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Posterior corneal astigmatism: a review article

This article was published in the following Dove Press journal:
Clinical Optometry

Seyed-Farzad Mohammadi 1 Abstract: Most human eyes show at least a small degree of corneal astigmatism and it can
Masoud Khorrami-Nejad 1,2 arise from both surfaces of the cornea. The shape of the anterior corneal surface provides no
Moein Hamidirad 2 definitive basis for knowing the toricity of the posterior surface. In the previous studies,
1
average astigmatism of the posterior corneal surface was −0.26 to −0.78 diopter. The radius
Translational Ophthalmology Research
Center, Farabi Eye Hospital, Tehran of the posterior corneal surface is less than the radius of the anterior corneal surface. Most
University of Medical Sciences, Tehran, studies have found a clear correlation between the anterior and posterior corneal asphericities
Iran; 2School of Rehabilitation, Shahid and the asphericity of the posterior surface is independent of the vertex radius of curvature,
Beheshti University of Medical Sciences,
Tehran, Iran refractive error and gender. In contrast to the anterior corneal surface, the asphericity of the
posterior corneal surface varies significantly between meridians. The anterior and posterior
corneal surface would have approximately parallel principal meridians and both of these
surfaces are often flatter in the horizontal meridian than the vertical one. This is especially
true in the higher degrees of corneal astigmatism, and then about 10% of any anterior corneal
astigmatism is neutralized by an astigmatism arising from the posterior corneal surface.
Although the second corneal surface only contributes to about 10% of the total refractive
power of the eye, a precise knowledge of its morphology is needed for the correct diagnosis and
monitoring the corneal diseases or the surgical interventions and in many eyes neglecting the
posterior corneal surface measurement may lead to significant deviations from the corneal
astigmatism estimation. In this article, we have reviewed the shape and the toricity of the
posterior corneal surface and also the effect of age on it. We investigated the contribution of
posterior corneal astigmatism to the total corneal astigmatism and evaluated the accuracy of
corneal astigmatism estimation by neglecting the posterior corneal surface measurement.
Keywords: cornea, posterior corneal astigmatism, corneal toricity

Introduction
Astigmatism is a prevalent optical disorder that affects different visual functions, for
instance, visual acuity and sensitivity to the intensity of darkness and brightness of the
contrast. It can cause some problems such as reduced vision, and causing some symp-
toms for the patients such as epiphora, unilateral diplopia, asthenopia and distortion.1–3
The treatment of astigmatism is more difficult than other types of refractive errors due to
making some distortions after correction.4 These problems are posing a challenge for the
patient and the physician.3,5 Some studies have shown that age, sex, environment and
genetic factors are important points that affect type and amount of astigmatism.3,6 Studies
estimated that the prevalence of astigmatism is 10–13 percent of the refractive errors.3,7
Correspondence: Masoud Khorrami- The optical surface of the cornea is the first and the most important optical surface
Nejad of the eye and its center thickness is about 550 μm, its vertical diameter is about 11.5
School of Rehabilitation, Shahid Beheshti
University of Medical Sciences, Damavand mm and its horizontal diameter is 12.5 mm.8 Due to the fact that there is a significant
Street, Tehran, Iran difference between the refractive index of the air and the anterior surface of the cornea,
Tel +98 217 754 2057
Email [email protected] in comparison to the other optical surfaces, the greatest proportion of the dioptric power

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of the eye has been allocated to it. Totally, the power of the irregularity and non-uniformity of the anterior and poster-
cornea is 43 diopter which is about 2/3 total dioptric power of ior corneal surface in which, we cannot create a clear
the eye. This power is lower in the peripheral part in compar- image on the retina just by simple cylinder correction in
ison with the center and it is optically an aspheric surface. one specific meridian.8,14
The posterior corneal radius is 6.5 mm on average that is On the other hand, we can classify astigmatism into: 1.
