NEWS & OPINION EWAP MARCH 2022 63 odds of not achieving 20/20 UDVA, with an odds ratio (OR) of 1.7 and p-value of <0.0001. However, the same amount of residual astigmatism was not associated with decreased odds of “not being satisfied” (defined as a score of Î or higher on the survey), OR 1.1, p-value 0.1911. If the amount of residual astigmatism rose to 0.75–1.00 D, the odds ratio of not achieving 20/20 UDVA increased to 6.5 (p-value <0.0001), while the odds ratio of “not being satisfied” increased to 1.x and gained statistical significance (<0.0001). The trend continued with higher levels of residual astigmatism, and there were nearly identical results within the monofocal IOL cohort. The authors also analyzed the association of residual hyperopic and myopic sphere with UDVA and patient satisfaction. Among patients with multifocal IOLs, residual hyperopic sphere of 0.25–0.50 D was tolerated without an increase in OR of not achieving 20/20 vision (OR 1.1, p-value 0.0647) or of “not being satisfied” (", 0.9, p-value 0.4308). The same amount of residual postoperative myopic sphere (0.25–0.50 D) was associated with an OR of 5.0 (p-value <0.0001) of not achieving 20/20 UDVA, and an OR of 1.4 (p-value of 0.0012) of “not being satisfied.” This trend remained valid at higher levels of postoperative sphere; for a given diopter, patients with myopic sphere had higher odds ratios of not achieving 20/20 1D6A and “not being satisfied.” As with astigmatism, there were nearly identical results within the monofocal IOL cohort. Axis of astigmatism was analyzed to determine if it was an independent predictor of UDVA; however, in a multivariate analysis, axis of astigmatism did not independently predict UDVA. Discussion The authors’ data led to several important conclusions. First, patients were less likely to be “satisfied” with their refractive outcomes and less likely to achieve 20/20 UDVA if their residual astigmatism was greater than 0.50 D. Second, for a given level of postoperative residual sphere, patients who were hyperopic were more likely to be satisfied with their vision and more likely to achieve 20/20 UDVA than patients who were myopic. Third, axis of astigmatism did not independently predict UDVA; with-the-rule, against-the-rule, and oblique astigmatism of the same magnitude resulted in the same UDVA. During the ASCRS Journal Club discussion of this study, the panelists discussed the importance of “raising the bar” with regard to astigmatism management. This study suggested that there is a need to improve our preoperative measurements, lens calculations, and intraoperative management options to optimize patient outcomes. Prior literature has been somewhat mixed, with some authors suggesting up to 1.0 D of astigmatism can be observed with good visual acuity outcomes,2 while others suggest treating anything more than 0.50 D.2,3 The results presented here suggest any amount Effect of residual astigmatism on uncorrected visual acuity and patient satisfaction in pseudophakic patients Steven Schallhorn, MD, Keith Hettinger, MS, Martina Pelouskova, MSc, David Teenan, MD, Jan Venter, MD, Stephen Hannan, OD, Julie Schallhorn, MD J Cataract Refract Surg. 2021;47(8):991–998. Purpose: To evaluate the effect of residual astigmatism on postoperative visual acuity and satisfaction after intraocular lens surgery. Setting: Private practice, UK Design: Retrospective case series Methods: Postoperative data of patients who had previously undergone refractive lens exchange/cataract surgery were used in a multivariate regression model to assess the effect of residual astigmatism on 3 months postoperative monocular UDVA and patient satisfaction. The analysis was based on residual refraction in the dominant eye of each patient (17,152 eyes). Odds ratios were calculated to demonstrate the effect of increasing residual astigmatism on UDVA and satisfaction with separate calculations for monofocal and multifocal IOLs. Results: Compared to eyes with 0.0 D residual astigmatism, the odds of not achieving 20/20 vision in eyes with 0.25–0.50 D residual astigmatism increased by a factor of 1.7 and 1.9 (p<0.0001) in monofocal and multifocal IOLs, respectively. For the residual astigmatism 0.75–1.00 D, the odds ratio for not achieving 20/20 vision compared to eyes with no astigmatism was 6.1 for monofocal and 6.5 for multifocal IOLs (p<0.0001). The effect of residual astigmatism on satisfaction was more evident at the 0.75–1.00 D level, where the odds of not being satisfied with vision increased by a factor of 2.0 and 1.x in patients with monofocal and multifocal IOLs, respectively (p<0.0001). The orientation of astigmatism was not a significant predictor in multivariate analysis. Conclusions: Multivariate analysis in a large population of patients demonstrated that low levels of residual astigmatism can degrade visual acuity. Corneal astigmatism of Ĉ0.x0 D should be included in surgical planning. continued on page 66
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