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3 • 2018 ASCRS Clinical Survey Key findings Overall, 95% of respondents agree or strongly agree that all patients with clinically significant astigmatism should be offered astigmatism correction at the time of cataract surgery. Respondents, on average, reported that 20% of these patients receive toric IOLs. The most common reasons cited for not implanting a toric IOL, despite the patient being a candidate, were cost to the patient, not enough surgical training, and toric IOLs not being avail- able. More than 65% of respondents think 5 degrees of postop rotation or less is acceptable before it can impact visual quality and acuity. "As an indication of just how standard toric IOLs have become, nearly all of the respondents think that appropriate patients should be offered astig- matism correction at the time of cataract surgery. Despite this, more than 30% of respondents do not feel sufficiently trained to integrate toric IOLs into their practices. Among American respondents, this number surprisingly jumps to 39%, which may reflect a major knowledge gap in residency training. I would urge every cataract surgeon to become comfortable with toric IOL technology. There are no optical disad- vantages to correcting astigmatism; we virtually all concur that appropriate patients deserve the option, and surgeons are additionally compensated for this refractive service, which has a high satisfaction rate. "How to manage posterior corneal astigmatism (PCA) is a significant knowledge gap. The survey shows that many surgeons still don't know how to measure or calculate PCA and don't understand or believe in its significance. As a positive, this survey shows an increasing appreciation of the importance of proper toric IOL alignment when compared to 2017 results." —David F. Chang, MD ASCRS Cataract Clinical Committee What percentage of your cataract patients with clinically significant astigmatism receive a toric IOL? • On average, 20% of all respondents' patients with clinically significant astigmatism receive toric IOLs • For 40% of respondents, 21% or more of their patients with clinically significant astigmatism receive toric IOLs All 20% US 22% NonUS 18% Average Pct n=463 22 After implanting a toric IOL, how many degrees of postoperative rotational error is acceptable before visual quality and degradation of visual acuity are significantly affected? • Overall, 16% of respondents think 10 degrees or more is acceptable • Responses for U.S. and Non-U.S. respondents are very similar, 17% and 14%, respectively • More than 65% of respondents think 5 degrees or less is acceptable n=814 27 Why don't you use posterior corneal astigmatism (PCA) in your toric calculations? • Overall, 17% of respondents do not think it is a clinically significant variable • Non-U.S. response is more than two times the rate of the U.S., 27% to 11% • 35% do not think there is a good way of measuring it • 29% Don't know how to calculate PCA / don't understand its significance n=187 31 Describe your usage of intraoperative aberrometry: • Overall, nearly 60% of respondents have no plans to use intraoperative aberrometry, 59% • Non-U.S. usage: 72% • Overall, only 3% of respondents currently use on all cataract patients • 18% use on premium IOL patients, 26% U.S. compared to 6% Non-U.S. n=474 36 Astigmatism management

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