Sharper vision starts here

Recent data suggest that more than 75% of patients with cataract have at least 0.5 diopter (D) of preoperative corneal astigmatism.¹ However, findings from a recent survey among members of the American Society of Cataract and Refractive Surgery showed only 20% of their eligible patients receive toric IOLs.² Also, according to results from the 2023 European Society of Cataract and Refractive Surgeons Clinical Trends Survey, 18% of cataract procedures for patients with clinically significant astigmatism involve toric IOLs (Figure).³

Managing astigmatism at the time of cataract surgery is essential for optimizing visual outcomes and reducing spectacle dependence. As patient expectations continue to rise, precise correction of astigmatism can significantly impact their satisfaction and the perceived level of success of surgery. However, achieving these outcomes requires careful planning and meticulous surgical execution.

If astigmatism has not been addressed during cataract surgery, the following best practices can help integrate astigmatism management into the surgical workflow and improve patient outcomes. These include preoperative, intraoperative, and postoperative considerations, as well as the benefits of utilizing the latest technology.

Preoperative

Patient education and consulting

Patient selection and education on available options and expected outcomes with a premium toric lens are crucial for managing expectations, helping to increase patient satisfaction, and ensuring appropriate lens selection.

When talking to patients with cataracts about astigmatism correction, the first step is to help them understand astigmatism. One analogy I use is to explain that the front of the eye should ideally be shaped like a basketball, with even curvature in all directions that allows light to focus at a single point. With astigmatism, however, the cornea is shaped more like a football, with steeper and flatter curves along different meridians, causing light to focus at multiple points instead of just 1. These explanations set the stage for addressing astigmatism during cataract surgery.

Once patients understand the concept, attention shifts to their everyday life requirements, which helps determine how much they need to use their distance, intermediate, and near vision. For instance, my patients have indicated that they work at a computer screen 40 hours a week or ride a motorcycle and must be able to see the gauges clearly. Knowing more about their lifestyle enables a tailored discussion of lens options that will deliver the vision they expect and need.

Exam and evaluation

Next, it is essential to confirm that the cornea and macula are healthy and there is no ocular disease, as that could impact surgical outcomes. This involves utilizing several diagnostic technologies that provide crucial information prior to surgery (Table):

• Biometry provides key information for calculating the patient’s spherical and astigmatic lens power.
• Keratometry measures the radius of curvature of the cornea, specifically the central zone. This measurement helps determine the cornea’s refractive power and identify any irregularities, such as astigmatism.
• Topography shows whether the patient has regular or irregular astigmatism or any ocular surface irregularities that would affect how light rays enter the cornea.

Compared with a decade ago, the latest versions of these technologies offer improved consistency in refractive prediction accuracy, detailed high-resolution imaging, and data integration for efficient surgical planning.^4,5 For example, modern devices can precisely measure posterior corneal astigmatism and account for subtle irregularities that might have previously gone undetected.⁶

Differentiating between regular and irregular astigmatism is particularly important prior to surgery. This is especially true for patients who have previously undergone refractive surgery, because irregular astigmatism can limit the effectiveness of toric IOLs and may require alternative management strategies. Today’s patients undergoing cataract surgery—the first generation with a history of refractive surgery—are more likely than ever to have undergone LASIK or other refractive procedures.⁷ As a result, surgeons must be adept at evaluating complex corneas and tailoring their approach to this patient population.

All this information is integrated into modern toric IOL formulas to calculate the appropriate lens power. Calculations for toric IOLs must be precise to produce the quality of vision patients expect. Even a 0.75-D deviation from target can result in uncorrected distance vision and out-of-focus vision.

Ocular surface health

It is essential to ensure that the ocular surface is healthy before surgery, which requires proper diagnosis and treatment of any preexisting dry eye disease (DED). This must be completed before biometry, as DED can affect the accuracy of those measurements. Study data indicate that more than 50% of patients presenting for cataract surgery have some degree of DED, even in the absence of symptoms, making this a common and often underappreciated factor in preoperative planning.⁸

All forms of DED cannot be treated in the same manner, so it is important to first determine whether the patient has aqueous-deficient DED, caused by insufficient tear production, or evaporative DED, which results from rapid tear evaporation due to meibomian gland dysfunction. For aqueous-deficient DED, initial management may involve artificial tears, with the option to progress to prescription medications. For evaporative DED, a thermal meibomian gland treatment may be appropriate.

Marking the eye

Finally, cyclorotation is a key factor to manage. Because the eye undergoes rotation when the patient transitions to a seated position, accurately marking the astigmatism axis is essential. To address cyclorotation, surgeons can mark the eye while the patient is sitting and use anatomical landmarks as reference points. Alternatively, they can use technologies such as intraoperative aberrometry or digital marking systems that track the rotation through iris registration or by identifying the limbal vessels.

