Eye (2016) 30, 562–569

© 2016 Macmillan Publishers Limited All rights reserved 0950-222X/16

www.nature.com/eye

Relationship between O Collier Wakefield1, R Annoh2 and

CLINICAL STUDY

MA Nanavaty2
age, corneal
astigmatism, and
ocular dimensions
with reference to
astigmatism in eyes
undergoing routine
cataract surgery

Abstract
Purpose To assess the relationship inversely correlates to AL. With increasing
between age, corneal astigmatism, and ocular age, the magnitude of astigmatism increases
dimensions with reference to astigmatism and ATR astigmatism becomes increasingly
correction during cataract surgery. prevalent. The likelihood of a patient requiring
Methods In this cross-sectional study of astigmatic correction increases with age.
right eyes of 2247 consecutive patients Eye (2016) 30, 562–569; doi:10.1038/eye.2015.274;
1
Brighton and Sussex attending cataract surgery preassessment, published online 22 January 2016
Medical School, data on patient demographics, axial length
Brighton, UK (AL), anterior chamber depth (ACD), and
Introduction
keratometric astigmatism were collected.
2
Sussex Eye Hospital, Astigmatism was further analyzed as Cataract surgery aims to eliminate or reduce
Brighton and Sussex
against-the-rule (ATR: steepest meridian preexisting refractive error and is one of the
University Hospitals NHS
Trust, Brighton, UK 180 ± 30°), with-the-rule (WTR: 90 ± 30°), most commonly performed operations globally.
and oblique (OB: 30–60°or 120–150°). Patient demands and postoperative expectations
Correspondence: Results Mean age, AL, and ACD were are continuously increasing with advances
MA Nanavaty, Sussex Eye 72.28 ± 13.84 years, 23.99 ± 1.85 mm and in surgical technique and improvement in
Hospital, Brighton and 3.08 ± 0.52 mm, respectively. In all, 20.4% intraocular lens (IOL) design and calculations.
Sussex University Hospitals
eyes had ≤ 0.50 diopters (D), 55.2% had To achieve best postoperative visual outcomes,
NHS Trust, Eastern Road,
Brighton BN2 5BF UK 0.51–1.50 D, 7.9% had 2.01–3.00 D, and 3.7% spherical and astigmatic components of
Tel: +44 (0) 7947166134; eyes had 43.00 D of astigmatism. Overall, refractive error should be corrected during
Fax: +44 (0) 01273 664942. 44.2% of eyes had corneal astigmatism cataract surgery.1 The prevalence of corneal
E-mail: mayank.nanavaty@ 41.00 D. Average astigmatism in age astigmatism has been widely reported in
bsuh.nhs.uk
ranges 40–49, 50–59, 60–69, 70–79, 80–89, and several parts of the world.
90+ years were 0.82, 1.04, 1.04, 1.02, 1.15 It is useful to assess the relationship of corneal
Received: 24 June 2015
Accepted: 9 November and 2.01 D, respectively. The magnitude of astigmatism, age, and ocular dimensions to further
2015 preoperative astigmatism positively correlated understand and predict the necessity for offering
Published online: with age (Po0.0001), with increasing and astigmatism correction procedures such as
22 January 2016 decreasing prevalence of ATR and WTR peripheral corneal-relaxing incisions (PCRIs) and
astigmatism, respectively, with advancing age. toric IOLs in publicly funded National Health
A brief version of this paper
The magnitude of ATR astigmatism inversely Service (NHS) government hospitals, such as in
has been presented at the
Annual Meeting of the correlates to AL (Po0.0001). ATR astigmatism the United Kingdom, as these procedures have
British Society of Refractive is more prevalent with increasing magnitude to be cost-effective. PCRIs are proven to neutralize
Surgery, Birmingham, UK, of astigmatism (Po0.0001). more astigmatism compared with on-axis
March 2015, as well as at Conclusions A majority of patients for incisions (on steep axis),2,3 which are limited to
the Annual Meeting of
Students' Independent
cataract surgery have astigmatism between 0.51 approximately 1.0 dioptre (D).4 However, PCRIs
Research Project and 1.5 D. ATR astigmatism increases, whereas are shown to have regression when performed
Conference, Brighton, UK. WTR decreases with age. ATR astigmatism for ≥ 3.5 D of astigmatism.5 Toric IOLs are effective
 Astigmatism and ocular dimensions in eyes with cataract
O Collier Wakefield et al
563

for treating 41 D of corneal astigmatism at the time of Table 1 Patient demographics

cataract surgery.6 Characteristic Value
This study aims to identify any relationship between
preexisting corneal astigmatism with age, axial length Eyes (n) 2247
(AL), and anterior chamber depth (ACD) of the eyes Patients (n) 2247
undergoing preassessment for routine cataract surgery. Age (years)
Mean ± SD 72.28 ± 13.84
Range 10, 109
Patients and methods