lower than the anterior corneal radius which is 7.8 mm.8,9 corneal, 2. lenticular and 3. total. Astigmatism may occur
Astigmatism occurs when our visual system does not because of the toricity of the cornea that is calculated through
have a good perception of a point from a point source due keratometry (corneal astigmatism) or it maybe due to the
to the fact that there are different powers in the different crystalline lens (lenticular astigmatism). The sum of both
meridians of the cornea. Total corneal astigmatism is made the corneal and lenticular astigmatism is known as the total
by both the anterior corneal surface and the posterior astigmatism, which is captured during retinoscopy.8
corneal surface. Due to the point that there is a significant Idiopathic astigmatism occurs because of the abnorm-
difference between the refractive indices of the anterior alities that exist through the optical system of the eye in
corneal surface and the air, anterior corneal astigmatism is which the most prevalent cause is the anterior and poster-
much greater than the posterior corneal astigmatism (there ior corneal surface.15 On average, there is 0.50 to 0.75
is a minute difference between the refractive index of the difference between the principal meridians of the cornea
posterior corneal surface and the aqueous humor; this on the anterior surface and the posterior corneal surface is
would impose some limits for the posterior corneal astig- vectorially added to those of the anterior surface to yield
matism). In essence, anterior corneal astigmatism plays the the total amount of corneal astigmatism.16,17 In the past,
more prominent role in comparison with the posterior keratometry was used and anterior corneal astigmatism
corneal astigmatism but we should not turn a blind eye was measured and the result was known as the total
to the effect of the posterior corneal astigmatism.10,11 amount of astigmatism. This was due to the fact that we
The criteria that were taken into consideration for this had limitations when we wanted to measure the exact
study were having at least one of the keywords and a good amount of lenticular astigmatism. Measuring the toricity
relation with this subject of the article (between 1980 and of the posterior corneal surface is clinically difficult and in
2019). PubMed’s articles were our first priority and in case normal population, it has a low share in the total astigma-
of repetition with the published article in scientific pub- tism so that it is generally neglected.18
lication, the priority was given to the article that had the When it is talked about the origin of an astigmatism,
higher impact factor. The exclusion criteria were repetition definitely the crystalline lens should not be forgotten. In the
and irrelevance. The purpose of this study is the review of crystalline lens, horizontal radius is steeper than the vertical
the posterior corneal astigmatism. one. Furthermore, cortical lamella is mostly not concentric
so it makes some different refractive indexes in the different
Different classifications of meridians of the crystalline lens.16,19 Astigmatisms that are
astigmatism iatrogenic or related to some illnesses usually have a greater
Astigmatism is classified in different ways and diagnosing dioptric power and are more irregular. Corneal scars, kera-
the type of astigmatism is the most important point that toconus, different operations and corneal transplants, crys-
should be taken into consideration before trying to correct talline lens dislocation and large incisions in the cataract
it.12 Totally, it is classified into two main groups that are surgery can all cause astigmatism.20,21
known as regular and irregular.13 In the regular astigma-
tism, there is 90-degree difference between the steepest Corneal astigmatism
and the flattest meridian and it is classified into different Cornea is a transparent avascular tissue that is responsible for
groups: simple myopic astigmatism, compound myopic the 2/3 dioptric refractive power of the normal human eye.
astigmatism, simple hyperopic astigmatism, compound Moreover, cornea is the main source of astigmatism in the
hyperopic astigmatism and finally mixed astigmatism in optical system.13,22 Total corneal stigmatism is due to the
which one meridian is focused in front of the retina and anterior and posterior surface and it occurs when the shape
the other behind the retina. In the irregular astigmatism, of the cornea is toroidal.23 Launching an investigation into the
the difference between the steepest and flattest meridian is optical calculation on the Gullstrand’s schematic eye is really
lower than 90 degrees and usually this is because of the helpful in the perception of the real origin of the astigmatism.24

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In this model, in order to make an astigmatism, we assume that should be taken into consideration is that, the principal
the radius of curvature in the horizontal meridian of the ante- meridians of the two corneal surfaces are not always
rior corneal surface is 7.70 mm and the radius of curvature in parallel and moreover, this counteraction of the anterior
the vertical meridian is 10 percent lower (6.93 mm), so the corneal astigmatism is not at all related to the refractive
radius of curvature in the vertical meridian of the anterior index of the RGP lens and any amount of astigmatism that
surface is steeper and thus creating more power in this mer- is related to the crystalline lens is remained uncorrected.
idian and finally it causes anterior corneal astigmatism that is According to this theory, every degree of corneal astigma-
with the rule and its amount is 5.42 diopter. According to the tism could be counteracted by fitting a spherical GP.
