Astigmatism management at the time of cataract surgery is something that, in my opinion, all surgeons should be comfortable addressing. Whether you treat it with a blade, laser, or intraocular lens, management of astigmatism is critical to ensure optimal postoperative vision.
It's estimated that 37.5% of cataract patients have astigmatism >1 D (Market Scope, 2013, Comprehensive Report on Global IOL Market). Depending on the axis and magnitude of astigmatism, most will recommend corneal-based treatments for lower astigmatism and toric IOLs for higher astigmatism. Each surgeon has their own threshold for what they consider lower and higher amounts of astigmatism. I am a believer in posterior corneal astigmatism (PCA) and its effect on refractive outcomes.
Factoring PCA into your astigmatism calculations is now very easy, as most commercially available calculators (Barrett Toric Calculator, Johnson & Johnson, Alcon, others) allow for PCA compensation. Whether or not you compensate for PCA will affect your threshold for corneal- vs lens-based approaches to astigmatism management.
Ocular surface optimization is one of the more important steps in astigmatism management. Assuring for regular astigmatism and that values are in agreement across various measurement modalities (eg, biometer, topographer, tomographer, auto-refractor, others) is essential.
Although toric IOLs are very safe and effective in managing astigmatism, their penetration in the US market remains limited.
