Eyeworld Supplements

Astigmatism Management: Inside the Mind of the Cataract Refractive Surgeon Journey to Current Approach to Astigmatism Management How did you become aware of the importance of astigmatism management? Dr. Vann: When I was aim- ing for a certain prescrip- tion after surgery, I started to realize that the formulas don't take astigmatism into account. If you don't start paying attention to astigmatism, you can get a patient to zero sphere, but he or she can still have a lot of residual astigmatism after surgery, resulting in blur and distorted vision. Patients like this will still need to wear glasses after surgery. It defeats the pur- pose of aiming for this goal if the patient is still going to end up wearing glasses. Depending on the amount of astigmatism and where it is located, the patient can have very poor vision at all ranges. It's not just blurred for distance or blurred for near. Their vision will be blurred at every point of focus. Dr. Henderson: I became aware of it when I made the transition from an academic practice to a private prac- tice. During the first half of my career, I was at an academic institution, and the patients were not as demanding. Many of them had very severe cataracts. They either did not have previous health care or they just had lower expectations. In that institution, the focus was on the actual specifics of the cataract surgery. My main role in the academic center was teaching cata- ract surgery to residents, who were just trying to get through the case safely amount of astigmatism. Some patients only have a small amount, and some have a large amount. If you don't pay attention to the astigmatism that is already pre-existing on the cornea and you make an incision on the flat axis, you are in- ducing more flattening and therefore inducing more refractive astigmatism error at the end of the case. Un- less you are thinking about it, you may inadvertently cause patients to have worse uncorrected vision than they would like or than you would like. For every patient, I always look at the corneal astigmatism, and I think about where my inci- sion is going to be made. I think about the magnitude of the astigmatism, and that always comes into play when we are talking about lens options and corneal incisions to decrease the amount of astigmatism. Dr. Berdahl: All patients have a right to understand how they could use their eyes after cataract surgery. When I am describing the treatment options to a pa- tient, the first thing I need to do is understand his or her postoperative goals. If the goal is to have good vision while wearing glass- es after surgery, then the astigmatism can be man- aged with glasses. If the goal is to be independent of glasses after surgery, then I need to try to remove that astigmatism. Dr. Hovanesian: Many surgeons who do not focus on astigmatism correction feel like that's OK. If you don't see that you have a problem, you don't have the opportunity to correct it. this is one of the ways that we can do that for people without them even realiz- ing it. When I talk to other physicians privately, the choice of whether or not to manage astigmatism in every patient often comes down to remembering to think about it when they are assessing the patient at the time of cataract consul- tation. On many occasions, they just don't take the time to add that step to the consultation and planning of the procedure. Unfortu- nately, that is the mindset of a lot of surgeons. I've had to convince our res- idents and fellows who rotate through my service that this can and should be one of the fundamental components to developing a plan for cataract surgery. Dr. Henderson: I think about it in multiple layers. I always operate on the steep axis, which means that I'm always thinking about astigmatism for every single cataract patient, regardless of the type of lens he or she chooses. I do that because a lot of patients have some whether or not they choose to pay extra to correct it by using a toric lens or laser or manual astigmatic kera- totomy. When a thought-leader like you says or thinks, "I am passionate about astigmatism manage- ment," what does that mean exactly? Where does that mindset come from? Why doesn't everyone have that philosophy as it re- lates to cataract surgery? Dr. Vann: If the surgeon is passionate about astigma- tism management, that can change patients' mindset about their astigmatism. Some of these cases em- power you to show patients that you can make their lives better and they may not even realize it. There is satisfaction in being able to do that from a short outpa- tient procedure. It doesn't make your surgery any more dangerous or difficult, so why wouldn't you want to do that for patients? You can change their vision for life. It's very powerful. We went into medicine to improve people's lives, and " Every cataract surgeon should be considering astigmatism management for every single one of his or her cataract surgeries. " –Bonnie An Henderson, MD

• Cover