ARTICLE

Correcting astigmatism with toric intraocular

lenses: Effect of posterior corneal astigmatism
Douglas D. Koch, MD, Richard B. Jenkins, MD, Mitchell P. Weikert, MD, Elizabeth Yeu, MD,
Li Wang, MD, PhD

PURPOSE: To evaluate the impact of posterior corneal astigmatism on outcomes with toric
intraocular lenses (IOLs).
SETTING: Cullen Eye Institute, Baylor College of Medicine, Houston, Texas, USA.
DESIGN: Case series.
METHODS: Corneal astigmatism was measured using 5 devices before and 3 weeks after cataract
surgery. Toric IOL alignment was recorded at surgery and at the slitlamp 3 weeks postoperatively.
The actual corneal astigmatism was calculated based on refractive astigmatism 3 weeks postoper-
atively and the effective toric power calculated with the Holladay 2 formula. The prediction error was
calculated as the difference between the astigmatism measured by each device and the actual
corneal astigmatism. Vector analysis was used in all calculations.
RESULTS: With the IOLMaster, Lenstar, Atlas, manual keratometer, and Galilei (combined Placido–
dual Scheimpflug analyzer), the mean prediction errors (D) were, respectively, 0.59 @ 89.7, 0.48 @
91.2, 0.51 @ 78.7, 0.62 @ 97.2, and 0.57 @ 93.9 for with-the-rule (WTR) astigmatism (60 to 120
degrees), and 0.17 @ 86.2, 0.23 @ 77.7, 0.23 @ 91.4, 0.41 @ 58.4, and 0.12 @ 7.3 for against-
the-rule (ATR) astigmatism (0 to 30 degrees and 150 to 180 degrees). In the WTR eyes, there
were significant WTR prediction errors (0.5 to 0.6 diopters [D]) by all devices. In ATR eyes,
WTR prediction errors were 0.2 to 0.3 D by all devices except the Placido–dual Scheimpflug
analyzer (all P<.05 with Bonferroni correction).
CONCLUSIONS: Corneal astigmatism was overestimated in WTR by all devices and underestimated
in ATR by all except the Placido–dual Scheimpflug analyzer. A new toric IOL nomogram is proposed.
Financial Disclosure: Drs. Koch, Weikert, and Wang received research support from Ziemer USA,
Inc. Dr. Koch has a financial interest with Alcon Laboratories, Inc., Abbott Medical Optics, Inc.,
Optimedica Corp., and Ziemer USA, Inc. No other author has a financial or proprietary interest in
any material or method mentioned.
J Cataract Refract Surg 2013; -:-–- Q 2013 ASCRS and ESCRS

Accurate measurement of total corneal astigmatism in
cataract patients is crucial for achieving optimum
postoperative uncorrected visual acuity and patient
satisfaction, especially with the implantation of toric
intraocular lenses (IOLs). Traditionally, keratometers
and Placido-disk corneal topographers have been
used to measure the curvature of the anterior surface
of the cornea and corneal power and astigmatism
values have been calculated by assuming a fixed pos-
terior:anterior curvature ratio. Since Jaffe and Clay-
man1 first analyzed the relationship between cataract
surgical technique and refractive results in individual
patients in 1975, ophthalmic surgeons have calculated
surgically induced refractive change in an attempt to
minimize postoperative corneal and ocular astigma-
tism. Unfortunately, several studies suggest that cur-
rent methodology is inadequate for achieving
optimum astigmatic outcomes. In 3 studies of results
with toric IOLs,2–4 the mean postoperative refractive
astigmatism after implantation of a toric IOL ranged
from 0.72 diopter (D) G 0.43 (SD) to 1.03 G 0.79 D.
Traditionally, it has been assumed that the posterior
cornea induces minimal refractive astigmatism and
can therefore be ignored in astigmatic calculations.
However, several studies using different methodolo-
gies5–11 recently reported that the posterior cornea
has astigmatism that ranges from 0.26 to 0.78 D. In
our recent study,11 we found that in most eyes, the

