ORIGINAL ARTICLE

Changes in corneal astigmatism among patients with visually

signicant cataract
Douglas A.M. Lyall, MRCOphth,* Sathish Srinivasan, FRCSEd, FRCOphth, FACS,*,
Jia Ng, MBChB,* Elizabeth Kerr, BSc*
ABSTRACT RSUM
Objective: To determine the prevalence of corneal astigmatism, changes in astigmatism, and biometry measurements with age and
to correlate fellow eye measurements of patients undergoing cataract surgery.
Design: Prospective, observational study.
Participants: 3498 eyes of 1814 patients undergoing cataract surgery.
Methods: Setting was a single center teaching hospital. Preoperative biometry data measured by partial coherence interferometry
(IOLMaster; Carl Zeiss Meditec, Jena, Germany) were collected and analyzed.
Results: Mean age of the cohort was 74.52 10.23 years. Mean corneal astigmatism was 1.04 0.78 D OD and 1.04 0.79 D
OS. About 19.7% and 4.9% of eyes had corneal astigmatism greater than 1.5 and 2.5 D, respectively. The prevalence of against-
the-rule astigmatism significantly increased with age bilaterally. Paired fellow eye analysis found a positive correlation for corneal
astigmatism, axial length, anterior chamber depth, and white-to-white distance (p o 0.001). About 33.33% of right eyes with
corneal astigmatism greater than 2.5 D had more than 2.5 D of astigmatism in the fellow eye. This is in comparison with only 1.5%
of right eyes with corneal astigmatism of less than 1.5 D having corneal astigmatism greater than 2.5 D in the fellow eye.
Conclusions: Patients with high corneal astigmatism in 1 eye are more likely to have significant astigmatism in the fellow eye. This
may necessitate the need for bilateral toric intraocular lens (IOL) implantation during cataract surgery. Against-the-rule
astigmatism should be treated more aggressively during cataract surgery, because this is likely to worsen with age. Such
information is useful when calculating toric IOL power at the time of surgery.

Objet : Dtermination de la prvalence de lastigmatisme cornen, des changements des mesures astigmatiques et biomtriques
avec lge et corrlation des mesures de lil contralatral des patients subissant une chirurgie de la cataracte.
Nature : tude prospective dobservation.
Participants : 3 498 yeux de 1 814 patients subissant une chirurgie de la cataracte.
Mthodes : Une seule institution denseignement hospitalier. Collection et analyse des donnes biomtriques propratoires,
mesures par interfromtrie de cohrence partielle (IOLMaster, Carl Zeiss Meditec).
Rsultats : La moyenne dge de la cohorte tait de 74,52 10,23 ans. La moyenne dastigmatisme cornen tait de 1,04 0,78D
dans lil droit (D) et 1,04 0,79D dans lil gauche (G). 19,7 % et 4,9 % des yeux avaient un astigmatisme cornen plus
grand que 1,5D et 2,5D, respectivement. La prvalence dastigmatisme contre la rgle a significativement augment bilatrale-
ment avec lge. Lanalyse par paire de lautre il a rvl une corrlation positive dastigmatisme cornen, de longueur axiale, de
profondeur de la chambre antrieure et dcart blanc blanc (po0,001). 33,33 % des yeux droits ayant un astigmatisme
cornen plus grand que 2,5D avaient un astigmatisme plus grand que 2,5D dans lil voisin. Cela se compare seulement 1,5 %
des yeux droits qui, ayant un astigmatisme cornen infrieur 1,5D, avaient un astigmatisme plus grand que 2,5D dans lautre
il.
Conclusions : Les patients qui ont un astigmatisme cornen important dans un il sont plus enclins avoir un astigmatisme
significatif dans lautre il. Cela peut ncessiter le besoin dimplanter bilatralement des lentilles intraoculaires (LIO) toriques au
moment de la chirurgie de la cataracte. Lastigmatisme contre la rgle devrait tre trait de faon plus agressive pendant la
chirurgie de la cataracte, car il est probable quil pourrait saggraver avec lge. Une telle information est utile pour calculer le
pouvoir de la LIO torique lors de la chirurgie.