power of the principal meridian on the posterior surface, the However, when the corneal astigmatism is 2.50 diopter
amount of astigmatism is −0.65 diopter that is against the rule. or more, in order to have a proper and comfortable fit, a
If we neglect the corneal thickness and presume that the cornea back surface toric RGP is needed, because in fitting RGP
is a thin surface, then total corneal astigmatism is sum of the lens, the point is not just about counteracting an astigma-
two corneal surfaces so that the total astigmatism is 4.77 tism and in addition to a good vision, we should consider
diopter and with the rule. the ease of the patient and its physiological processes.35,36
According to the calculations that were pointed out, if we An amount of astigmatism that is counteracted by a RGP
presume that the radius of curvature in one of the principal lens, in addition to the power of the tear layer behind the
meridians of the two surfaces is equal to the average popula- lens, is dependent on the anterior corneal power. If we
tion and the other is 10% lower, then the total astigmatism is divide the refractive index of the tear layer by the refractive
lower than the anterior corneal astigmatism and approxi- index of the cornea (n.tear/n.cornea:1.336/1.376=0.89), we
mately 88% of the anterior corneal astigmatism is equal to can conclude that 89% of the anterior corneal astigmatism is
the total astigmatism so the posterior corneal astigmatism counteracted by the tear layer that is located behind the RGP
will nearly counteract 10–12 percent of the anterior corneal lens and 11% of the remained anterior corneal astigmatism
astigmatism.25–28 could be corrected by the posterior corneal surface.16,37–41
When a RGP lens with a posterior spherical surface is Many surveys have shown that corneal astigmatism is
worn in this eye, the anterior tear layer follows the poster- compensated by the optics of the eye. The results of these
ior spherical surface of the RGP lens and the posterior tear surveys match with the research conducted by Shankar and
layer would have the shape of the toroidal cornea and the Bibber about the relationship between the corneal and
torical shape of the anterior cornea causes the tear layer lie refractive astigmatism for 12 people. In this research, it
on the cornea in a torical shape, so if we want to presume was pointed out that the amounts of refractive and corneal
that the tear layer has a role in counteracting corneal astigmatism were higher in the astigmatic group and in the
astigmatism, definitely this is due to the posterior tear high corneal astigmatism there would be no compensation
interface. If you compare an against-the-rule cylinder that in the lens.42 Bernen and McKendrick by using vector
is made by the posterior tear surface (4.8484) with the rule analysis mentioned that there is a little relationship
cylinder that is made by the anterior corneal surface between the corneal and refractive astigmatism but Kelly
(5.4256), it will be shown that the tear layer cannot coun- and her colleagues emphasized on the relation between the
teract all astigmatism that is made by the anterior corneal corneal and refractive astigmatism. Moreover, in another
surface and 0.57 diopter of an uncorrected cylinder of the research carried out by Huynh and his colleagues they
anterior corneal surface still remains. This means that 89% pointed out that there is a relation between corneal, refrac-
of the anterior corneal astigmatism is counteracted due to tive and lenticular astigmatism and their compensation
using spherical RGP. Moreover, as it was pointed out, during emmetropization.43,44 Other studies have shown
posterior corneal astigmatism can counteract 10–12 per- that there is a linear relationship between the corneal and
cent of anterior corneal astigmatism.29–34 refractive astigmatism.39,45,48,47
So, nearly total amount with the rule astigmatism that The result of Liu and his colleague’s research specified
is made by the anterior surface will be corrected by an the fact that during aging, the corneal changes are reflected
against-the-rule astigmatism which is made by the poster- on the refractive astigmatism but lens' opacity has a little
ior tear layer surface and the posterior corneal surface; in effect on the total astigmatism.48 The reason for different
this way, corneal astigmatism is counteracted by using results in various studies was due to measuring astigmatism
spherical RGP contact lens. Another important point that with different instruments, way of choosing and patient

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referral, different ages of patients for examination, different same; so choosing and measuring the exact amount of
classifications of refractive errors, methodologies, types of astigmatism is still a challenge. In some studies, that was
studies and different analysis by researchers. In the past, done on accuracy of the auto keratometer; it was pointed
because of some limits on the technology that we had, it was out that it was roughly reliable in terms of determining the
not possible to directly measure the posterior cornel astig- axis but the total power of the cornea was a little bit lower
matism and usually corneal power and astigmatism were than the measured power by corneal topographers.50,53–59
measured only just by the data from the anterior corneal Different studies have shown the specific relation
