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patients aggressively prior to their preoperative mea- surements so that there is a more reliable result. Summary Dr. Vann: As you can see, each of us has had unique experiences to shape our approach to astigmatism. Despite our different ex- periences, we all feel that addressing astigmatism during cataract surgery planning is a necessary step in becoming a successful cataract refractive surgeon. We hope that sharing our stories about transitioning from cataract surgeons to cataract refractive surgeons will help our colleagues to take this step as well to provide better outcomes for patients. Reference 1. Hovanesian J. Preoperative and surgical factors that correlate with the highest patient-reported satisfaction with multifocal IOLs. Paper presenta- tion. 2015 ASCRS•ASOA Symposium & Congress, San Diego. Don't assume that patients may not be interested in one of the astigmatism cor- rection options. Have a plan to get them all the way into the end zone. That means either the ability to go in and rotate a lens or do a laser enhancement. Dr. Hovanesian: Most im- portantly, assess your own results to refine your tech- nique and your nomogram based on the unique way you do surgery. My practice uses intraoperative aber- rometry because it not only enhances my likelihood of reaching the target, but it also very elegantly collects data when using the postop data input to tell us what our outcomes are. That helps me to keep refining my nomogram. There are many tools online that will provide the same kind of in- formation. During the initial cataract consult, I evaluate the ocular surface. If there is a non-uniform wetting on the cornea, usually from dry eye, it is going to greatly influence the astig- matism measurements and the surgical results. Treat keep track of my surgically induced astigmatism. It was an eye-opening experience when Doug Koch, MD, in- troduced to us the very real issue of posterior corneal astigmatism and how it can influence our outcomes. I am trying to pay more attention to that. Because I have focused on those 2 things, particularly in the past 2 to 3 years, I am now realizing that having an intraoperative aberrome- ter to accurately measure those things at the time of the surgery for a particular patient is something I am looking forward to incor- porating into my manage- ment. I wish I had joined this bandwagon 4 years ago. This allows us to fine- tune things for each individ- ual patient. From an educa- tion perspective, I wish I'd had a more consistent set of patient education materi- als earlier, so that patients can be educated about cataracts before they meet the doctor. Dr. Henderson: Although uncommon, I recommend operating on the steep axis, and I think it's a good idea to follow the astigmatism on every patient. Therefore, if someone has 0.5 D of astigmatism, we can mini- mize that 0.5 D by operat- ing on the steep axis. Op- erating on the flat axis may inadvertently double that amount. Dr. Berdahl: As physicians, we should be giving pa- tients all of their options. Dr. Berdahl: I am ap- proaching patient education very simply and not tech- nology focused. We simply say, "How do you want to use your eyes after cataract surgery? Would you prefer to wear glasses for every- thing you do? Would you prefer to not have to wear glasses much for distance but still use reading glass- es? Or would you prefer to not have to use glasses much at all?" Based on their answer, we will help guide them through their options and determine whether the cost of astigmatism correc- tion is worth it to them. Dr. Henderson: Fortunate- ly, the majority of patients understands or at least has heard of astigmatism, so I am not starting from scratch. I explain that their corneas are not perfectly round and spherical and that they have an area in their cornea that is steep and an area that is flat. In order to correct their vision as well as possible, the IOL or the corneal incisions can help decrease some of the steepness. Therefore, the overall quality of the im- age without glasses will be better if the astigmatism is corrected during surgery. Are there specific tips or pearls with regard to astig- matism management that you were slow to adopt and wish you had sooner? Dr. Vann: My appreciation of surgically induced astig- matism took longer than I wanted it to. Now, I try to 4/16 US-CRS-16-E-1642 " Today, as I train our fellows, we look at the astigmatism in every single patient. " –John Berdahl, MD Astigmatism Management: Inside the Mind of the Cataract Refractive Surgeon

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