Q 2013 ASCRS and ESCRS 0886-3350/$ - see front matter 1

Published by Elsevier Inc. http://dx.doi.org/10.1016/j.jcrs.2013.06.027
2 CORNEAL ASTIGMATISM PREDICTION ERROR
posterior corneal steep meridian is aligned vertically
and proposed a theory that for toric IOL implantation,
ignoring the posterior corneal astigmatism would
result in overcorrection in eyes having with-the-rule
(WTR) anterior corneal astigmatism and undercorrec-
tion in eyes with against-the-rule (ATR) astigmatism.
Validation of this theory in patients having toric IOL
implantation is desirable.
The purposes of this study were (1) in eyes with toric
IOLs, to evaluate the prediction errors of total corneal
astigmatism with 5 devices, 1 of which uses Scheimp-
flug imaging and ray-tracing analysis to measure
anterior and posterior corneal astigmatism and 4 of
which measure the anterior surface only, and (2) to
provide a nomogram for selecting the appropriate
toric power for astigmatic correction that factors in
posterior corneal astigmatism.
PATIENTS AND METHODS
Patients
Institutional review board approval was obtained for
this study. Prospectively, patients who were willing to
participate in this study and met the following inclusion
criteria were enrolled from July 2011 to September 2012:
(1) good quality scans with all 5 devices, (2) no previous
ocular trauma or surgery, (3) no corneal or other ocular
disease, (4) no contact lens wear within 2 weeks before the
corneal measurements, and (5) Acrysof toric IOL (models
SN6AT3 to SN6AT8, Alcon Laboratories, Inc.) implantation
without postoperative IOL decentration or tilt under the
slitlamp examination. One eye from each patient was
included in this study. Any eye with more than 5 degrees
of IOL rotation from the intended meridian was excluded
from the study. Patients with oblique corneal astigmatism
(steep corneal meridian at 30 to 60 degrees or 120 to 150
degrees) measured by partial coherence interferometry
(PCI) were also excluded because of the small number of
eyes in that group.
Corneal Astigmatism Measurements
The following 5 devices were used for corneal astigmatism
measurements in this study:
Submitted: April 29, 2013.
Final revision submitted: June 12, 2013.
Accepted: June 14, 2013.
From the Cullen Eye Institute, Department of Ophthalmology,
Baylor College of Medicine, Houston, Texas, USA.
Supported in part by an unrestricted grant from Research to
Prevent Blindness, New York, New York, USA.
Presented in part at the ASCRS Symposium on Cataract, IOL and
Refractive Surgery, Chicago, Illinois, USA, April 2012.
Corresponding author: Douglas D. Koch, MD, Department of
Ophthalmology, Baylor College of Medicine, 6565 Fannin, NC205,
Houston, Texas 77030, USA. E-mail: dkoch@bcm.edu.
J CATARACT REFRACT SURG - VOL -, - 2013
1. IOLMaster (Carl Zeiss Meditec AG). This PCI device
measures corneal power by automated keratometry and
uses data from a hexagonal array of 6 points reflected
off the surface of the cornea at a diameter of approxi-
mately 2.5 mm, depending on the corneal curvature.
2. Lenstar (Haag-Streit AG). This optical low-coherence
reflectometry (OLCR) device calculates keratometry
(K) from an array of 32 light reflections projected off the
anterior corneal surface. Sixteen measuring points on
each eye are arranged in 2 rings at diameters of approxi-
mately 1.65 mm and 2.30 mm, respectively, again depend-
ing on the corneal curvature.
3. Atlas corneal topographer (Carl Zeiss Meditec AG). This
Placido disk–based corneal topographer provides simu-
lated K values along the steepest and flattest meridians
at the 3.0 mm zone.
4. Manual keratometer (Bausch & Lomb). Manual keratom-
etry is the conventional method for measuring corneal
power at a diameter of approximately 3.0 mm, depending