surface and they presumed that the parameters of the poster- between the shape of the anterior and posterior corneal
ior corneal surface can be derived by a constant ratio. In surface in the normal human eye.58,61,62,63,59 In some other
some instruments such as handheld and auto keratometer instruments such as manual and auto keratometer and
and corneal topography that all just analyze the cornea corneal topography that all analyze the cornea based on
based on the placido disk, a constant and standard refractive the placido disk, a constant and standard refractive index
index (mostly n=1.337) is used in order to convert the (1.337 at most of the instruments) is used for converting
calculation of the anterior corneal surface to the total cor- the calculation of the anterior corneal surface into the total
neal power and the total corneal astigmatism.18 The kerato- power and the total corneal astigmatism; however, these
metric index was developed so that it could measure the days newer technology such as OCT and Scheimpflug
total corneal power without considering the data from the device can be used for measuring the parameters of the
posterior corneal surface and just by recording the findings posterior corneal surface directly. The toricity of the pos-
of the anterior corneal surface. If one wants to use kerato- terior cornea is calculated in different ways, such as
metric index, then with the rule astigmatism, the estimation Purkinje images, Scheimpflug photography and Slit scan
of total corneal astigmatism is higher and against the role images.8,14,17,35,37,60,61,66–72
astigmatism, it is lower.8,14,49 Pentacam Scheimpflug imaging system (Oculus) not only
captures an accurate image of the cornea but also interpret the
Measuring corneal astigmatism different parts of the anterior segment’s features.69,70 Dual
For many medical purposes and diagnosis in ophthalmol- Scheimpflug analyzer is another instrument for measuring
ogy, the cornea should be evaluated completely and accu- the parameters of the cornea. This device combines and unifies
rately. One of the quantitative parameters of the corneal the data from the Placido disk and Scheimpflug in a particular
evaluation is measuring its highest and lowest power. If way, in order to calculate the numerical values of the anterior
the cornea is normal, for many medical purposes, the corneal surface; however, for checking the information of the
anterior surface keratometry is sufficient. For evaluating posterior corneal surface, just Scheimpflug data are used. The
the power of the cornea, many different instruments such other important point that should be taken into consideration is
as different keratometers, topographers, and tomographers the fact that, for checking the exact asphericity of the posterior
have all been produced. Keratometers, which are known as corneal surface, in addition to the Purkinje images, the data
the first instruments for corneal evaluation are based on from the videokeratoscopy and the pachymetry (for measuring
some assumptions that one may find the correct measure- the corneal thickness) should be used.71,72
ments only in those patients who have normal cornea, so Something that is visible on the ruler of the hand-held
in other patients who have corneal diseases or refractive keratometer, in addition to the radius of curvature of the
surgery, their result could be incorrect. Keratoscope is also anterior corneal surface, is the total power of the cornea.
based on the same principles; they have errors and the Both the anterior and posterior surface have a prominent
physician might make mistakes in the diagnosis and the role in specifying the total corneal power. In order to
treatment of the disease. Nowadays, different instruments understand the fact how the keratometers are calibrated
are available for measuring astigmatism, for instance, for measuring the total corneal power without surveying
instruments for refraction, manual and auto keratometer the posterior corneal surface.35,73–75 Particularly, the cor-
and some new types of corneal topographies and different rectness of this claim that the parallelism of the principal
types of corneal surface imaging techniques such as meridians of the anterior and posterior surface in people
Scheimpflug images, Ray tracing and OCT (optical coher- who have high amount of astigmatism is almost definite
ence tomography). The amount of astigmatism that is and if the keratometer just wants to estimate the total
calculated with different instruments is not exactly the corneal power without evaluating the posterior corneal

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surface and just by the information of the anterior corneal curvature of the anterior surface is 7.79±0.27; hence, the
surface, the refractive index of the cornea should be chan- posterior corneal astigmatism is 0.3 and anterior surface is
ged; this means that instead of using 1.376, we can use 0.99 such that both of them were flatter on the horizontal
1.3375. By using the lower refractive index for the cornea meridian than vertical one. The results showed that it is
in the keratometer, an amount of the calculated power is better to use the refractive index of 1.329 instead of 1.3375
nearer to the total corneal power in comparison with the (that is used by default in many keratometers) which is
anterior surface.76,81,82,79 lower than the present amount.
