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7 cataract evaluation, we take measurements of the cor- nea early on in the process, usually as part of his or her preparation for cataract surgery. Once patients are dilated and ready to see me, they have already gone through a tablet-based tutorial program that dis- cusses cataract surgery in general and options related to cataract surgery, includ- ing astigmatism manage- ment. When I first meet with them, we discuss their need for cataract surgery, and I explain all of their op- tions. I start by explaining the importance of quality of vision and how astigmatism can affect quality of vision. If patients have a great deal of astigmatism, I will lean toward one modality over another modality, but I tell them that I am going to be addressing their astigma- tism as part of the cataract procedure. Dr. Henderson: Preoper- atively, I do topography on a patient to look at the corneal regularity as well as the astigmatism. I also always do autokeratometry, manual keratometry, and noncontact biometry, so I do 4 different measures of corneal astigmatism. Those are done preoperatively for every single patient. Intra- operatively, I manage the astigmatism in a variety of ways. Depending on the amount of astigmatism, the patient may not need any intraocular correc- tion. I may just operate on the steep axis for a small amount of astigmatism. I may do corneal incisions in order to decrease the amount of corneal astig- matism. Or I may choose to implant a toric intraocular lens. Ultimately, if patients have high levels of astigma- tism, I augment 2 different modalities, such as a toric IOL combined with corneal incisions during surgery. Postoperatively, if they still have any residual astigma- tism, I may enhance it with either laser refractive sur- gery or manual incisional astigmatism correction. Dr. Berdahl: I wasn't trained in manual astig- matic keratotomy (AK), so I never felt very comfortable with that. However, I felt comfortable with low-pow- er toric lenses. Then, with the advent of the femto- second laser, the more artful manual AKs became more reproducible AKs, so I started performing AKs with the femtosecond laser. The other incredibly important tool for us is intraoperative aberrometry. This is critical because it provides infor- mation that is not easily obtainable such as the posterior corneal curva- ture in its wavefront. It also includes the surgically in- duced astigmatism because the incision has already been made, and I feel that more variability comes from surgically induced astigma- tism than most surgeons re- alize. So, the 2 big techno- logical advances that have helped me better manage astigmatism in my career have been femtosecond AKs and aberrometry; how- ever, the most important tool to correct astigmatism is the toric lens, which has been available for my entire career. Dr. Hovanesian: On the initial cataract consult, my staff measures keratome- try, so we have an idea of the level of corneal astig- matism the patient has. This allows me to discuss astigmatism correction with patients during the initial conversation. I explain that we are already performing steps of the procedure, and the insurance com- pany is already paying for the surgery center and the anesthesia and my time. It doesn't take much more to take the patient's vision to a higher level by correct- ing astigmatism. I educate patients about astigmatism management from the beginning. In my practice, about 80% of patients elect to have their astigmatism corrected. All cataract sur- geries are refractive proce- dures because we target a certain visual outcome, but about 80% in my practice are also astigmatism cor- recting. If we are planning surgery, we rely on topog- raphy and keratometry as measured by an optical biometer, and I use those numbers to generate my plan for astigmatism cor- rection. How are you approaching patients and educating them about astigmatism management? Dr. Vann: Currently, when a patient comes to me for continued on page 8 The cataract refractive mindset is built on a foundation that addresses defocus and astigmatism in every patient. Cataract Refractive Outcomes Defocus Sphere Astigmatism Cylinder

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