The public perception of cataract surgery is such that there
is an expectation of a high standard of postoperative visual
performance, including spectacle independence among
some patients.1,2 For patients with high corneal astigma-
tism, both spherical and cylindrical components of their
refractive error need to be addressed at the time of surgery
for this to be achieved.36 Current modalities to treat pre-
existing corneal astigmatism include placing the corneal
incision on the steep meridian, opposite clear corneal
incisions, peripheral corneal relaxing incisions, and the use
of a toric intraocular lens (IOL).7,8
If a patient has bilateral high corneal astigmatism,
then this cylindrical error would need to be addressed
in both eyes at the time of cataract surgery if best
uncorrected distance visual acuity (UDVA) is to be
achieved bilaterally.9 The purpose of this study is to report

From the *Department of Ophthalmology, University Hospital Ayr, Ayr;
and Faculty of Medicine, University of Glasgow, Glasgow, United Kingdom
Originally received Aug. 26, 2013. Final revision Dec. 9, 2013. Accepted
Feb. 5, 2014
Can J Ophthalmol 2014;49:297303
0008-4182/14/$-see front matter & 2014 Canadian Ophthalmological
Society. Published by Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.jcjo.2014.02.001

Address correspondence to Sathish Srinivasan, FRCSEd, FRCOphth,

FACS, Department of Ophthalmology, 3rd Floor, University Hospital
Ayr, Dalmellington Road, Ayr, KA6 6DX Scotland, United Kingdom;
sathish.srinivasan@gmail.com

CAN J OPHTHALMOL VOL. 49, NO. 3, JUNE 2014 297

Changes in corneal astigmatismLyall et al.

the prevalence of astigmatism and other biometric data RESULTS

in a population of patients presenting for cataract surgery
at a university hospital practice in Scotland, and to
establish intereye correlations of magnitude and type of
corneal astigmatism that exists between eyes of an
individual.
METHODS
In this prospective observational study, preoperative
biometric data performed by partial coherence interferom-
etry (IOL Master; Carl Zeiss Meditec, Jena, Germany) on
patients attending the cataract service at University
Hospital Ayr, Scotland, were collected and analyzed.
Trained staff who routinely performed biometry at the
cataract Day Surgery Unit took measurements. Institu-
tional review board permission was granted, and the study
adheres to the Declaration of Helsinki.
Patients aged Z18 years with visually signicant
cataract were included. Patients were excluded if they
wore contact lenses or had a history of corneal disease
(including corneal ectasia and secondary irregular astigma-
tism), previous intraocular surgery, or trauma. Patients
were required to have adequate visual acuity to allow
xation on an instrument-projected target so that reliable
measurements could be obtained. Patients also underwent
manifest refraction, slit-lamp biomicroscopy, dilated fun-
dus examination, and applanation tonometry as part of
routine preoperative assessment.
To avoid any bias where an individual patient con-
tributed both right and left eye measurements, data from
right and left eyes were analyzed separately to identify
changes with age. Only data from patients who had both
eyes measured were included in analysis to identify
correlations between right and left. With-the-rule
(WTR) astigmatism was taken as a cylindrical error
where the steep corneal meridian was within 30 degrees
of the vertical 90 degrees, and against-the-rule (ATR)
astigmatism was taken as a cylindrical error with the
steep corneal meridian within 30 degrees of the hori-
zontal 180 degrees. All other astigmatic measurements
outside these parameters were regarded as oblique
astigmatism. Changes with age in both the prevalence
and magnitude of both WTR and ATR astigmatism were
analyzed.
Data analysis was performed using SPSS statistical
package version 19.0 (SPSS, IBM Corp, Armonk, NY).
Changes in biometric data with age were studied by
A total of 3498 eyes of 1814 patients were included for
analysis. A total 1090 patients (60.1%) were female, and
there were 1750 right eyes (50%) in the cohort. Mean age of
the cohort was 74.52 10.23 years. Table 1 shows the age
and sex distribution of the cohort and the laterality of the
eyes. Because each decade group younger than 40 years had
fewer than 20 patients contributing data, these age groups
were excluded from analysis to identify changes with age.
Mean astigmatism was 1.04 0.78 D OD and 1.04
0.79 D OS (Fig. 1A). Using ANOVA, we found no
signicant difference in the magnitude of astigmatism
between age groups (right eye: F 1.744, df 5, p
0.121; left eye: F 1.666, df 5, p 0.140), and there
were no signicant differences observed between the
means for right and left eyes for each decade of age
(Fig. 1BF). Mean WTR was 1.11 0.81 D OD and
1.14 0.82 D OS. Mean ATR was 1.10 0.75 D OD
and 1.06 0.82 D OS. There was a signicant increase in
the prevalence of ATR (right eye: F 27.77, df 5, p
0.006; left eye: F 122.9, df 5, p o 0.001) and
reduction in WTR (right eye: F 44.36, df 5, p
0.003; left eye: F 211.6, df 5, p o 0.001) with age
(Fig. 2). There were no signicant changes in the
prevalence of oblique astigmatism across age groups.
There was a strong correlation for corneal astigmatism
between right and left eyes (p o 0.001; Fig. 3A, Table 2).
The distribution of corneal astigmatism, categorized by the
magnitude of astigmatism of the fellow eye, is illustrated in
Figure 4. About 33.33% of right eyes with corneal
astigmatism greater than 2.5 D had more than 2.5 D of
astigmatism in the left eye. This is in comparison with
only 1.5% of right eyes with corneal astigmatism of less
than 1.5 D having corneal astigmatism greater than 2.5 D
in the fellow eye (Fig. 4A). Using 2 multiple comparison
test, we found signicant differences in the prevalence in
fellow eye astigmatism based on magnitude of astigmatism
for both the right and the left eye (both p o 0.001;
Fig. 4A, 4B). There was also a signicant correlation for
axial length (AL; p o 0.001), anterior chamber depth
(ACD; p o 0.001), and white-to-white distance (WTW;
p o 0.001) between eyes (Fig. 3BD, Table 2). No
correlation was found between corneal astigmatism and
AL, ACD, or WTW in either eye.
Table 1Age and sex distribution of patients
Age Group Patients Total Eyes Right Eyes Left Eyes Male Female
(y) (n) (n) (n) (n) (n) (n)

