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Astigmatism Management: Inside the Mind of the Cataract Refractive Surgeon the astigmatism, why shouldn't I do it? My stan- dard of care has evolved to the point that I am always thinking about astigmatism as part of my surgical plan. Whether patients elect to consider options is com- pletely up to them. Several years ago, I treated a gen- tleman who had cataract surgery elsewhere about 3 years before I saw him. He had 2 or 3 D of astigma- tism, and the surgeon who did his cataract surgery on his first eye didn't offer a toric lens implant, nor did he reduce his astigmatism. When he came to me for the second eye, which had almost 2 D of astigmatism, I told him that a toric lens implant would be best for him, and he asked if he would still have to wear glasses for the astigmatism in his other eye. I said, "Yes, but if you're caught in an emergency without glass- es, at least you'll have one eye with which you can see well." Then I offered to do arcuate incisions, and he agreed. He ended up 20/20 in that eye. About a month or 2 postop, he asked if I could do the same thing on the first eye that the other surgeon operated on. We pushed it off for a couple of years, but I ended up doing an arcuate incision in his other eye because he realized how much better his vision was by reducing his astigmatism. He wasn't thinking about that and nei- ther was his previous sur- geon. I helped change that mindset, and he ended up being able to see very well at distance without glasses after surgery. surgery. I would train resi- dents very similarly to the way that I perform surgery today. I would make sure that they understand that astigmatism is an important factor for all patients. They must think about where they are making their inci- sion, and they have to think about the architecture of their incision as well. They also have to think about what the postoperative outcome will be if they don't correct the astigma- tism, and if they do correct the astigmatism, they need to consider how they are going to correct it. Many factors should come into play when they really start thinking about outcomes. Incorporating Astigmatism Management Into a Modern Practice How have you incorporat- ed astigmatism manage- ment into your practice? Dr. Vann: Every practice and every surgeon has to decide for him- or herself how to incorporate astig- matism management into the scope of practice ser- vices. For me, it has been a continual evolution. I have evolved to the point that now I am always thinking about astigmatism man- agement for every case. I may not always be able to treat it surgically, but I am always thinking about it. For example, being in a tertiary referral center, I have some tough cases referred to me where they have limit- ed central visual potential after cataract surgery. If all I have to do is move my incision from 180 degrees to 160 degrees to reduce wasn't commonplace to cor- rect astigmatism. We didn't have toric lenses, and only a few surgeons around the country were performing limbal relaxing incisions. In private practice, I learned very quickly from my for- ward-thinking colleagues that this was a great op- portunity to build my prac- tice and to make patients thrilled with their results. I also learned that astig- matic keratotomy is a very easy procedure either with a laser or with a diamond blade. It is so easy for an accomplished cataract surgeon to adopt astig- matism management that everyone should do it. Dr. Henderson: I didn't re- ceive any training on astig- matism management as a resident. We barely even discussed astigmatism. We learned about it for approx- imately a week when we started residency in relation to prescribing glasses, but not in regard to cataract it home much more when they are leading the sur- gery instead of observing me doing the surgery. Now, every resident that comes through our program and rotates with me considers astigmatism management as integral to cataract sur- gery. In our minds, the 2 are inseparable. Dr. Berdahl: I was trained at Duke University and Minnesota Eye Consultants, both of which do a good job understanding the refrac- tive needs associated with cataract surgery, so I was lucky in that regard. Today, as I train our fellows, we look at the astigmatism in every single patient. We let patients know that they have astigmatism and that we can fix it either at the time of surgery or after- ward with glasses. Dr. Hovanesian: During my residency, I wasn't trained to think about astigmatism. I finished my residency training in 1996, and it " I am always looking at astigmatism. Whether a patient is interested in me taking care of his or her astigmatism or not, I am looking at it. " –Robin Vann, MD

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