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4 | 2022 ASCRS CLINICAL SURVEY HIGHLIGHTS FROM THE 2022 ASCRS CLINICAL SURVEY ASTIGMATISM Most surgeons have a "sweet spot" for residual refractive astigmatism in the first few weeks postop after cataract surgery. The most common (36%) "sweet spot" target was 0.3 D with-the-rule, followed by no residual astigmatism, then 0.5 D or greater with-the-rule. Twenty-two percent of respondents said they don't have a "sweet spot." At what level of corneal astigmatism do surgeons begin to consider a toric IOL? Most who responded to this survey reported their threshold is 1 D of cylinder (34%), followed by 0.75 D (25%) and 1.25 D (17%). Eight percent of respondents did not use toric IOLs. When it comes to preoperative measurement decisions for astigmatism power and axis for toric IOL planning, 35% said topography automated biometry was the most significant and 17% favored Scheimpflug tomography. Thirty percent said they base these decisions on a combination of topography, tomography, autorefractor Ks, intraoperative aberrometry, manual Ks, OCT, and/or manifest astigmatism. There is a lot of interesting information in this data, and rather than commenting on it globally, I'd like to highlight and expand on some of the observations. There is minimal variability in terms of "percent who implant toric IOLs" (all greater than 90%) when segmented by years in practice. I think this demonstrates the effectiveness of residency training with these IOLs, the value of the ASCRS Young Eye Surgeons (YES) programs, and the robustness of this technology in delivering excellent visual results for our patients. With regard to, "At what level of total corneal astigmatism do you consider a toric IOL?" 76% of respondents answered 0.75 to 1.25 D, and 88% if this range was expanded to 1.50 D. When I looked at this question, my first thought was, "Is this in patients with with-the-rule or against-the-rule astigmatism?" I then realized "total corneal astigmatism" was included to take into account the potential for the impact of posterior corneal astigmatism. Nonetheless, with this question following the "sweet spot" question, which does break down desired residual astigmatism in terms of with-the-rule or against-the-rule, I wonder if some surgeons' answers did reflect this as well, causing the amount of corneal astigmatism to be treated as higher. With regard to preoperative measurements and data to plan for implantation of a toric IOL, it's clear that the majority of surgeons utilize topography/tomography or a combination of technologies, although I would have estimated this percentage to be even higher. One of the unsung benefits of performing surface analysis with tomography or topography is that these images are a great tool for educating patients and their families about what astigmatism is and why treating it leads to better uncorrected visual function. —Richard Tipperman, MD Chair, ASCRS Cataract Clinical Committee Based on those who currently implant toric IOLs (92%) n=858 What are the primary preoperative measurements that drive your astigmatism power and axis decisions when implanting a toric IOL? Topography automated biometry (IOLMaster/Lenstar) Scheimpflug tomography (Pentacam, Galilei, Orbscan) Autorefractor Ks Intraoperative aberrometry Manual Ks from a keratometer OCT Manifest astigmatism Some combination of the above N/A 35% 17% 5% 4% 3% 2% 1% 30% 3%

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