performing analysis of variance (ANOVA) and linear 1819 1 2 1 1 1 0

2029 3 6 3 3 2 1
regression analysis between mean values of age per decade 3039 5 10 5 5 2 3
of life. The intereye relationship between right and left eye 4049 26 52 26 26 14 12
5059 103 204 102 102 49 54
biometric values was analyzed by calculating the Pearson 6069 341 661 331 330 130 211
correlation coefcient to identify correlations between 7079 738 1426 711 715 289 449
eyes. A p value less than 0.05 was regarded as statistically 8089 531 1018 511 507 204 327
9099 66 119 60 59 24 42
signicant.

298 CAN J OPHTHALMOL VOL. 49, NO. 3, JUNE 2014


Fig. 1 Distribution of magnitude of corneal astigmatism for whole cohort (A) and for different age groups per decade of life
(BF). Mean and standard deviation for each group are also shown.
DISCUSSION
Advances in surgical technique and technologic improve-
ments in biometric measurement and IOL power calculation
have resulted in a high percentage of patients undergoing
cataract surgery achieving a good level of postoperative visual
acuity and a postoperative refractive mean spherical equiv-
alent close to the predicted outcome.10 In such circum-
stances, the presence of corneal astigmatism can be one of the
major determinants that affects the quality of postoperative
UDVA. As a result, there has been an increase in the use of
several techniques during cataract surgery designed to address
astigmatism and improve refractive outcomes.7,11 The tech-
nique chosen by an individual clinician is dependent on his
or her individual preference and practice, and the magnitude
of astigmatism present in each patient. In a previous review,
Changes in corneal astigmatismLyall et al.
Amesbury and Miller7 suggested placing the main corneal
wound on the steep corneal meridian for patients with less
than 1.0 D of corneal astigmatism, performing corneal
relaxing incisions between 1.0 and 1.5 D, and using a toric
IOL in patients with greater than 1.5 D of pre-existing
corneal astigmatism. However, several studies have shown
toric IOLs to be effective at managing corneal astigmatism at
lower levels of 1.0 D12,13 and even 0.75D.14
Previous studies on toric IOL use have included
patients with moderate corneal astigmatism greater than
1.5 D,1517 whereas others have included only patients
with larger amounts of astigmatism of Z2.5 D.5,18 Thirty
percent of the population older than 65 years has visually
signicant cataract.19 In Scotland, it is estimated that 34
560 cataract operations are performed each year,20 and
approximately 312 310 operations are performed in
CAN J OPHTHALMOL VOL. 49, NO. 3, JUNE 2014 299
Changes in corneal astigmatismLyall et al.
Fig. 2 Change in prevalence of each type of corneal astig-
matism with age. (A) Right eye; (B) left eye.
England and Wales annually.21 If one were to propose
regularly using a toric IOL in patients with greater than
2.5 D of corneal astigmatism, this would equate to 16 240
toric IOLs being used on an annual basis in England,
Scotland, and Wales based on our gures. However, if one
were to propose using a toric IOL in patients with greater
than 1.5 D, as has been performed in some studies, this
would equate to approximately 62 149 operations with
toric IOL use on an annual basis. Normative data on the
prevalence of corneal astigmatism, as presented in this
study, provide useful information to clinicians when
developing guidelines on corneal astigmatism manage-
ment, because it allows them to estimate the number of
operations that require toric IOL use and the associated
projected costs. This should be balanced with the lifetime
economic benets of achieving spectacle independence
with a toric IOL.22
Currently, there is no standardized provision across
