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2019 ASCRS CLINICAL SURVEY | 3 HIGHLIGHTS OF THE 2019 ASCRS CLINICAL SURVEY Astigmatism management The survey asked respondents about the most common procedure to manage with-the-rule (WTR) astigmatism in a cataract patient with 0.75 D of cylinder. The majority (29.5%) said they would use an on-axis incision. Just over 17% said that no special correction is needed for this cataract patient, and 17.6% said they would use a femto- second laser LRI or AK. When asked about the primary preoperative measurements that drive the surgeon's astigmatism power and axis decisions when implanting a toric IOL, 85.7% said they use automated biometry. Additionally, 76.9% use topography. The survey found that 51% of respondents were still using auto Ks and manual Ks as the primary measure- ment. "Virtually all patients who undergo cataract surgery have some amount of corneal astigmatism, but most don't have enough to warrant placement of a toric IOL. If a surgeon is comfortable moving around the eye, the easiest way to erase 0.3 to 0.5 D of astigmatism is to place the phaco incision on the steep axis. When placed superiorly, a standard 2.4 or 2.6 mm phaco incision will produce a greater effect than one placed elsewhere because the equatorial diameter is smaller in the vertical meridian and the incision is nearer to the center of the cornea. I typically get about 0.5 D of corneal flattening when I operate at 90 degrees. It doesn't matter whether the incision is made with a metal, diamond, or femto blade. The sweet spot for me postop- eratively is to leave an eye with +0.3 D of WTR astigmatism. For someone with +0.75 D of WTR astigmatism, a phaco incision on-axis will produce a great result. A toric IOL could be used, but at greater expense. If a surgeon isn't comfortable operating superiorly, he or she could make a temporal incision and add relaxing incisions superiorly and inferiorly, but this is more work, and the final result will be less predictable. "The gold standard for years for measuring corneal astig- matism had been corneal topography. A topographer sees the entire anterior surface of the cornea and not just 1 or 2 central rings, as you get with auto Ks, manual Ks, and optical biometers. Increasingly, however, corneal topography is being replaced by corneal tomography, which can generate a topography-like map from elevation data and which sees both the anterior and pos- terior surfaces of the cornea. Some corneas have considerable posterior surface astigmatism, to which topographers are blind. Intraoperative aberrometry can be a useful adjunct but cannot be used for planning astigmatism surgery without some other preoperative tool. Intraoperative aberrometry is blind to wound healing, as are all methods of measuring astigmatism." Kevin Miller, MD ASCRS Cataract Clinical Committee WHAT IS YOUR MOST COMMON PROCEDURE TO MANAGE WITH-THE-RULE ASTIGMATISM IN A CATARACT PATIENT WITH 0.75 D OF CYLINDER? WHAT ARE THE PRIMARY PREOPERATIVE MEASUREMENTS THAT DRIVE YOUR ASTIGMATISM POWER AND AXIS DECISIONS WHEN IMPLANTING A TORIC IOL? (Select all that apply.)

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