery with a sequentially shifting wavefront device.
J Refract Surg 2013; 29:630–635.
36. Watanabe K, Negishi K, Torii H, et al. Simple and accurate alignment of toric
intraocular lenses and evaluation of their rotation errors using anterior seg-
ment optical coherence tomography. Jpn J Ophthalmol 2012; 56:31–37.
37. Alpins NA, Goggin M. Practical astigmatism analysis for refractive outcomes
in cataract and refractive surgery. Surv Ophthalmol 2004; 49:109–122.
38. Chang DF. Repositioning technique and rate for toric intraocular lenses.
J Cataract Refract Surg 2009; 35:1315–1316.
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