Intraoperative

On the day of surgery, a crucial step is to ensure precise axis alignment for toric IOL placement. This can be achieved using iris registration and modern femtosecond laser platforms, which allow for highly accurate capsulotomy and lens fragmentation while integrating preoperative data to guide alignment.

Intraoperative aberrometry can also be used to refine IOL power and axis selection in real time, especially in eyes with prior refractive surgery or irregular corneas. These technologies help compensate for the cyclorotation and anatomical variability that can occur.

The rest of the procedure should follow the steps of a typical cataract surgery. The latest toric IOL technologies offer a wide range of toric correction and allow surgeons to address astigmatism in smaller steps of correction. One recently introduced lens (enVista Envy; Bausch and Lomb) offers an option for patients with low astigmatism (something not available on other platforms). Modern toric lenses are designed to minimize glare and halos, which enhances patient satisfaction. I have had particular success with newer IOL models in patients who drive at night or are sensitive to visual disturbances. These lenses also allow for finer increments of astigmatism correction, helping to achieve optimal refractive outcomes.

Postoperative

The final steps of ensuring positive patient outcomes occur postoperatively. At my practice, North Georgia Eye Associates, patients with toric IOLs are seen the day after surgery, as well as at 1- and 4-week postoperative intervals. During these visits, clinicians assess for cornea edema, macular edema, elevated IOP, or any signs of infection. Monitoring also includes evaluation for significant rotation of the IOL. If there is rotation that causes residual astigmatism, it may be necessary to rotate the IOL back to the intended axis or consider laser vision correction to address any remaining refractive error.

Beyond ruling out complications postoperatively, it is important to be prepared to manage the patient’s vision and fine-tune outcomes. If the patient’s vision is not adequate, this may involve an IOL exchange, a photorefractive keratectomy, or a LASIK procedure.

Conclusion

Managing astigmatism during cataract surgery requires a comprehensive approach that begins with patient education and careful preoperative planning, continues with precise intraoperative technique, and is completed with diligent postoperative care. By leveraging the latest diagnostic, surgical, and toric lens technologies, surgeons can consistently deliver excellent visual outcomes and high patient satisfaction. These best practices can help patients achieve clear, sharp vision and spectacle independence after cataract surgery.

Jack M. Chapman, MD

E: [email protected]

Chapman is an ophthalmologist specializing in cataract surgery at North Georgia Eye Associates in Gainesville, Georgia. He is a consultant for Alcon, Amring Pharmaceuticals (now Nordic Pharma, Inc), Bausch + Lomb, Bruder Healthcare, and LENSAR.

References

1. Day AC, Dhariwal M, Keith MS, et al. Distribution of preoperative and postoperative astigmatism in a large population of patients undergoing cataract surgery in the UK. Br J Ophthalmol. 2019;103(7):993-1000. doi:10.1136/bjophthalmol-2018-312025

2. Cimberle M. Surgeons discuss how to address astigmatism during cataract surgery. Ocular Surgery News. January 10, 2021. Accessed July 10, 2025. https://www.healio.com/news/ophthalmology/20210104/surgeons-discuss-how-to-address-astigmatism-during-cataract-surgery

3. ESCRS clinical trends survey 2023 results. EuroTimes. September 2024(supp):6. Accessed July 10, 2025. https://www.escrs.org/media/jg0hzpys/escrs_clinicaltrendssurvey2023_sept24.pdf

4. Ma S, Li C, Sun J, et al. Assessing the interchangeability of keratometry measurements from four biometric devices in intraocular lens power calculations: insights into the predictive accuracy of five modern IOL formulas. BMC Ophthalmol. 2025;25(1):236. doi:10.1186/s12886-025-04067-y

5. Moore JE, McNeely RN, Moutari S. Cataract surgery in the small adult eye: a review. Clin Exp Ophthalmol. 2025;53(5):558-569. doi:10.1111/ceo.14510

6. Kanclerz P, Khoramnia R, Wang X. Current developments in corneal topography and tomography. Diagnostics (Basel). 2021;11(8):1466. doi:10.3390/diagnostics11081466

7. Mu J, Xu F, Guo W, et al. Updated study on demographic and ocular biometric characteristics of cataract patients indicates new trends in cataract surgery. Sci Rep. 2025;15(1):17289. doi:10.1038/s41598-025-02311-5

8. Trattler WB, Majmudar PA, Donnenfeld ED, McDonald MB, Stonecipher KG, Goldberg DF. The prospective health assessment of cataract patients’ ocular surface (PHACO) study: the effect of dry eye. Clin Ophthalmol. 2017;11:1423-1430. doi:10.2147/OPTH.S120159