If we want to accept this algorithm, we should presume The topographical system of the Orbscan (Bausch &
that there is a direct and linear relation between the cur- Lomb, USA) makes a good topographic image of both the
vature of the anterior and posterior corneal surface and the anterior and posterior surface; moreover, it can calculate the
radius of curvature of the anterior cornea to the radius of corneal thickness accurately. This device has made it pos-
curvature of the posterior cornea (AP ratio) has defined sible for us to increase the level of our knowledge about the
this point. In the schematic eyes, AP ratio is set between shape and the function of normal and diseased cornea.
1.2 and 1.32. AP ratio has been studied in the human eye Orbscan can measure many points (up to 9000 points) at
in different surveys. These studies have used some special both the anterior and posterior corneal surface in a short
techniques, for instance, Slit lamp photography, Purkinje period of time (1.5 sec). However, it is sometimes not very
images, Pachymetry, Photokeratoscopy, Corneal topogra- accurate to measure the parameters of the posterior corneal
phy, Scheimpflug photography and Slit scan topography. surface especially after refractive surgeries. Pentacam uses
The average of the AP ratio in the human eye is between dual Scheimpflug camera for capturing an image of the
1.177 and 1.235. This constant ratio between the radius of anterior part of the eye and it can also take some images,
curvature of the anterior and posterior corneal surfaces for instance, elevation maps of both corneal surfaces,
which has been obtained in different studies is used in pachymetry maps and biometric measurements of the ante-
determining the optimum refractive index of the rior parts of the eye; this device can collect data from 2500
keratometer.17,80,85,86,83 points in less than 2 seconds.88,93,90
One of the hypotheses of the keratometer is using the Here, we have 4 groups of corneal measurements:
refractive index of 1.3375 for the cornea that is based on
this fact that the ratio of the posterior corneal radius of 1. Corneal astigmatism that is calculated by the total
curvature to its anterior is 0.883, while the refractive index power. In this method for calculating corneal astig-
of the cornea is 1.376 which shows why the power of the matism, the data from the anterior and posterior
posterior surface is negative.84 This discrepancy in the surface.
normal eyes will make some minor faults that can be 2. Corneal astigmatism that is calculated by the Sim-
neglected, but for the eyes that have diseases or a history K: in this method, corneal astigmatism is calculated
of refractive surgeries, using this refractive index (1.3375) by the data from keratometry in 1–4 mm of the
will make some mistakes that will sometimes overcorrect central cornea and the total astigmatism which is
the result of the surgery; hence, in order to compensate this the difference between the steepest and the flattest
mistake, the anterior and posterior surface and their power meridian, measured by keratometry and in line with
should be evaluated separately and then the total power be the steep meridian. Obviously, in this method, all of
calculated; so in order to reach this goal, the topographic the collected data are based on the keratometric
technology that can evaluate the posterior corneal surface measurements of the anterior corneal surface and
such as dual Scheimpflug camera technology or Slitscan corneal astigmatism is calculated by defining a
could be used.85,90,87 However, in some researches, the refractive index for keratometer, based on the col-
refractive index that is presumed in the keratometer is lected data.
different in comparison with the number that is used 3. Anterior corneal astigmatism: In this method, ante-
these days; for example, in a survey that was done by rior corneal astigmatism is calculated by the data
Doobleman and his colleagues in 2006 about the features from the anterior corneal surface.
