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5 that residents who rotate with me learn astigmatism management. Beginning residents are in the operat- ing room as well as the clin- ic with me, and as we see patients together, I share my viewpoint on taking care of the whole patient. I am always looking at astigma- tism. Whether a patient is interested in me taking care of his or her astigmatism or not, I am looking at it. I try to think about how to approach it, and I share my strategy with residents. The introduction of toric lens implants amplified the in- terest both from residents and from my perspective because it expanded my range of ability to address astigmatism. It also elevat- ed my level of sophistica- tion of astigmatism treat- ment. When residents have their own cases later in their residencies, they tell me that they are excited to implement what they have learned about astigma- tism management. At this point, I can fine-tune their thinking because it drives As it pertains to cataract surgery, how were you initially trained to think about or approach astigmatism management (if at all), and how would you train a resident today? Dr. Vann: During my train- ing in the late 1990s, I was not trained at all in astigmatism management. Although some surgeons were doing it and were talking about nomograms for taking care of astigma- tism, it was not something they wanted residents to do. To be honest, I don't think the faculty members were addressing it either. They didn't feel comfortable teaching us something that they weren't doing them- selves. When I graduated in 1998 and started at Duke, I became a more cataract-fo- cused surgeon. Now, my practice is exclusively fo- cused on cataract surgery. I made the decision to start addressing astigmatism in my practice to try to get pa- tients better quality vision without glasses. I make sure I assumed that my incision would have a small effect and the patient would have very little residual astigma- tism. I ended up worsening the astigmatism and leaving the patient with poor vision. The patient ended up hav- ing to wear glasses for that eye. This case taught me that it is not just how much astigmatism a patient has but where it is located and how the incision affects the astigmatism. I have started digging deeper into how I look at someone with astig- matism. Dr. Hovanesian: Not that long ago, I had a patient with a high degree of astig- matism (about 2.5 D). He came to me for cataract surgery, and postoperative- ly, he was sobbing because he was so happy with his vision. Years ago, he had gone to LASIK consulta- tions and was told that his astigmatism couldn't be corrected. On the day after cataract surgery, he had uncorrected vision of 20/20, and this was life-changing for him. For many patients with lesser amounts of astigmatism, it's not quite the same experience. Dr. Berdahl: For me, there was no specific case. I have always thought that astig- matism mattered. I am a relatively young surgeon, and I have practiced all of my career in an era of toric lenses. I have felt from the very beginning that we should understand how much astigmatism a patient has and that it is part of our duty as physicians to let pa- tients know their options. without breaking the poste- rior capsule. For them, little nuances like astigmatism management were not high on their radar. At the time, I didn't care much about astigmatism management, but when I transitioned to a private practice, the pa- tients' demands were much greater. Those patients ex- pected a perfect outcome. They want their eyes to look white and quiet after sur- gery, and they don't want to wear glasses. For that rea- son, I became more acutely aware of postoperative refractive error. Second, I started learning a lot from more experienced senior ophthalmologists. Jim Gills, MD, is a mentor of mine in regard to astigmatism man- agement. He has performed tens of thousands of cases and has always been very interested in astigmatism. He and I collaborated on a textbook for astigmatism management, and from writing that textbook to- gether, I learned a lot about astigmatism and how to combat it in multiple ways. Has there been a specif- ic case or patient who changed your mindset? Dr. Vann: I wish it was just one case. As surgeons, we always remember our bad cases and rarely remem- ber our good ones. I have an example that not only gave me a sense of how important it is to address astigmatism, but also high- lighted the fact that I am always learning and trying to become better. One of my patients was the rela- tive of a colleague, and this patient traveled a great distance to come see me. I looked at the patient's astig- matism before surgery, and continued on page 6 " 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. " –John Hovanesian, MD

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