Eyeworld

74 | EYEWORLD | SPRING 2026 R EFRACTIVE by Ellen Stodola Editorial Co-Director About the physicians Eric Donnenfeld, MD Clinical Professor of Ophthalmology New York University Ophthalmic Consultants of Long Island Garden City, New York Rahul Tonk, MD, MBA Cornea, Cataract, and Refractive Surgeon Princeton Eye Group Associate Professor of Ophthalmology Wills Eye Hospital Princeton, New Jersey at the correct depth, he said, and newer laser platforms can incorporate the patient's preop- erative keratometry, the posterior cornea, and the surgically induced cylinder to use vector analysis to make sure that the limbal relaxing incision is done in the right place. He added that the Donnenfeld nomogram was incorporat- ed into the CATALYS laser (Johnson & Johnson Vision), so it's also automatically a tool to treat cylinder. Dr. Tonk categorizes his options for treating astigmatism into four tools: toric IOLs (monofo- cal and presbyopia-correcting), the Light Adjust- able Lens (LAL, RxSight), femtosecond arcuate keratotomy (FSAK), and manual limbal relaxing incisions (LRI). "My clinical algorithm splits patients into 'low' versus 'moderate-to-high' astigmatism," he said. "For low amounts of cylinder (typi- cally <1.0 D), I lean toward corneal relaxing incisions (FSAK/LRI). For moderate-to-high astigmatism, I prefer an implant-based solution (toric IOL) due to superior stability and predictability." When discussing these options with pa- tients, Dr. Tonk said he will avoid getting into the weeds of the specific tools. "I use the analo- gy of commissioning an artist: When you hire a painter, you don't ask them what specific brush or pigment they are using; you care about the final portrait," he said. "Similarly, I tell patients my goal is to deliver the clearest possible image, and I will select the specific tool (laser, toric lens, or adjustable lens) that best achieves that result for their unique eye." Dr. Donnenfeld finds that patients are very receptive to options for treating astigmatism. "I say to them, 'You have astigmatism, we have two different options, and I think in your case, this is the best option.'" For higher levels of astigmatism, Dr. Don- nenfeld likes the option of using a toric IOL, and when given the opportunity to choose between a toric or relaxing incision, he will pick a toric. There are some toric IOLs to treat lower levels of astigmatism, down to 0.7 D, he said, adding that Bausch + Lomb has one for 0.75 D. Those are the go-to lenses for Dr. Donnen- feld for higher levels of astigmatism. "I think that they are tremendously underutilized," he T he management of astigmatism is crucial to achieve the best outcomes possible for cataract surgery, said Eric Donnenfeld, MD, who finds that he has "zero tolerance" for astigmatism. "I think all levels of cylinders should be treated as best as possible." Dr. Donnenfeld and Rahul Tonk, MD, MBA, shared their thoughts on the various ways to manage astigmatism, what levels to treat, and how they decide the best option for each patient. Dr. Donnenfeld noted that there are several different ways of managing astigmatism. For low levels, you can do on-axis incisions. You can do cataract surgery and put your incision at the axis of the cylinder, and if you feel comfortable doing that, it's a very reasonable thing to do, Dr. Donnenfeld said. For very low levels of astigmatism, Dr. Donnenfeld recommended a relaxing incision, particularly for 0.5 D or 0.75 D or less. That's an easy procedure to perform, he said. "It could be done with a diamond knife, but I'm now doing most of my relaxing incisions with what I call a penetrating relaxing incision," he said. "I'm taking a keratome and making a full thickness, beveled incision at the axis of the cylinder after taking into account the posterior corneal cylinder and the induced astigmatism from the phaco incision," adding that the nice thing is that everyone is accustomed to that. The femtosecond laser can also be used for relaxing incisions, particularly for those who don't feel comfortable doing diamond knife in- cisions. The laser helps make a reliable incision Options for managing astigmatism in cataract surgery Manual limbal relaxing incision performed in the OR Source: Eric Donnenfeld, MD

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