Table of Contents  
Year : 2021  |  Volume : 29  |  Issue : 1  |  Page : 13-16

Surgically Induced Astigmatism After Phacoemulsification with Clear Corneal 2.75 mm Incision Using Superior Approach

1 Departement of Ophthalmology, School of Medicine and Health Sciences, Atma Jaya Catholic University of Indonesia, Indonesia
2 Department of Ophthalmology, Faculty of Medicine Udayana University/Sanglah General Hospital, Bali, Indonesia
3 Department of Health Science, The University of Canterbury, Christchurch, New Zealand

Date of Submission10-Sep-2020
Date of Decision03-Mar-2021
Date of Acceptance14-Apr-2021
Date of Web Publication16-Jul-2021

Correspondence Address:
Angela S.D Amita
Jl. Pluit Raya 2, Department of Ophthalmology, School of Medicine and Health Sciences, Atma Jaya Catholic University of Indonesia
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/njo.njo_35_20

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Context: Optimal postoperative vision can be achieved through a low surgically induced astigmatism (SIA), which is closely related to the site of incisions. Studies showed that temporal incision gives low SIA. However, a temporal incision is not convenient for some surgeons and in a small operating room with a limited number of assistants. These limitations can be overcome by using a superior approach. Aims: The aim of the study was to evaluate SIA after phacoemulsification with clear corneal incision using superior approach in different kinds of astigmatism as an alternative site of incision. Settings and Design: Medical records of patients who underwent cataract surgery were collected retrospectively between April and August 2017. Appropriate statistical analyses using Kruskal–Wallis, analysis of variance (ANOVA), Games-Howell test were done to assess the effect of superior approach on corneal curvature and whether it varies between different kinds of astigmatism. Results: Kruskal-Wallis test shows that there was no significant postoperative power change across different astigmatism groups (χ2 (2) = 0.805, P = 0.669). ANOVA and Games-Howell test show that oblique astigmatism had higher changes to its curvature compared with against the rule or with the rule astigmatism. Conclusions: The average SIA from the study was 0.34 diopter. Our study concludes that there is no statistically significant difference to SIA between three groups of astigmatism when they were operated using superior approach.

Keywords: Cataract, phacoemulsification, superior approach, surgically induced astigmatism

How to cite this article:
Amita AS, Djunaedi LA, Doniho A, Halim AA. Surgically Induced Astigmatism After Phacoemulsification with Clear Corneal 2.75 mm Incision Using Superior Approach. Niger J Ophthalmol 2021;29:13-6

How to cite this URL:
Amita AS, Djunaedi LA, Doniho A, Halim AA. Surgically Induced Astigmatism After Phacoemulsification with Clear Corneal 2.75 mm Incision Using Superior Approach. Niger J Ophthalmol [serial online] 2021 [cited 2023 Jun 5];29:13-6. Available from:

Key Messages: Clear corneal incision using superior approach in phacoemulsification cataract surgery gives a low SIA in any type of astigmatism. This site of incision can be a preferred choice in a small operation room with a limited number of assistants. Besides, superior site may overcome limitations in some surgeons.

  Introduction Top

An excellent evaluation of corneal curvature is needed for the best result of uncorrected visual acuity after cataract surgery.[1],[2] Phacoemulsification technique can be used to minimize surgically induced astigmatism (SIA), which will produce optimal postoperative vision.[3],[4] In addition, clear corneal incision (CCI) technique can further minimize SIA that was induced by surgical sutures.[5] A previous study showed that temporal site gave a better result in minimizing SIA.[6] However, performing temporal CCI might be not suitable in all cases. In this study, we want to find out how high is the SIA after phacoemulsification cataract surgery when using a superior approach.

  Subjects and Methods Top

Medical records of patients who underwent phacoemulsification cataract surgery with three-plane incision and superior approach between April 2017 and August 2017 at a teaching hospital were collected. The keratometry information contains dioptric power and axis of astigmatism before and from 21 to 35 days after the surgery. The same instrument was used to do the keratometry during this data collection period.

A single operator was performing all the phacoemulsification cataract surgeries with a 2.75 mm superior CCI. The patients were assigned to each of the preoperative groups of astigmatism, which are against the rule, oblique, and with the rule. This grouping of astigmatism is divided in accordance with cornea’s steepest curve. Against the rule astigmatism is eye with steepest curve lies near 180-degree meridian (150–180 and 0–30), with the rule astigmatism steepest curve located near the 90-degree meridian (60–120), and oblique astigmatism steepest curve lies between 120–150 degree and 30–60 degree. Only patients with in the bag intraocular lens (IOL) implantation using a square edge, aspheric, and foldable IOL was included. In addition, all patients in this study need to use their eye patch for 12 hours. Those with previous history of eye surgery and eye diseases were excluded.

Sample size for one-way analysis of variance (ANOVA) with P value of 0.05, 80% power, and effect size of 0.6 is 42. Statistical analysis was done using R 3.5.3 and R Studio.[7],[8] Descriptive statistics were done for the patient characteristics and their keratometry results. Change in dioptric power was assessed using Kruskal-Wallis test. Changes in axis groups of astigmatism were assessed using ANOVA and Games-Howell post hoc tests.

