eMedicine Specialties > Ophthalmology > Refractive Disorders

Astigmatism, LASIK

Author: David R Hardten, MD, Phillips Eye Institute; Adjunct Clinical Associate Professor, Director of Refractive Surgery at Minnesota Eye Consultants, Pennsylvania College of Optometry; Clinical Associate Professor, Department of Ophthalmology, University of Minnesota, Minnesota VAMC
Coauthor(s): Ahmad M Fahmy, OD, Fellow, Department of Ophthalmology, Minnesota Eye Consultants; Scott G Hauswirth, OD, Consulting Staff, Department of Optometry, Minnesota Eye Consultants
Contributor Information and Disclosures

Updated: Jan 2, 2007

Introduction

The surgical correction of astigmatism was first attempted with astigmatic keratotomy, which is described in this article, along with compression sutures and wedge resection. More recently, excimer laser photoastigmatic refractive keratectomy (PARK), conventional laser in-situ keratomileusis (LASIK), and wavefront-guided LASIK have been used to reduce astigmatism. Although astigmatic keratotomy is gradually being replaced by excimer laser techniques, it is still used by many surgeons, and, as such, a discussion of the surgical techniques is warranted.

History of the Procedure

Astigmatic keratotomy was first performed in 1885, when Schiötz, a Norwegian ophthalmologist, treated a patient with 19.50 diopters (D) of astigmatism after cataract surgery with a 3.5-mm penetrating incision at the limbus in the steep meridian, which reduced the astigmatism to 7.00 D. Faber, a Dutch ophthalmologist, performed perforating anterior transverse incisions in a 19-year-old patient with 1.50 D of idiopathic astigmatism, which reduced the astigmatism to 0.75 D and allowed him to pursue a career in the Royal Military Academy. Lucciola of Terrin, Italy was the first surgeon to use nonperforating corneal incisions to correct astigmatism. In 1894, Bates of New York City, described 6 patients who developed flattening of the cornea in the meridian that intersected a surgical or traumatic scar. He postulated that incisions of the cornea made at right angles to the steeper meridian might be used to correct astigmatism.

Lans showed that flattening in the meridian perpendicular to a transverse incision was associated with steepening in the orthogonal meridian, as well as demonstrating that deeper and longer incisions have a greater effect. In the 1940s and 1950s, Sato of Tokyo, Japan, investigated both radial and astigmatic keratotomy. He used tangential posterior corneal incisions to decrease astigmatism an average of 2.50 D in 15 eyes and also reduced astigmatism an average of 4.20 D in 18 eyes with perforating tangential incisions near the limbus. Fyodorov later described the correction of myopic astigmatism using several nonperforating anterior keratotomy patterns.

Over the last few years, the use of photorefractive techniques to treat various types of refractive error has increased in popularity among surgeons. Initially, the excimer laser was used only to treat myopia and low amounts of myopic astigmatism. Since new software has become more available and reliable, it has been shown in many studies that excellent results also can be obtained for correcting low-to-moderate amounts of hyperopia and hyperopic astigmatism.

Problem

Astigmatism, like myopia or hyperopia, can decrease visual acuity. However, astigmatism is much more complex because it has both magnitude and orientation. Thus, it is more difficult to correct in spectacles, contact lenses, or surgery than are spherical forms of refractive error.

Frequency

Naturally occurring (idiopathic) astigmatism is common. Clinically detectable refractive astigmatism is present in as many as 95% of eyes. Incidence of clinically significant astigmatism has been reported to be 7.5-75%, depending on the specific study and the definition of what degree of astigmatism is determined to be clinically significant. Approximately 44% of the population has more than 0.50 D of astigmatism, 10% has more than 1.00 D, and 8% has 1.50 D or more.

Etiology

Visually significant astigmatism is common after various kinds of ophthalmic surgery, including cataract extraction, penetrating or lamellar keratoplasty, and trabeculectomy. Astigmatism greater than 1.00 D often occurs after extracapsular cataract extraction, and astigmatism greater than 3.00 D is present in as many as 20% of cases with 10-mm incisions. High astigmatism after penetrating keratoplasty is even more common.

Indications

Correction of astigmatism by means of surgery is indicated when the amount of the astigmatism affects the vision. Usually visually significant astigmatism is defined as being more than 1 D. Surgical intervention is especially important in those patients who have had previous forms of ocular surgery. Patients who are intolerant or desire to be free from contact lenses or glasses also can become candidates for surgical correction.

Special considerations for postsurgical astigmatism

If astigmatism is caused by wound dehiscence after cataract extraction, in many cases revising the wound itself may be preferred over astigmatic keratotomy or LASIK. If the wound dehiscence is a structural threat to the eye, wound revision is recommended. If the globe is structurally intact, refractive rehabilitation with the reduction of astigmatic anisometropia becomes most important, and astigmatic keratotomy or photoastigmatic refractive keratectomy may be appropriate. The spherical equivalent should be taken into account when considering these procedures. Astigmatic keratectomy incisions, unless extremely short or long, typically are neutral with respect to the spherical equivalent. Photoastigmatic refractive keratectomy typically induces a hyperopic shift in the refractive error. Newer laser software is now able to correct hyperopic astigmatism by steepening the flat axis.