Health Boards in Scotland for toric IOL use, with the
mean cost of commercially available toric IOLs approx-
imately 120 ($208). In a US-based study, Pineda et al.22
estimated that overall, the combined saving to the state
and patient of using a toric IOL instead of a monofocal
IOL without refractive correction was US$34 ($36). This
increased to US$393 ($419) if the patient achieved an
acuity of 20/25 or better. Using our gure of 16 240
patients with more than 2.5 D in the United Kingdom
undergoing cataract surgery annually, if all were to have a
toric IOL implanted, this would result in an overall
300 CAN J OPHTHALMOL VOL. 49, NO. 3, JUNE 2014
saving of $584 640. Patient-incurred costs over the course
of their lifetime after cataract surgery will be dependent
on their need for spectacles, whether they choose to wear
spectacles or contact lenses, how often they need spec-
tacles replaced, and how long they live for after surgery.
In the same study, Pineda et al.22 estimated that after the
rst year and initial costs, patients saved US$1086
($1157) if a toric IOL was used instead of monofocal
IOL without refractive correction. Again, if all 16 240
patients in the United Kingdom with more than 2.5 D
undergoing cataract surgery annually had a toric IOL
implanted, this would result in an overall patient pop-
ulation saving of more than $18 million. Admittedly,
Pineda et al.22 found that most of these patient savings
were offset by increased patient costs in the rst year after
surgery, but it is unclear whether patients would incur
such higher costs in different health care systems around
the world.
Toric IOL use and achieving spectacle independence
have been shown to improve quality of life after cataract
surgery.22 As progressive bifocal spectacles increase the risk
for falls in people with a refractive error,23 removing the
need for either bifocal or progressive bifocal spectacle wear
by using a toric IOL in patients with corneal astigmatism
may reduce the risk for falls in elderly patients.23
There have been previous reports on the prevalence of
corneal astigmatism in the general population.2427 This
study reports the prevalence of corneal astigmatism in a
Scottish cohort of patients in addition to analyzing other
biometric data. We also analyzed left and right eye data
separately to identify intrasubject correlations of such
parameters.
We have found that there is a strong correlation
between the right and the left eye of the same individual
for biometric parameters including corneal astigmatism,
AL, ACD, and WTW. If a patient has less than 1.5 D of
corneal astigmatism in 1 eye, it is unlikely that they will
have visually signicant astigmatism of greater than 2.5 D
in the fellow eye (less than 2%; Fig. 4). However, we
found that if operating on a patient with greater than
2.5 D of corneal astigmatism in 1 eye, there is greater than
a 1 in 3 chance that the patient will have astigmatism of a
similar magnitude in the fellow eye (Fig. 4). This is
important when considering the use of a toric IOL because
potentially, both eyes may need to undergo toric IOL
implantation if spectacle independence and maximum
patient satisfaction is to be achieved.9 Correlation between
right and left phakic eyes of biometric data supports
current practice that both eyes should have biometry
performed even if only unilateral surgery is planned.28
This allows for any erroneous measurement to be identi-
ed if there is any large discrepancy between the right and
the left eye.
We have found that there is a systematic increase in the
prevalence of ATR astigmatism with age and an accom-
panying decrease in WTR astigmatism. This is in keeping
 Changes in corneal astigmatismLyall et al.

