Surgeons should perform more intraoperative astigmatism management
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Uncorrected astigmatism degrades quality of vision in the phakic and pseudophakic eye.
The degradation of vision quality created by residual astigmatism is especially high in an eye implanted with a diffractive or refractive multifocal or extended depth of focus IOL. As little as 0.25 D of astigmatism when evaluated on an optical bench can cause a meaningful degradation in image quality. Today, according to surveys by the American Society of Cataract and Refractive Surgery and the European Society of Cataract and Refractive Surgeons, surgeon members believe a postoperative target of 0.5 D of astigmatism or less is appropriate for the patient who desires reduced dependance on spectacles.
Two large case cohorts have given us insight into the prevalence of astigmatism at various magnitudes in the United States. Warren Hill, MD, has published a series of 6,000 eyes that presented for cataract/IOL surgery, and Guy Kezirian, MD, has reported on 45,678 patients from his SurgiVision data registry. The results are similar, and the interested reader can look up the exact numbers. I will provide my summary average of the two papers in a format that I can remember.
Rounded off, about 30% of patients present to the cataract surgeon with 0.5 D or less of refractive astigmatism. In these cases, the surgeon’s goal is to reduce surgically induced astigmatism to a minimum. Most U.S. surgeons have found a small 2.2-mm temporal incision is nearly astigmatism neutral at 1 year after cataract surgery. That leaves a full 70% who enter the operating room for cataract surgery with more than 0.5 D of astigmatism. I believe these patients deserve the opportunity to have their astigmatism reduced in the operating room.
The cataract surgeon of today has five available surgical strategies to reduce astigmatism: primary incision placement on the steeper meridian; limbal or corneal relaxing incisions; toric IOLs; the Light Adjustable Lens (LAL, RxSight); and postoperative enhancement with incisional keratotomy, PRK, LASIK or SMILE. A few thoughts on each of these strategies. About 30% of patients have 0.5 D to 1 D of astigmatism. These patients respond well to incision placement on the steeper meridian, a limbal/corneal relaxing incision or a combination of the two. At 1 D or greater, fully 40% of patients in the U.S. presenting for cataract surgery, a toric IOL or LAL is the most appropriate treatment. A postoperative corneal refractive surgical procedure is an option for all patients and will be required in 5% to 10% of patients who request intraoperative treatment of their astigmatism to achieve the best outcomes.
At first glance, if treatment is available to everyone with no cost barrier, we cataract surgeons arguably should be treating preexisting astigmatism in 70% of our patients. Looking at recent Market Scope data, how are we doing? According to Market Scope, U.S. surgeons treated astigmatism with a toric IOL in only 10.9% of patients in 2020. Cost is of course a factor, but informal studies suggest at least half of the 70% of patients who could benefit from intraoperative astigmatism management would be willing to pay a premium for this treatment. That would represent a target of 35% as a reasonable goal for intraoperative astigmatism management in the U.S. market. We are clearly well below that target.
What about cost? According to Market Scope, in 2020, the average charge for a limbal/corneal relaxing incision with a blade was $700, and when a femtosecond laser was used, $1,200. The average charge for a toric IOL was $1,400, and for a laser corneal refractive procedure when not part of an astigmatism management package, also $1,400. The LAL also corrects any residual sphere and is appropriately priced higher. To me, these are reasonable fees for a lifetime of enhanced visual performance. A single dental implant is on average more than twice the cost of a toric IOL. From a patient benefit vs. cost perspective, astigmatism management at the time of surgery is a bargain.
I believe the biggest barrier to greater adoption resides with we surgeons. A thoughtful discussion with every preoperative cataract surgery patient about the potential benefits of astigmatism management during cataract surgery along with a confident surgeon recommendation and a structured payment plan, when necessary, would rapidly increase patient adoption. As I have mentioned in previous commentaries, we can and should be doing more intraoperative astigmatism management and also more MIGS procedures in the U.S. All it takes is a little chair time to educate the patient and the confidence to offer the treatment. To do so is a win for the patient, surgeon and industry.
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