on the corneal curvature.
5. Galilei Placido–dual Scheimpflug analyzer (Ziemer
Ophthalmic Systems AG). The anterior corneal measure-
ments are made by a proprietary method of merging
Placido and Scheimpflug data, and the posterior corneal
surface is constructed using Scheimpflug data. The device
calculates the total corneal power (TCP) using ray tracing,
which propagates incoming parallel rays and uses Snell
law to refract the rays through the anterior and posterior
corneal surfaces.
Of the 5 devices, the first 4 systems measure anterior
corneal curvature only and astigmatism values were calcu-
lated from the differences between the steep K and flat
K values based on these anterior corneal data. For the
Placido–dual Scheimpflug analyzer, the TCP astigmatism
value, which is the difference between the steep TCP and
flat TCP at the 1.0 to 4.0 mm central zone, was used. Corneal
astigmatism was measured with all 5 devices at the preoper-
ative and 3-week postoperative visits.
Biometry was performed using the PCI device and the
OLCR device. The Holladay 1 formula was used for toric
IOL power calculation. Selection of the toric IOL power
and alignment was determined by the surgeons based on
all data available and a previous study of posterior corneal
astigmatism.11 Three surgeons (D.D.K., M.P.W., E.Y.)
performed the surgeries through 2.4 mm clear corneal inci-
sions. The axis of the alignment of the toric IOL was recorded
at the time of surgery and at the slitlamp during the 3-week
postoperative visit. Manifest refraction was performed
3 weeks postoperatively.
Data Analysis
Eyes were divided into 2 groups depending on the
anterior corneal steep meridian measured by the PCI device
as follows: (1) WTR group with corneal steep meridian at
60 to 120 degrees and (2) ATR group with corneal steep
meridian at 0 to 30 degrees or 150 to 180 degrees.
Vector analysis was used in all calculations.12 To account
for the impact of IOL power and anticipated effective lens
position (ELP), the effective toric power of the IOL at the
corneal plane was calculated using the Holladay 2 Consul-
tant Program (Holladay Consulting). The assumed actual
corneal astigmatism was calculated as the difference
between the postoperative manifest refraction corrected to
the corneal plane and the effective toric power. Then, for
 CORNEAL ASTIGMATISM PREDICTION ERROR
each device, the corneal astigmatism prediction error, or the
deviation from actual corneal astigmatism, was obtained by
subtracting the actual corneal astigmatism from the corneal
astigmatism measured by each device.
Analysis of aggregate corneal astigmatism prediction er-
rors was performed. Using preoperative and postoperative
corneal astigmatism measurements, preoperative and
postoperative corneal astigmatism prediction errors were as-
sessed for each device. The corneal astigmatism prediction
errors were further analyzed as follows: (1) WTR/ATR
prediction errors, which are displayed along the horizontal
axis in the double-angle plot of the prediction errors, with
negative values indicating WTR prediction errors (the device
overestimates corneal WTR astigmatism compared with
the actual amount) and positive values, ATR errors, and
(2) oblique prediction errors, which are displayed along
the vertical axis in the double-angle plot of the prediction
errors, with positive values indicating oblique astigmatism
prediction errors along 45 degrees and negative values,
along 135 degrees.
Statistical Analysis
A sample-size calculation was performed to detect a
corneal astigmatism prediction error of more than 0.2 D.
The primary data showed that the standard deviation
of corneal astigmatism prediction error was approximately
0.4 D. With a significance level of 5% and a test power
