Justin Cooper , 2025-05-07 21:05:00
Key takeaways:
- Toric IOLs and femtosecond laser arcuate keratotomy were comparable in the overall cohort.
- Residual astigmatism was lower with toric IOLs in patients with against-the-rule astigmatism or astigmatism above 1.5 D.
Patients with astigmatism above 1.5 D or against-the-rule astigmatism had significantly less residual astigmatism with toric IOL implantation than with femtosecond laser arcuate keratotomy, according to a study.
However, overall study results showed no significant difference in astigmatism 3 months after either procedure.
Patients with astigmatism above 1.5 D or against-the-rule astigmatism who underwent femtosecond laser-assisted cataract surgery had significantly less residual astigmatism with toric IOL implantation than with femtosecond laser arcuate keratotomy. Image: Adobe Stock
“With decades of advancements and innovations in ophthalmology, cataract surgery has undergone a paradigm shift to refractive surgery in this modern era. Nevertheless, residual astigmatism continues to be one of the major factors influencing patients’ visual acuity and satisfaction,” Yueyang Zhong, MD, of the Eye Center of the Second Affiliated Hospital, Zhejiang University School of Medicine, China, and colleagues wrote in JAMA Ophthalmology. “As both [toric IOL] implantation and [femtosecond laser arcuate keratotomy] are effective methods for addressing astigmatism, there has been much interest in comparing their efficacy in cataract surgery.”
Zhong and colleagues conducted a randomized clinical trial in patients at their center scheduled for femtosecond laser-assisted cataract surgery with IOL implantation. The study included 196 patients who were randomly assigned 1:1 to receive either a toric IOL or femtosecond laser arcuate keratotomy (FSAK) with a monofocal IOL. The primary outcome was subjective manifest refraction 3 months after surgery.
Mean refractive astigmatism at 3 months was not significantly different between the two groups, 0.64 D in the FSAK group and 0.54 D in the toric IOL group, with a difference of 0.11 D.
Mean uncorrected distance visual acuity was similar, 0.15 logMAR in the FSAK group and 0.14 logMAR in the toric IOL group.
In a subgroup analysis of patients with preoperative astigmatism greater than 1.5 D, mean residual astigmatism was greater in the FSAK group than the toric IOL group, 0.82 D vs. 0.53 D, with a difference of 0.28 D (P = .009).
For against-the-rule astigmatism, mean residual astigmatism was greater in the FSAK group than the toric IOL group, 0.72 D vs. 0.5 D, with a difference of 0.22 D (P = .04).
“Both procedures demonstrated comparable clinical outcomes in terms of refractive astigmatism and visual acuity, whereas [toric IOL] implantation showed greater effectiveness in astigmatism correction, although this was not the primary outcome,” Zhong and colleagues wrote.
“This investigation supports the possibility that FSAK can be performed together with femtosecond laser procedures and therefore might be considered when addressing mild astigmatism. Nevertheless, further studies with extended follow-up periods are necessary to refine and improve the existing nomogram, as well as to elucidate the underlying mechanisms of astigmatism correction.”
Reference:
- Luensmann D, et al. Contact Lens Spectrum. 2018;33(9):12-13.
Perspective
Astigmatism correction remains underutilized across both refractive and cataract care. Nearly 45% of contact lens wearers present with 0.75 D or more of cylinder, yet only about 25% are prescribed toric lenses (Luensmann et al.). A similar pattern persists in cataract surgery, in which patients often receive spherical IOLs despite having clinically significant astigmatism.
This randomized clinical trial compared femtosecond laser arcuate keratotomy (FSAK) with toric IOL implantation in femtosecond laser-assisted cataract surgery for mild to moderate astigmatism. At 3 months postop, refractive astigmatism and uncorrected distance acuity were comparable between groups. However, toric IOLs outperformed FSAK in cases with astigmatism greater than 1.5 D and against-the-rule astigmatism, emphasizing their value in patients with more complex corneal profiles.
While FSAK remains a viable non-IOL alternative, particularly in patients with low astigmatism or financial limitations, its long-term corneal stability and refractive predictability are less established. Surgical precision, accessibility and cost-effectiveness also warrant further investigation, especially given the study’s short follow-up and limited data on these real-world considerations.
For optometrists, this study reinforces the importance of comprehensive preop topography, accurate refractive analysis and patient education. Toric IOLs offer a more predictable outcome for moderate to high astigmatism, and ODs are well positioned to guide patients in making informed surgical decisions for optimized outcomes.
Jade Coats, OD
McDonald Eye Associates, Rogers, Arkansas. This perspective is powered by the American Academy of Optometry Communications Committee.
Disclosures: Coats reports being on speaker bureaus for Alcon, Bausch + Lomb, Dompe, Harrow, Orasis, Sun and Tarsus and consultant/advisory boards for AbbVie, Novaliq and Thea.
Sources/Disclosures
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Disclosures:
The authors report no relevant financial disclosures. The study was supported by grants from the National Natural Science Foundation of China and the Central Guidance for Local Scientific and Technological Development Funding Projects.
