ARTICLE

Expected effects of surgically induced astigmatism

on AcrySof toric intraocular lens results
Warren Hill, MD

PURPOSE: To evaluate the expected effects of including surgically induced astigmatism (SIA) in
surgical planning for the AcrySof toric intraocular lens (IOL) (Alcon Laboratories, Inc.).
SETTING: Private practice, Mesa, Arizona, USA.
METHODS: Keratometric data were obtained for a large patient population (806 eyes) with
preoperative corneal astigmatism of 2.50 diopters (D) or less. Anticipated residual astigmatism
was calculated using nominal SIA values in the AcrySof Toric IOL Calculator for superior and
temporal incisions. Anticipated residual astigmatism was also calculated without considering SIA
in the planning process but with a nominal value applied when calculating the surgical result.
RESULTS: Using a 0.50 D SIA value for superior or temporal incisions, there was a statistically, but
not clinically significant, difference (mean approximately 0.05 diopter [D]) in the anticipated residual
astigmatism by incision location (P<.05). Anticipated residual astigmatism, when including or not
including SIA in the planning process, was statistically significantly different by IOL and incision
location (P<.05), with anticipated differences that were clinically significant (>0.50 D) for all toric
IOLs. These large differences appeared to be driven by changes in IOL selection as a result of
including SIA in the AcrySof Toric IOL Calculator.
CONCLUSIONS: With the AcrySof toric IOL, consideration of SIA from temporal or superior
incisions resulted in statistically and clinically significantly lower anticipated residual astigmatism.
The most important effect of including SIA appears to be more appropriate IOL selection.
J Cataract Refract Surg 2008; 34:364–367 Q 2008 ASCRS and ESCRS

Cataract surgery has evolved considerably from the
time when it was sufficient to remove the cataractous
lens and provide spectacles to aphakic patients. The
use of intraocular lenses (IOLs) revolutionized this
procedure, and the introduction of small-incision
phacoemulsification has lead to increasingly stable
predictable results, with a reduction in healing time
and number of postoperative complications.
Current surgical techniques provide refractive correc-
tion with an IOL that is often within G0.50 diopter (D)
Accepted for publication October 10, 2007.
From a private practice, Mesa, Arizona, USA.
Dr. Hill is a consultant to Alcon Laboratories, Inc., in the area of
intraocular lens mathematics. He has no financial or proprietary
interest in any material or method mentioned.
Corresponding author: Warren Hill, MD, East Valley Ophthalmology,
5620 East Broadway Road, Mesa, Arizona, USA 85206. E-mail: hill@
doctor-hill.com.
of the targeted spherical correction.1,2 The challenge
at this point becomes reducing preexisting or surgi-
cally induced corneal astigmatism. The reduction of
corneal astigmatism remains a significant barrier to
optimizing outcomes in a significant number of pa-
tients. Moderate amounts (!2.0 D) of corneal astig-
matism have traditionally been addressed through
peripheral corneal relaxing incisions or judicious
selection of incision site.3–5
The introduction of the AcrySof toric IOL (Alcon
Laboratories, Inc.) provided a new method for correct-
ing corneal astigmatism in pseudophakic patients.6
The IOL can be readily oriented in the eye and has
shown excellent postoperative stability, with 95% of
IOLs within 10 degrees of the intended axis of implan-
tation 6 months after surgery. With the introduction of
this IOL, companion software was introduced in the
form of a toric IOL calculator (Alcon Laboratories,
Inc. AcrySofÒ Toric IOL Calculator Online [online].
Available at: www.acrysoftoriccalculator.com. Ac-
cessed November 15, 2007). The calculator uses sur-
geon-provided keratometry and surgically induced