of the anterior and posterior corneal surface in 114 normal 4. Posterior corneal astigmatism: In this method, pos-
people, the average of the radius of curvature of the poster- terior corneal astigmatism is calculated by the data
ior surface is 6.53±0.25, the average of the radius of from the 1–4 mm central part of the posterior

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corneal surface. The refractive index of the cornea measured based on the information of the anterior corneal
is 1.376 and the refractive index of the aqueous surface alone. Vector analysis can be used in order to find
humor is 1.336. out the errors, resulted from the calculation of total astig-
matism just by using the anterior corneal power.8,61,92,94,95
Amount of posterior corneal
astigmatism The relation between the anterior
In the studies that have been done about this topic, it was and posterior corneal astigmatism
reported that an amount of this astigmatism is −0.26 to So far, several groups of researchers have been
−0.76 diopter.11,91,92 In an extensive research that was working on the relation between the two corneal
done by Douglas and his colleagues in 2003 on 715 surfaces.11,13,35,39,48,59,93,96–99,101–111 They have shown
people, ranging from 20 to 89 years old, an average that, when the steepest meridian of the anterior corneal
amount of astigmatism was 0.3 diopter; in this study, in surface is vertical or nearly vertical, there is a direct
order to measure an amount of astigmatism, both corneal correlation between an amount of corneal astigmatism
surfaces were considered. Optically, the power of an opti- on both the anterior and posterior surface, but when
cal surface has a linear relation with the refractive index of the steepest meridian of the anterior corneal surface is
its surrounding environment; and the greater the difference oblique, the intensity of this correlation is reduced so
between these two environments, the greater the power at that there would be no relationship between the cor-
the optical surface; hence, the little difference between the neal astigmatism of the anterior and posterior corneal
refractive indices of the aqueous and the cornea is the surface in the eyes that the steepest meridian of the
main reason that why an amount of posterior corneal anterior corneal surface is horizontal. However, clini-
astigmatism is insignificant. However, the toricity of the cally the changes of the posterior corneal astigmatism
posterior corneal surface is more than its anterior one. In play an important role at most of these groups. In the
addition to this, the posterior surface is steeper than the other study that was surveyed by Dubbelman and his
anterior one, despite the lower radius of curvature.20,93 colleagues in 2007 on the relationship between the two
corneal surfaces, it was understood that there was a
Evaluation of the posterior corneal strong relation between the shapes of the two corneal
astigmatism to the total astigmatism surfaces in normal population.15 Some studies have
It is obvious that the total corneal astigmatism is measured found a correlation between an asphericity of both
by the sum of anterior and posterior surfaces. On average, the anterior and posterior surface in the vertical mer-
an amount of astigmatism that is seen on the posterior sur- idian; in contrast, other studies found no correlation
face is lower than the anterior one; and its type of astigma- between the asphericity of the surfaces. What is clear
tism is usually the opposite of what is seen on the anterior right now is the point that we cannot evaluate aspheri-
surface, because most of the principal meridians are parallel city of the posterior corneal surface just by the shape
on the two corneal surfaces. The reason for this point that of the anterior surface.
types of corneal astigmatism are reversed on the two sur-
faces is due to the negative power of the posterior corneal Effect of increasing age on the anterior
surface, despite the parallel meridians. This topic is so and posterior corneal astigmatism
evident especially when a person has a higher amount of Increasing age mostly affects astigmatism of the anterior
astigmatism; therefore, an astigmatism of the posterior cor- corneal surface and posterior corneal surface is less affected
neal surface neutralizes part of an astigmatism of the ante- by the age. By increasing age, the steep meridian of the
rior corneal surface. As we know the posterior corneal anterior corneal surface tends to change its direction from
surface has a negative dioptric power, the steeper curve in vertical to horizontal, while these changes did not reported in
the vertical meridian will make an ATR astigmatism, so the steep meridian of the posterior corneal surface.8,14,17
mostly the calculated total corneal power (in which the Since the prevalence of with-the-rule astigmatism is higher
posterior corneal astigmatism is also calculated) will show in the youth and by increasing age it tends to change to
lower amount of with-the-rule astigmatism in comparison against-the-rule astigmatism, the posterior corneal astigma-
with the point that when the corneal astigmatism is tism acts relatively as a compensating factor for anterior

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corneal astigmatism in the young people (the steep meridian distortions at the time of surgery. These methods are very
is vertical). However, in the older population, the posterior useful in patients who have an astigmatism 2 or more
corneal astigmatism has a boosting effect and increases the diopters.126 In the latest methods of cataract surgery, despite
anterior corneal astigmatism (the steep meridian is horizon- the recent developments, lens extraction without any possible
tal). Actually, the posterior corneal astigmatism will com- harm and reducing the need for using spectacles after surgery
pensate the anterior corneal astigmatism in the younger is still challenging. In order to achieve this goal, it is very
population and increases the total astigmatism in the older important to consider all of the refractive errors especially
population.35,48,108,113,110 Finally, knowing about the changes astigmatism at the time of the surgery. Due to the fact that
of the corneal shape with increasing age is very important there are new technologies for this surgery and new formulas
because these changes can affect the stability of the corneal are used to measure intra ocular lens power, spherical errors
shape after refractive surgery.111,116,113 after surgery have greatly reduced. In spite of this, 20% of
these people who have cataract have a corneal astigmatism
The effect of posterior corneal that is more than 1.50 diopter before surgery.127,128 In the
astigmatism on eye surgeries people who have cataract surgery, failure to estimate an exact
Accurate screening before surgery is one of the key factors in amount of astigmatism by neglecting the posterior astigma-
the success of the refractive surgery that would reduce the tism can cause some errors in correcting an astigmatism and
unpleasant results and patient dissatisfactions.91–116 In the due to the point that most of the eyes have a posterior
past, the classical screening method was used for the patients astigmatism, which is ATR, if this negligence occurs in
who were candidate for refractive surgery; it included cor- toric intra ocular lens use, it overcorrects WTR astigmatism
neal topography based on placido disk (evaluation of the and undercorrects ATR astigmatism. Controlling this astig-
anterior corneal surface) and measuring the corneal matism is vital for the best outcome.