This is a retrospective cross-sectional study of the right Corneal astigmatism (D)

Mean ± SD 1.11 ± 0.88
eyes of 2247 consecutive patients who attended the Range 0.02, 13.71
cataract surgery preassessment clinics between October
2012 and October 2014 at the Sussex Eye Hospital, K1 (D)
Brighton, UK. This study was approved by the Hospital's Mean ± SD 43.18 ± 1.64
Audit Committee and followed the tenets of the Range 32.19, 48.98
Declaration of Helsinki. K2 (D)
Inclusion criteria was eyes preassessed for cataract Mean ± SD 44.29 ± 1.70
surgery and optical biometry performed using the principle Range 36.97, 52.53
of partial coherence tomography (IOLMaster 500, Carl
Zeiss, Jena, Germany) with reliable scans. Reliable scans AL
Mean ± SD 23.99 ± 1.85
were defined as scans with SNR (signal-to-noise ratio) 43. Range 19.75, 33.72
Exclusion criteria included eyes where biometry was
not possible with IOLMaster, eyes that had A-scan ACD
ultrasonographs, eyes with preexisting corneal pathology, Mean ± SD 3.08 ± 0.52
any previous surgery, trauma, and left eyes. All eyes Range 1.99, 5.82
were examined before the cataract surgery procedure, Abbreviations: ACD, anterior chamber depth; AL, axial length; K1, flat
including an uncorrected and best-corrected vision, keratometry; K2, steep keratometry.

slitlamp examination, tonometry, and ophthalmoscopy

through dilated pupils. Data on patient age, AL, ACD, The relationship between age and the magnitude of total
and keratometric astigmatism were collected. Astigmatism corneal astigmatism is shown in Figures 1c and d.
was further analyzed as against-the-rule (ATR: steepest The magnitude of total corneal astigmatism was
meridian 180 ± 30°), with-the-rule (WTR: 90 ± 30°), and positively correlated with age (r = 0.149, Po0.0001).
oblique (OB: 30–60° or 120–150°). Further analysis indicates where the magnitude of
Patients were divided into seven distinct age groups corneal astigmatism was o1 D the prevalence decreased
(o40, 40–49, 50–59, 60–69, 70–79, 80–89, 490 years) with increasing age (Po0.00001) and where the magnitude
for further analysis, and all patients were analyzed of corneal astigmatism was 1–3 D the prevalence increased
irrespective and with respect to the axis of corneal with increasing age (P = 0.0009). Furthermore where the
astigmatism (WTR/OB/ATR). In addition, the magnitude magnitude of corneal stigmatism was 43 D the prevalence
of corneal astigmatism was divided into three distinct positively correlated with age (Po0.00001). This is
groups (o1, 1–3, and 43 D). Kolmogorov–Smirnov illustrated in Figure 2.
test was used to check the normality of the data. There was a statistically significant linear relationship
Pearson's coefficient was used for calculating correlation between the axis of astigmatism (WTR/OB/ATR) and
coefficients. All statistical analyses were two-sided and age (r = 0.301, Po0.00001); irrespective of the axis, there
P-values o0.01 were considered statistically significant. was a positive correlation between age and mean corneal
astigmatism in the WTR/ATR/OB groups as illustrated
in Figure 3a. Analysis of the WTR/ATR/OB prevalence
Results
by age showed that ATR astigmatism was increasingly
This study evaluated 2247 eyes from 2247 patients. prevalent with increasing age (r = 0.256, Po0.00001),
Patient demographics are shown in Table 1. Figure 1a whereas WTR astigmatism was less prevalent with
shows the distribution of corneal astigmatism in the entire increasing age (r = − 0.294, Po0.0001). However OB
sample in 0.25-D steps. Figure 1b shows the distribution astigmatism did not clearly correlate to age (P = 0.0415)
of number of eyes with reference to age. In all, 22.4% as illustrated in Figure 3b.
eyes had ≤ 0.50 D, 55.2% had 0.51–1.50 D, 7.9% had Prevalence of WTR/ATR/OB astigmatism in different
2.01–3.00 D, and 3.7% eyes had 43.00 D of astigmatism. magnitudes of astigmatism is shown in Figure 3c. This