364 Q 2008 ASCRS and ESCRS 0886-3350/08/$dsee front matter

Published by Elsevier Inc. doi:10.1016/j.jcrs.2007.10.024
 EFFECTS OF SIA ON ACRYSOF TORIC IOL RESULTS
astigmatism (SIA) to select the correct toric IOL and
calculate the optimum angle of placement
Surgically induced astigmatism is a known conse-
quence of creating the incision necessary for cataract
removal and IOL implantation.7,8 Because corneal
astigmatism is a vector quantity (comprising a magni-
tude and a direction), simply adding and subtracting
astigmatism values will not yield useful information.
The amount of astigmatism to be corrected at the
time of surgery must be the vector sum of the preoper-
ative corneal astigmatism and any SIA.9
Figure 1 shows the phenomenon of summing vector
quantities. Imagine that a boat on one bank of a river is
to cross to the other side, but there is a slight current. If
the boat is steered directly across the river, it will be
carried downstream by the current and miss the land-
ing site (Figure 1, A). The ‘‘current vector’’ adds to the
‘‘crossing vector’’ to produce this final result.
Now consider that the current effect is known. The
boat is now aimed upstream to compensate for the
effects of the current. The sum of the new crossing
vector and current vector combine to produce a vector
that ends at the desired landing site (Figure 1, B).
The same compensation for a known second vector
can be applied to cataract surgery, as shown in
Figure 2. The corneal astigmatism is measured preop-
eratively. The effects of the surgical incision can be
determined from historical results based on incision
size and location. These 2 vectors are added together
to generate the desired correction.
Some surgeons may believe that the use of small-
incision surgery effectively negates any SIA. However,
an analysis of cases submitted to our clinic for the cal-
culation of SIA by multiple surgeons reveals that the
average SIA calculated by vector analysis does not
Figure 1. A: Crossing a river with a current, aimed across river. B: Crossing a river with a current, aimed upstream.
J CATARACT REFRACT SURG - VOL 34, MARCH 2008
365
drop much below 0.50 D when an incision smaller
than 2.4 mm is used and the SIA may be greater
when the incision is 3.0 mm or larger. The reason there
is no linear decrease in SIA with decreasing wound
size may be because very small incisions can be
stretched during insertion of a folded IOL.
The question addressed here is how much a nominal
amount of SIA (0.50 D) will affect surgical results. This
can be answered in a theoretical fashion using sample
corneal astigmatism data and the AcrySof Toric IOL
Calculator, which was designed to simplify the process
of vector addition of the toric IOL and expected SIA.
PATIENTS AND METHODS
Sample data for keratometric astigmatism were obtained for
a large patient population (806 eyes) with preoperative
corneal astigmatism of 2.50 D or less.
The target refraction in each eye was calculated using a su-
perior incision and a temporal incision, with a presumed SIA
of 0.50 D in each case. This value is arbitrary but represents
a typical value for surgeons using incision sizes in the 2.4 mm
range. Larger incisions tend to produce larger SIA. Although
smaller incisions reduce the SIA, there is a diminishing
return. Incision type can also affect SIA. Surgeons using
the AcrySof Toric IOL Calculator will find it most accurate
when their own known SIA, rather than the Alcon default
value, is used in the calculation.
The effect of SIA also depends on the corneal topography
and incision location. An incision on the steep axis will
flatten that axis (reducing corneal astigmatism), while an in-
cision on the flat axis will tend to steepen that axis (increasing
corneal astigmatism). Surgeons may elect to use this infor-
mation in the toric calculator to determine the best location
for the incision (eg, run the calculator with a superior, then
a temporal incision to calculate the IOL–incision combina-
tion likely to yield the lowest residual cylinder).
Using the AcrySof Toric IOL Calculator, the appro-
priate IOL was selected based on the manufacturer’s
366 EFFECTS OF SIA ON ACRYSOF TORIC IOL RESULTS

Figure 2. Histogram of preoperative corneal astigmatism. Figure 3. Difference in anticipated residual astigmatism by IOLs and
incision location.

recommendations, and the appropriate axis of the correction likely that it was related to a change in IOL selection.
was applied. The anticipated residual astigmatism was then In other words, consideration of the SIA effect might
calculated by subtracting the planned correction vector from
the preoperative corneal astigmatism.
be sufficient to cause the AcrySof Toric IOL Calculator
A second set of data was created by presuming SIA was to suggest a higher (or lower) cylinder toric IOL. To
ignored in the planning stage but occurred at the time of sur- investigate this, the IOL selection, when SIA was
gery. In other words, IOL selection and angle of orientation included, was compared with the IOL selection
were determined from preoperative corneal astigmatism when SIA was not included in the planning process.
alone. Then, SIA of 0.50 D was assumed to occur at the
time of surgery and its effect on the postoperative result
Table 1 summarizes the results. Both incision locations
was calculated using a temporal incision and a superior resulted in a change in IOL selection in approximately
incision. half the eyes. However, when a superior incision was
used, there was a slightly higher likelihood (60% to
RESULTS 40%) of choosing a lower power IOL than a higher
power IOL. When a temporal incision was used, the
Figure 2 shows the distribution of the preoperative
calculation yielded a higher power IOL recommenda-
corneal astigmatism in the sample patient population.
tion far more often (85% to 15%).
Looking at this by axis of astigmatism, 61% of astigma-
For example, patient X had a preoperative corneal K
tism was with the rule (within 30 degrees of horizon-
readings of 43.00 @ 97/41.75 @ 7, for a corneal astigma-
tal), 25% was against the rule (within 30 degrees of
tism value of 1.25 D and a steep meridian of 97 degrees.
vertical), and the remaining 14% was oblique.
The recommended IOL would be a T3 to correct 1.03 D
Figure 3 shows the anticipated residual astigmatism
calculated for the sample eyes based on a temporal or
nasal incision. Although the differences between the 2
incision locations were statistically significant for all
IOL models (P!.05), the magnitude of the differences
was clinically insignificant (!0.05 D). The anticipated
residual astigmatism for the spherical and T5 model
IOLs was higher than for the T3 and T4 model IOLs.
Figure 4 shows the effect of not including SIA
considerations in the planning process. The difference
between including SIA and not including SIA in the
planning was statistically significant (P!.05) and clin-
ically significant; the difference was somewhat higher
for the temporal incisions (mean difference approxi-
mately 0.5 D for temporal incisions and 0.37 D for
superior incisions).
Looking for the reasons there would be a difference Figure 4. Anticipated residual astigmatism by IOL, incision site, and
in SIA effect by incision location, it was presumed SIA consideration.