of 80%, 32 eyes were required.
To assess whether the prediction errors were WTR/ATR
or oblique, a 1-sample t test was performed to evaluate
whether the mean vector component values were signifi-
cantly different from zero. Bonferroni correction was used
for multiple comparisons. Statistical analysis was performed
using SPSS for Windows software (version 15.0, SPSS, Inc.).
A probability of less than 5% (P!.05) was considered statis-
tically significant.
RESULTS
Forty-one eyes of 41 patients were enrolled. The mean
age of the 18 men and 23 women was 71 G 9 years
(range 46 to 91 years). The mean IOL power was 18.0
G 6.0 D (range 6.0 to 28.0 D). Table 1 shows the
mean preoperative corneal astigmatism measured by
each device. The mean postoperative refractive
Table 1. Preoperative corneal astigmatism (D) measured by
each device.
Device WTR (n Z 17) ATR (n Z 24)
PCI 1.78 @ 91 1.28 @ 1
OLCR 1.66 @ 92 1.24 @ 2
Placido-disk corneal 1.66 @ 88 1.22 @ 0
topographer TCP
Combined Placido–dual 1.76 @ 93 1.56 @ 1
Scheimpflug
Manual keratometry 1.91 @ 94 1.32 @ 8
ATR Z against the rule; OLCR Z optical low-coherence reflectometry;
PCI Z partial coherence interferometry; TCP Z total corneal power;
WTR Z with the rule
J CATARACT REFRACT SURG - VOL -, - 2013
3
astigmatism was 0.08  11 and 0.12  148 in the
WTR group and ATR group, respectively.
Aggregate Corneal Astigmatism Prediction Errors
With the 4 devices that measure anterior corneal
curvature only, the mean preoperative and postopera-
tive corneal astigmatism prediction errors in WTR
eyes ranged from 0.27 to 0.62 D, all aligned along
the vertical meridian (Figure 1, A to D) and in ATR
eyes ranged from 0.17 to 0.37 D, also aligned along
the vertical meridian (Figure 1, A to D). With the
combined Placido–dual Scheimpflug analyzer TCP,
the mean preoperative and postoperative corneal
astigmatism prediction errors were 0.57 @ 93.9 and
0.26 @ 97.0, respectively, in the WTR eyes and 0.12 @
7.3 and 0.18 @ 8.7, respectively, in the ATR eyes
(Figure 1, E).
With-the-Rule/Against-the-Rule and Oblique
Corneal Astigmatism Prediction Errors
In the WTR group, the WTR/ATR prediction errors
ranged from 0.60 to 0.26 D and oblique prediction
errors, from 0.26 to C0.20 D (Table 2). There were
significant WTR prediction errors (0.5 to 0.6 D) by all
devices except the Placido-disk corneal topographer
and combined Placido–dual Scheimpflug analyzer
postoperative measurements. There was a significant
oblique prediction error of 0.26 D by the OLCR
device for postoperative corneal astigmatism mea-
surements (all P!.05 with Bonferroni correction).
In the ATR group, the WTR/ATR prediction errors
ranged from 0.29 to C0.17 D and oblique prediction
errors, from 0.13 to C0.36 D. There were significant
WTR prediction errors of 0.2 to 0.3 D by the PCI device,
OLCR device, Placido-disk corneal topographer, and
manual keratometer and oblique prediction errors of
0.3 to 0.4 D by manual keratometry corneal astigma-
tism (all P!.05 with Bonferroni correction). There
was no significant WTR/ATR or oblique prediction
error by the combined Placido–dual Scheimpflug
analyzer.
DISCUSSION
Accurate correction of astigmatism requires accurate
measurements. In this study, in eyes implanted with
toric IOLs, we assessed the prediction errors of total
corneal astigmatism using 4 devices that estimate total
corneal astigmatism based on anterior surface
measurements only and 1 device that measures both
anterior and posterior corneal astigmatism.
To account for the ELP variations in different
eyes, we used the Holladay 2 Consultant Program to
calculate the effective toric power of the IOL at the
corneal plane. Based on actual postoperative refractive
4 CORNEAL ASTIGMATISM PREDICTION ERROR