Fig. 3 Correlation between right and left eyes of different biometric parameters. (A) Corneal astigmatism; (B) axial length;
(C) anterior chamber depth; and (D) white-to-white distance.

with previous reports that found similar changes in
astigmatism in both Asian and European popula-
tions.25,26,2932 Whereas Ho et al.32 found an increase
in oblique astigmatism with age, there was no change in its
prevalence as per our denition in our cohort. This
demonstrates that it is important to consider factors other
than magnitude of astigmatism alone when considering
management strategies of corneal astigmatism at the time
of cataract surgery. Other factors such as patient age
should be considered. One should consider treating ATR
astigmatism more aggressively with the aim to fully correct
it as its magnitude is likely to increase with age. With
respect to correcting WTR astigmatism, patients should be
aware that if corrected fully at the time of surgery, then

Table 2Descriptive statistics of biometry data of right and left eyes of the cohort

Right Left Difference between Right and Left

Mean SD Mean SD Mean Difference SD of Difference Pearson Correlation Coefficient

Corneal cylinder (D) 1.03 0.77 1.04 0.77 0.01 0.73 0.550
Axial length (mm) 23.43 1.33 23.36 1.29 0.07 0.41 0.951
Anterior chamber depth (mm) 3.00 0.45 3.02 0.45 0.02 0.33 0.733
White-to-white (mm) 11.95 0.41 11.94 0.42 0.01 0.23 0.850

CAN J OPHTHALMOL VOL. 49, NO. 3, JUNE 2014 301

Changes in corneal astigmatismLyall et al.
Fig. 4 Proportion of fellow eyes with magnitude of astigma-
tism, mild (o1.5 D), moderate (1.52.5 D), and significant
(42.5 D), when categorized by magnitude of astigmatism of
the right (A) and left (B) eyes.
there is the risk for progression to ATR astigmatism in
later years. This would especially be the case in younger
patients.
One weakness of managing corneal astigmatism based on
keratometry or anterior curvature topography measurements
alone is that the effect of the posterior corneal surface is not
taken into consideration. It is now recognized that the
refractive power of the posterior corneal surface does not
always correlate with the anterior surface.32,33 Therefore, the
posterior magnitude and type of astigmatism cannot be
accurately predicted by the anterior keratometry measure-
ments. As with the anterior surface, the posterior corneal
surface also changes with age, although the magnitude of
such changes is signicantly less than the anterior sur-
face.32,33 Measurement of the posterior corneal surface
would have to be performed as part of normal preoperative
assessment of patients undergoing cataract surgery, to be able
to manage total corneal astigmatism.
In conclusion, this article presents data on prevalence of
corneal astigmatism in a cohort of patients undergoing
cataract surgery and shows that with age there is an
increase in ATR and reduction in WTR astigmatism.
We also present normative data for other biometric
measurements. We have also found that there is a
signicant correlation between the magnitude of corneal
astigmatism between right and left eyes of the same
individual. This is important when considering the use
of a toric IOL, because potentially both eyes may need to
undergo toric IOL implantation if spectacle independence
and maximum patient satisfaction are to be achieved.
302 CAN J OPHTHALMOL VOL. 49, NO. 3, JUNE 2014
Disclosure: The authors have no proprietary or commercial
interest in any materials discussed in this article.
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