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3 The Astigmatism Management Mindset Define "astigmatism management" as it relates to cataract surgery and why it is important. Dr. Vann: It is important for several reasons. Due to the rise in popularity and the success of refractive surgery, patients think that any major eye surgery is going to give them greater freedom from glasses, and many patients already have that expectation when they come to see physicians. We need to find ways to help patients achieve clearer and sharper vision without glasses at the end of sur- gery, or we are going to dis- appoint our patients. In the old days of cataract surgery, the goal was just to remove the cloudy lens and restore clear sight for the patient. Providing optimal vision with less need for glasses or no need for glasses after surgery was never a goal. As LASIK started to become a very popular procedure, patients assumed that ophthalmologists could also achieve spectacle indepen- dence with cataract surgery. John Hovanesian, MD: Managing astigmatism is essential for patients to experience the highest level of satisfaction during and after cataract surgery. We conducted a study about a year ago that assessed patients 2 months after their final cataract pro- cedure, and we looked at what factors correlate with the highest level of satis- faction, which is what we are hoping to achieve. 1 We found that the correlation was highest with astig- matism correction. When patients had their astigma- tism corrected within 0.5 D of sphere, there was an 80% chance of achieving the highest level of satisfac- tion. That dropped to about 56% for patients who had more than 0.5 D of astigma- tism after surgery. In other words, if all factors are tak- en into consideration, that one factor correlated most strongly with patients rating their happiness at the high- est level. For me, the take- home message from this is that you have to think about astigmatism correc- tion in every patient ap- proaching cataract surgery, However, there is no way to achieve spectacle inde- pendence if surgeons are only addressing whether a patient will be nearsighted or farsighted after surgery without considering astig- matism. These are the 2 orders of magnitude that we need to pay attention to when we are caring for patients with cataracts. Bonnie An Henderson, MD: The words "astigma- tism management" have become synonymous with refractive outcomes for routine cataract surgery. A decade ago, cataract sur- gery just consisted of re- moving a cloudy lens and replacing it with a clear one. Patients always needed to wear glasses for either just near vision or near and distance vision. That was the norm, and it was accepted by both health care providers and patients. The biggest change over the past decade has been that for many patients and surgeons, the purpose of cataract surgery is no longer just to remove the cloudy lens; it is also to try to provide patients with some independence from glasses, which can help them be more active during their senior years. Because of patients' growing desire to be free of spectacles post-surgery, we have to address not only refractive error but astigmatism as well. Every cataract sur- geon should be considering astigmatism management for every single one of his or her cataract surgeries to deliver true refractive outcomes. John Berdahl, MD: Astig- matism management means identifying patients who have astigmatism prior to cataract surgery and who would likely have clinically meaningful astigmatism af- ter surgery. Once you have identified those patients, astigmatism management is doing the appropriate pre- operative testing, the ap- propriate surgical planning, and the correct surgery with the correct intraoper- ative tools, and then hav- ing a strategy to treat any residual astigmatism after surgery. continued on page 4 Astigmatism Management Cataract Surgery Cataract Refractive Surgery Astigmatism management is the foundational bridge for transitioning from cataract surgery to cataract refractive surgery.

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