Figure 1. Double-angle plots of preoperative and postoperative

corneal astigmatism prediction errors in the WTR eyes (left)
and ATR eyes (right) using the PCI device (A), OLCR device
(B), Placido-disk corneal topographer (C), manual keratometry
(D), and combined Placido–dual Scheimpflug analyzer TCP
(E). (ATR Z against the rule; PE Z prediction error; WTR Z
with the rule).

astigmatism, the actual total corneal astigmatism was
determined; the corneal astigmatism prediction error
for each device was then calculated.
With the 4 devices that had measurements from the
anterior corneal surface only, the mean corneal
astigmatism prediction errors were 0.5 to 0.6 D WTR
in eyes with WTR corneal astigmatism and 0.2 to
0.3 D WTR in eyes with ATR corneal astigmatism for
preoperative and postoperative corneal measure-
ments. In a recent study,11 we found that (1) the poste-
rior cornea is steeper along the vertical meridian in
more than 85% of eyes and (2) the magnitude of poste-
rior corneal astigmatism increased with increasing
amounts of anterior corneal astigmatism in WTR

J CATARACT REFRACT SURG - VOL -, - 2013

 CORNEAL ASTIGMATISM PREDICTION ERROR
Table 2. Mean corneal astigmatism prediction errors (D): WTR/ATR and oblique by each device.
PCI OLCR
Parameter Preop Postop Preop Postop
WTR
WTR/ATR 0.59* 0.52* 0.48* 0.48*
Oblique C0.01 0.17 0.02 0.26*
ATR
WTR/ATR 0.17* 0.29* 0.21* 0.21*
Oblique C0.02 C0.02 C0.10 0.07
ATR Z against the rule; K Z keratometry; OLCR Z optical low-coherence reflectometry; PCI Z partial coherence interferometry; WTR Z with the rule
*Significantly different from zero (all P!.05 with Bonferroni correction)
eyes; whereas in ATR eyes, the average magnitude
of posterior corneal astigmatism was approximately
0.2 D and did not change with increasing amounts of
anterior corneal astigmatism. This shows that the total
corneal astigmatism prediction errors from these
devices were primarily caused by the posterior corneal
astigmatism.
With the Galilei TCP values, which account for both
anterior and posterior corneal astigmatism, we found
in the WTR group a significant WTR prediction error
of 0.57 D using preoperative corneal astigmatism;
however, in the ATR group, there were no significant
WTR/ATR prediction errors. This indicates that
the Galilei TCP may still underestimate the posterior
corneal astigmatism in WTR eyes. Further study eval-
uating the accuracy of posterior corneal astigmatism
measurements with this device is desirable. The Penta-
cam corneal topography system (Oculus, Inc.) also
uses a rotating Scheimpflug camera to measure ante-
rior and posterior corneal curvatures. Studies assess-
ing the prediction errors of total corneal astigmatism
with this device in eyes with toric IOLs are desirable.

In 1890, Emile Javal13 first characterized this rela-
tionship by publishing the Javal rule, which states
that the total astigmatism in the eye, or refractive astig-
matism, is equal to 1.25 (keratometric astigmatism)
0.50  90. In 1988, Grosvenor et al.,14 using more
than 600 eyes with refractive and keratometric data,
derived a simplified version of the Javal rule as
follows: refractive astigmatism Z (keratometric astig-
matism) 0.50  90. Several authors have since
confirmed the relationship described by the simplified
Javal rule with data from hundreds of eyes from
diverse populations ranging from Native American
school children to aging Hong Kong Chinese.15–21
In 1997, Alpins22 made a similar observation that
when the topographic astigmatism axis is closer to
90 degrees, the topographic astigmatism magnitude
J CATARACT REFRACT SURG - VOL -, - 2013
5
Device
Placido-Disk Topographer Manual K Placido–Dual Scheimpflug
Preop Postop Preop Postop Preop Postop
0.47* 0.27 0.60* 0.46* 0.57* 0.26
C0.20 0.10 0.15 0.25 0.08 0.06
0.23* 0.29* 0.18 0.26* C0.11 C0.17
0.01 0.13 C0.36* C0.26* C0.03 C0.05
exceeds the refractive astigmatism; however, when
the axis is closer to ATR at 180 degrees, the refractive
astigmatism has the greater value.
The difference between refractive and keratometric
astigmatism has been attributed to an intraocular
astigmatic component, which is believed to be pro-
duced mainly by the lens (ie, lenticular astigmatism).
However, 2 recent studies2,23 analyzed refractive and
keratometric astigmatism in pseudophakic eyes and
found that the relationship described by the simplified
Javal rule holds true. Because the posterior cornea is a
negative lens, refractive astigmatism with the steep
meridian aligned vertically on the posterior surface
produces net plus refractive power along the horizon-
tal meridian. These findings point to posterior corneal
astigmatism as the link between refractive and kerato-
metric astigmatism and the explanation of the simpli-
fied Javal rule.
There are some limitations to this study. We of
course did not actually measure the astigmatism
induced by the toric IOL, so we cannot rule out effects
from IOL tilt or variances in the actual toricity of
the IOLs. We did not measure actual total corneal
astigmatism but inferred it from other pertinent
clinical data. We do not have a sound explanation
for the greater-than-anticipated differences between
the actual corneal astigmatism and the values calcu-
lated by the Galilei device. Possible explanations for
this disparity are device inaccuracy, flaws in our meth-
odology for calculating the actual corneal astigmatism,
or some IOL tilt was present, creating an ATR refrac-
tive effect. However, it seems highly unlikely that tilt
could be the source of the magnitude of prediction
errors found in our patients because tilt was not detect-
able at the slitlamp examination.
In summary, our study found that using the devices
that calculate total corneal astigmatism based on ante-
rior corneal measurements only, WTR astigmatism
6 CORNEAL ASTIGMATISM PREDICTION ERROR

Table 3. Baylor toric IOL nomogram (target range up to 0.40 D

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