thickness.116,117 Due to the fact that corneal topography During recent years, correction of the astigmatism is one of
plays a prominent role and has been a great revolution in the main goals in the cataract surgery and this strong tendency
diagnosing and managing corneal diseases, it has a leading is increasing during phacoemulsification by having small inci-
role by surveying the results of the corneal refractive surgery sion and using foldable lenses in order to correct both spherical
and treating its complications after that.91,117,118 and cylindrical refractive errors.128 For correcting an astigma-
There are two important points that should be taken into tism in these cases, many different techniques are used; for
consideration about posterior corneal astigmatism; firstly, we instance, changing the size and the location of the incision,129
cannot definitely determine an amount of posterior astigma- using a loose incision in the cornea or limbus,130 using clear
tism based on the information of the anterior corneal surface corneal incisions anteriorly at steeper meridians,131 using toric
and secondly, posterior corneal astigmatism can affect the intra ocular lenses,132,133 and Excimer laser.134 The main
results of refractive surgeries for correcting astigmatism, if purpose of using these methods is correcting the astigmatism
they are only based on the information of the anterior corneal as much as possible, in order to make an appropriate and a
surface.91,119,120,123–127 For instance, failure in calculating an satisfactory uncorrected visual acuity (UCVA).
amount of posterior corneal astigmatism with a steep mer- The people who have cataract, after surgery, expect to
idian (that can cause against the rule astigmatism at the have a clear vision and reduce their dependency on spec-
posterior corneal surface) can cause more correction for the tacles. In the cataract surgery, because small incisions and
eyes that have with-the-rule astigmatism or less correction foldable lenses are used, most of the patients will be
for the eyes that have against-the-rule astigmatism. emmetropic.132–136 There are different methods for redu-
cing an astigmatism during the cataract surgery. Using an
incision in the steepest meridian is the first suggestion.126
Posterior corneal astigmatism and In the different studies, an amount of astigmatic correction
cataract surgery with this method is definite but it is usually lower than
Significant corneal astigmatism is observed in 14% of the 1.00 diopter, also having some incisions at some meridians
society. Using spectacles in high astigmatism has some lim- are technically hard or impossible.136 The other method is
itations because of inducing meridional magnification; there- astigmatic keratotomy that because of the incisions which
fore, these days, for those who have cataract surgeries, there are so close to the center of the cornea, the feeling of
is a tendency for correcting the astigmatism and reducing scattering, irregular astigmatism, diplopia, fluctuation in

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Mohammadi et al Dovepress

refractive errors and the need for pachymetry and diamond of its penetrating feature in comparison with the other non-
knife has some complications and limitations.137,138 penetrating methods and in case of having a leakage, a
Limbal relaxing incision (LRI)137 is another method for nylon suture can be used to close the wound.15,131,146–150
reducing an astigmatism during the cataract surgery that has
some advantages, for instance, simplicity of this method,
Disclosure
little discomfort for the patient, early stability due to the
The authors report no conflicts of interest in this work.
location of the incision at the limbus area and no change in
corneal spherical equivalent (SE) because of 1:1 coupling
effect (if two incisions are used); but it has some limitations References
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