  Results Top

Demographic and keratometric data in our retrospective study, which are taken from 51 patients, can be seen in [Table 1].
Table 1 Demographic and keratometric data

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Kruskal-Wallis test shows that there was no significant power difference between these three groups of astigmatism (χ2 (2) = 0.805, P = 0.669). “With-the-rule” astigmatism patients tend to have lower variability of power change compared with “Against-the-rule” and “Oblique” astigmatism patients [Figure 1].
Figure 1 Postoperative Power Mean Changes after Phacoemulsification using Superior Approach

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ANOVA test shows differences in corneal curvature between three astigmatism groups [Table 2]. Games-Howell test shows that changes in corneal curvature of postoperative astigmatism in oblique astigmatism patients were greater when compared with against the rule astigmatism patients (20.8 ± 4.2 degrees, P = 0.002) and with the rule astigmatism (25.5 ± 5, P = 0.018). However, test shows no significant difference between against the rule astigmatism and with the rule astigmatism (4.68 ± 3.1, P = 0.548).
Table 2 Differences in corneal curvature

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  Discussion Top

Getting accurate postoperative refraction will determine the success of cataract surgery.[9] One of the main factors that determine good postoperative refraction is SIA.[10] SIA is influenced by many factors, such as the type of cataract surgery, incision type, incision site, and suturing techniques.[11]

Nowadays, the two most common types of cataract surgeries are phacoemulsification and MSICS (manual small incision cataract surgery). In general, phacoemulsification surgery produces lower SIA when compared to MSICS.[4] One study suggests that MSICS induces SIA about 0.3 to 0.5 diopter (D) greater than phacoemulsification.[12] In this study, all of our patients underwent a phacoemulsification cataract surgery.

Another factor that affects SIA is the incision technique. The three-plane incision technique is considered to be quite difficult.[13] A study using optical coherence tomography showed that only 32% of patients had the expected three-plane structure, which might induce greater SIA, as the operator intended.[5] Nevertheless, when done right, this incision technique can efficiently reduce the chance of endophthalmitis owing to preventing particles from entering anterior chamber when there is a change in intraocular pressure.[14] We did three-plane incision to all of our patients.

In addition to incision techniques, Gokhale has found that temporal or superotemporal approaches would result in lower SIA when compared to superior approaches. The use of a superior approach results in a larger SIA due to gravitational force and the blinking of the eye at the incision point.[6] However, temporal approach might not be possible due to operator height related to the bed height, operator foot position, or in small operating room with limited personnel. Our study tried to overcome the gravitational force with longer eye patching time and it showed that superior incision approach that we used produces an average SIA of 0.34D, which is below the recommended keratometric shift limit (0.50D).[11]

Different locations of incision in different types of astigmatism will also affect SIA.[14] Superior incision will result in an astigmatism shift toward against the rule (ATR), while the temporal incision will cause an astigmatism shift toward with the rule (WTR).[15],[16],[17] Thus, other researchers said that superior incisions should be performed on astigmatism WTR, whereas temporal incisions should be carried out on ATR astigmatism.[18] This is because incision can decrease corneal curvature.[19] The incision is made on the site with more convex curvature, intended to balance the corneal curvature meridian and in turn reduce the SIA.[20] Our study did not show significant differences in SIA in ATR/WTR/oblique astigmatism group with the use of modified superior incisions. This might be due to the mean astigmatism of this study subjects (–0.97D), which is much smaller than the average astigmatism of the research by Masnec-Paskvalin et al. (2.00D). In addition, a smaller number of samples and smaller SIA of the operator also may affect results.

Another factor that can reduce SIA is doing incisions without suturing. The suturing process can change structures of the wound which may induce SIA. In addition, a procedure to remove the sutures itself require additional control time, giving the patient a feeling of discomfort and increasing the risk of infection.[5] Vasavada et al.[21] stated that any maneuvers carried out after operation will affect the amount of distortion in the incision site that in turn affects the integrity of the wound, leaving gaps for infection.

Some of the most recent techniques related to SIA include limbal relaxing incision that uses the principle of leveling the corneal curvature after incision. This technique resulted in an average decrease in astigmatism of 1.178D.[22] Another technique was used by Hassann et al. which obtained 1.71D in mean reduction of astigmatism after toric IOL insertion.[23] In addition, SIA can be minimized by using wound closure products such as cyanoacrylate, fibrin, or polyethylene glycol. Impermeable incisions can reduce the risk of IOL decentration and accelerate wound healing.[5]

There are various new methods to get a better uncorrected visual acuity after cataract surgery, but with limited resources we need to pick an effective and efficient method in accordance with the situation and condition we met.