J CATARACT REFRACT SURG - VOL 34, MARCH 2008

 EFFECTS OF SIA ON ACRYSOF TORIC IOL RESULTS
Table 1. Change in IOL selection by incision when SIA was
planned for.
Percentage of IOLs
Change Temporal Incision Superior Incision
Lower cylinder power 8 27
None 49 56
Higher cylinder power 43 17
IOLs Z intraocular lenses
of astigmatism. However, if the expected SIA of 0.50 D
were considered and a temporal incision used, the cor-
neal astigmatism would be increased by this incision
on the flat axis. The appropriate astigmatism to correct
would be 1.75 D at an angle of 95 degrees and the ap-
propriate IOL would be the T4 IOL. In the first case,
the expected postoperative residual astigmatism
would be 0.73 D. In the second case, the expected post-
operative residual astigmatism would be 0.20 D.
DISCUSSION
Consideration of even nominal SIA (0.50 D) produced
statistically significantly different expected results for
all toric IOLs. Differences were statistically significant
and clinically significant. The major impact of SIA
appears to be in the selection of the appropriate IOL.
In the population in this study, the impact of ignor-
ing the effect of temporal incisions appeared greater
than that of ignoring superior incisions. The reason
would appear to be related to the distribution of
corneal astigmatism in this sample population; the
steep axis of the cornea was horizontal in most
corneas, so the cornea was steeper vertically. A supe-
rior incision would reduce this astigmatism, while
a temporal incision would tend to increase it. Ignoring
a temporal incision in the planning process would,
therefore, be more likely to cause an underestimation
in the degree of astigmatism to correct and result in
a larger magnitude of residual postoperative astigma-
tism, as seen in this theoretical analysis.
If an older population group with a greater percent-
age of against-the-rule astigmatism were used, the
impact of ignoring the effect of a superior incision
J CATARACT REFRACT SURG - VOL 34, MARCH 2008
367
would be greater. In general, ignoring the impact of
an incision on the steep meridian of the cornea will
lead to the greatest potential for selecting a toric IOL
with too low a power.
The importance of SIA as a component in the
planning process for implanting toric IOLs is clear
from the results in this theoretical analysis. In a large
sample population, the anticipated residual astigma-
tism was lower for all toric IOLs when SIA was
included in surgical planning. The AcrySof Toric IOL
Calculator is an important component in surgical
planning for toric IOL implantation with a measurable
impact on expected results.
REFERENCES
1. Narváez J, Zimmerman G, Stulting RD, Chang DH. Accuracy of
intraocular lens power prediction using the Hoffer Q, Holladay
1, Holladay 2, and SRK/T formulas. J Cataract Refract Surg
2006; 32:2050–2053
2. Olsen T. Improved accuracy of intraocular lens power calculation
with the Zeiss IOLMaster. Acta Ophthalmol Scand 2007; 85:
84–87
3. Carvalho MJ, Suzuki SH, Freitas LL, et al. Limbal relaxing
incisions to correct corneal astigmatism during phacoemulsifica-
tion. J Refract Surg 2007; 23:499–504
4. Müller-Jensen K, Fischer P, Siepe U. Limbal relaxing incisions to
correct astigmatism in clear corneal cataract surgery. J Refract
Surg 1999; 15:586–589
5. Nichamin LD. Treating astigmatism at the time of cataract
surgery. Curr Opin Ophthalmol 2003; 14:35–38
6. Horn JD. Status of toric intraocular lenses. Curr Opin Ophthalmol
2007; 18:58–61
7. Altan-Yaycioglu R, Akova YA, Akca S, et al. Effect on astigmatism
of the location of clear corneal incision in phacoemulsification of
cataract. J Refract Surg 2007; 23:515–518
8. Borasio E, Mehta JS, Maurino V. Torque and flattening effects
of clear corneal temporal and on-axis incisions for phacoemulsifi-
cation. J Cataract Refract Surg 2006; 32:2030–2038
9. Eydelman MB, Drum B, Holladay J, et al. Standardized analyses
of correction of astigmatism by laser systems that reshape the
cornea. J Refract Surg 2006; 22:81–95
First author:
Warren Hill, MD
Private practice, Mesa, Arizona, USA