Postkeratoplasty astigmatism often necessitates surgical correction because of intolerance of glasses or contact lenses. The surgical correction can be difficult because astigmatism can be irregular and nonorthogonal, with a significant amount of higher order aberrations. Although an ideal goal is to correct all of the astigmatism, a more realistic goal is to reduce the amount of astigmatism, so that spectacles or contact lenses can be worn comfortably.

Before any surgical procedures for the correction of postkeratoplasty astigmatism are considered, all sutures should be removed because they can be the cause of the astigmatism. Also, the keratoplasty wound should be inspected for focal abnormalities. Wound dehiscence and graft override cause flattening of the central cornea in that meridian and may be best corrected by opening and resuturing the wound, despite the lengthy recovery.

Incisional techniques available for the correction of postkeratoplasty astigmatism include relaxing incisions with or without the use of compression sutures. Wedge resections also can be used for high degrees of astigmatism. Techniques that involve the excimer laser include photoastigmatic refractive keratectomy and LASIK.

Relevant Anatomy

The total amount of astigmatism is entirely dependent upon the anatomy of the eye. Therefore, the physical optical media including the cornea, the lens, and occasionally the retina can contribute toward development of astigmatism. Surgical correction of astigmatism takes place chiefly in the tissues of the cornea, so it is most desirable to have an intact, healthy cornea. Postsurgical patients, such as those who have undergone penetrating keratoplasty, will benefit from surgical correction of astigmatism, but careful consideration should be given to the strength and health of the corneal tissues and the method of correction used.

Contraindications

Contraindications to the surgical correction of astigmatism include forms of corneal or anterior segment diseases such as corneal ulcers, keratitis, or conjunctivitis. Ectatic disorders, such as keratoconus, may increase variability of the predicted outcome and may not be predictable in their outcome.

More on Astigmatism, LASIK

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References
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Further Reading

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Keywords

LASIK, astigmatism, PRK, PARK, refractive error, refraction, photoastigmatic refractive keratectomy, conventional laser in-situ keratomileusis, wavefront-guided laser in-situ keratomileusis, wavefront-guided LASIK, photorefractive keratoplasty, laser epithelial keratomileusis, LASEK, astigmatic keratotomy

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Contributor Information and Disclosures

Author

David R Hardten, MD, Phillips Eye Institute; Adjunct Clinical Associate Professor, Director of Refractive Surgery at Minnesota Eye Consultants, Pennsylvania College of Optometry; Clinical Associate Professor, Department of Ophthalmology, University of Minnesota, Minnesota VAMC
David R Hardten, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Ophthalmology, American College of Surgeons, American Medical Association, American Society of Cataract and Refractive Surgery, and International Society of Refractive Surgery
Disclosure: Alcon, Allergan, AMO, TLCVision, STAAR, Kolis, Ophtec Grant/research funds Other

Coauthor(s)

Ahmad M Fahmy, OD, Fellow, Department of Ophthalmology, Minnesota Eye Consultants
Ahmad M Fahmy, OD is a member of the following medical societies: American Academy of Optometry and American Optometric Association
Disclosure: Nothing to disclose.

Scott G Hauswirth, OD, Consulting Staff, Department of Optometry, Minnesota Eye Consultants
Scott G Hauswirth, OD is a member of the following medical societies: International Society of Refractive Surgery
Disclosure: Nothing to disclose.

Medical Editor

Daniel S Durrie, MD, Director, Department of Ophthalmology, Division of Refractive Surgery, University of Kansas Medical Center
Daniel S Durrie, MD is a member of the following medical societies: American Academy of Ophthalmology and Association for Research in Vision and Ophthalmology
Disclosure: Nothing to disclose.

Pharmacy Editor

Simon K Law, MD, PharmD, Assistant Professor of Ophthalmology, Jules Stein Eye Institute; Chief of Section of Ophthalmology Surgical Services, Department of Veterans Affairs Healthcare Center, West Los Angeles
Simon K Law, MD, PharmD is a member of the following medical societies: American Academy of Ophthalmology, American Glaucoma Society, and Association for Research in Vision and Ophthalmology
Disclosure: Nothing to disclose.

Managing Editor

Louis E Probst, MD, Medical Director of Refractive Surgery, Chicago, Madison, Milwaukee, and Windsor Centers, TLC the Laser Eye Centers
Louis E Probst, MD is a member of the following medical societies: American Academy of Ophthalmology, American Society of Cataract and Refractive Surgery, and International Society of Refractive Surgery
Disclosure: Nothing to disclose.

CME Editor

Lance L Brown, OD, MD, Ophthalmologist, Affiliated With Freeman Hospital and St John's Hospital, Regional Eye Center, Joplin, Missouri
Disclosure: Nothing to disclose.

Chief Editor

Hampton Roy Sr, MD, Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences
Hampton Roy Sr, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, and Pan-American Association of Ophthalmology
Disclosure: Nothing to disclose.

 
 
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