  Conclusion Top

The average SIA we have from phacoemulsification surgery with superior approach is 0.34D. This research also shows no significant difference in SIA in all groups of astigmatism.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Jauhari N, Chopra D, Chaurasia RK, Agarwal A. Comparison of surgically induced astigmatism in various incisions in manual small incision cataract surgery. Int J Ophthalmol 2014;7:1001-4.  Back to cited text no. 1
Cho YK, Kim MS. Perioperative modulating factors on astigmatism in sutured cataract surgery. Korean J Ophthalmol KJO 2009;23:240-8.  Back to cited text no. 2
Ernest P, Hill W, Potvin R. Minimizing surgically induced astigmatism at the time of cataract surgery using a square posterior limbal incision. J Ophthalmol 2011;2011:243170-4.  Back to cited text no. 3
Mahatme V, Rahman L, Pande C, Wairagade N, Singare R, M. D. P et al. Surgically induced astigmatism after implantation of foldable and non-foldable lenses in cataract surgery by phacoemulsification. J Evol Med Dent Sci 2015;4:1474-9.  Back to cited text no. 4
Potvin R, Makari S. Cataract surgery and methods of wound closure: a review. Clin Ophthalmol 2015;9:921-8.  Back to cited text no. 5
Gokhale N, Sawhney S. Reduction in astigmatism in manual small incision cataract surgery through change of incision site. Indian J Ophthalmol 2005;53:201-3.  Back to cited text no. 6
[PUBMED]  [Full text]  
R Core Team. R: A Language and Environment for Statistical Computing. Vienna, Austria: R Foundation for Statistical Computing; 2012.  Back to cited text no. 7
RStudio Team. RStudio: Integrated Development for R. Boston, MA: RStudio, Inc.; 2015.  Back to cited text no. 8
Reitblat O, Assia EI, Kleinmann G, Levy A, Barrett GD, Abulafia A. Accuracy of predicted refraction with multifocal intraocular lenses using two biometry measurement devices and multiple intraocular lens power calculation formulas. Clin Exp Ophthalmol 2014;43:328-34.  Back to cited text no. 9
Soekardi I HJ. Transisi menuju Fakoemulsifikasi. Jakarta: K: Kelompok Yayasan Obor Indonesia; 2004;2004:7.  Back to cited text no. 10
Jaggernath J, Gogate P, Moodley V, Naidoo KS. Comparison of cataract surgery techniques: safety, efficacy, and cost-effectiveness. Eur J Ophthalmol 2013;24:520-6.  Back to cited text no. 11
Mastropasqua L, Toto L, Mastropasqua A et al. Femtosecond laser versus manual clear corneal incision in cataract surgery. J Refract Surg 2014;30:27-33.  Back to cited text no. 12
May WN, Castro-Combs J, Kashiwabuchi RT, Tattiyakul W, Hirai F, Behrens A. Sutured clear corneal incision: wound apposition and permeability to bacterial-sized particles. Cornea 2013;32:319-25.  Back to cited text no. 13
Reddy Pujala S, Paspula R, Atti S. Effect of surgical incision site on astigmatism in cataract patients. IOSR J Dent Med Sci 2016;15:2279-861.  Back to cited text no. 14
Rajesh P, Safarulla MA, Mustafa Saad AK. Comparison of changes in astigmatism after cataract surgery in temporal versus superior incisions. 2016;64-9.  Back to cited text no. 15
Reddy B, Raj A, Singh VP. Site of incision and corneal astigmatism in conventional SICS versus phacoemulsification. Ann Ophthalmol 2007;39:209-16.  Back to cited text no. 16
Tejedor J, Pérez-Rodríguez JA. Astigmatic change induced by 2.8-mm corneal incisions for cataract surgery. Investig Ophthalmol Vis Sci 2009;50:989-94.  Back to cited text no. 17
Reading VM. Astigmatism following cataract surgery. Br J Ophthalmol 1984;68:97-104.  Back to cited text no. 18
Masnec-Paskvalin S, Cima I, Iveković R, Matejcić A, Novak-Laus K, Mandić Z. Comparison of preoperative and postoperative astigmatism after superotemporal or superonasal clear corneal incision in phacoemulsification. Coll Antropol 2007;31:199-202.  Back to cited text no. 19
Vasavada V, Vasavada AR, Vasavada VA, Srivastava S, Gajjar DU, Mehta S. Incision integrity and postoperative outcomes after microcoaxial phacoemulsification performed using 2 incision-dependent systems. J Cataract Refract Surg. 2013;39:563-71.  Back to cited text no. 20
Hosny M. Limbal Relaxing incisions versus penetrating limbal relaxing incisions for the management of astigmatism in cataract surgery. Adv Ophthalmol Vis Syst 2015;2.  Back to cited text no. 21
Leon P, Pastore MR, Zanei A et al. Correction of low corneal astigmatism in cataract surgery. Int J Ophthalmol 2015;8:719-24.  Back to cited text no. 22
Razmjoo H, Ghoreishi M, Milasi AM, Peyman A, Jafarzadeh Z, Mohammadinia M et al. Toric intraocular lens for astigmatism correction in cataract patients. Adv Biomed Res 2017;6:123.  Back to cited text no. 23


  [Figure 1]

  [Table 1], [Table 2]


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