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 Astigmatism and ocular dimensions in eyes with cataract
O Collier Wakefield et al
564

Figure 1 (a) Corneal astigmatism distribution in 0.25-D steps for the entire sample (2247 eyes). (b) Distribution of entire sample for each
age subgroup. (c) Frequency distribution of corneal astigmatism in 0.50-D steps for the seven age groups. (d) Correlation between
magnitude of total corneal astigmatism and age.

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 Astigmatism and ocular dimensions in eyes with cataract
O Collier Wakefield et al
565

concordant with these findings (Table 2a). As such, the

likelihood of a patient requiring astigmatic correction
at the time of cataracts surgery increases with age.
In this cohort, the prevalence of corneal astigmatism
o1 D decreased with increasing age (Po0.00001),
whereas reciprocally the prevalence of corneal
astigmatism between 1–3 D (P = 0.0009) and 43 D
(Po0.00001) increased with increasing age. This further
supports the positive correlation between the magnitude
of corneal astigmatism and age.
Our data show that an ATR corneal astigmatism is
increasingly prevalent with increasing age (r = 0.256,
Po0.00001), whereas WTR astigmatism is less prevalent
Figure 2 Prevalence of the amount of astigmatism by age. (r = − 0.294, Po0.0001). The shift from WTR to ATR
astigmatism with increasing age is well documented
demonstrates that ATR astigmatism is increasingly in other studies,1,9,13,14–16 although Hashemi et al17
prevalent with increasing magnitude of astigmatism identified no statistically significant correlation between the
(r = 0.166, Po0.00001), whereas OB astigmatism is less prevalence of WTR astigmatism and age. The reasons for
prevalent with increasing magnitude of astigmatism the age-dependent change in axis remain unclear, but they
(r = − 0.166, Po0.00001). The prevalence of WTR are hypothesized to be due to changes to upper eyelid
astigmatism did not correlate to the magnitude of tension,18,19 intraocular pressures,20 and possibly changes
astigmatism (r = 0.0384, P = 0.124). to corneal structure.13 The correlation between the axis of
Figure 3d shows the correlation between ACD and astigmatism and age is significant because residual
the magnitude of astigmatism. ACD did not correlate postsurgical WTR astigmatism has been shown to result in
to the magnitude of corneal astigmatism irrespective better distance Snellen visual acuity than OB astigmatism,4
or with respect to the axis of astigmatism. Analysis whereas residual ATR results in better unaided distance
of the correlation between AL and the magnitude of and near vision in some pseudophakics.21 This therefore
astigmatism is illustrated in Figure 3e. A WTR/OB poses the question as to whether corneal stigmatism should
magnitude of astigmatism did not significantly correlate be treated more aggressively in younger patients where
to AL (P = 0.775/0.0296, respectively); however, the WTR astigmatism is most prevalent. However, with the
magnitude of ATR astigmatism does significantly increasing popularity of toric presbyopic (multifocal and
correlate to AL (r = − 0.250, Po0.00001). depth-of-focus) IOLs this becomes less significant for
patients who can afford to pay for premium IOLs with
Discussion guaranteed multifocality and depth of focus.
To our knowledge, the relationship between the
A large proportion of patients with preexisting cataracts magnitude of preoperative corneal astigmatism and the
have some degree of corneal astigmatism. Correcting type of astigmatism (WTR/ATR/OB) has not yet been
astigmatism improves quality of life, provides spectacle reported. The degree of preoperative corneal astigmatism
independence, and improvement in visual outcomes.7 should be investigated at the time of cataract surgery. Data
In recent years, toric IOLs are increasingly used as first- from this cohort demonstrated that ATR astigmatism is
line measures for correcting corneal astigmatism of increasingly prevalent with increasing magnitude of
41.5 D at the time of phacoemulsification.6,8 In this astigmatism (Figure 3c). A large proportion of patients with
study, 44.2% of eyes had corneal astigmatism 41 D, ATR astigmatism may therefore benefit from toric IOLs at
which is higher than Chen et al9 (41.3%), Ferrer-Blasco the time of cataract surgery to improve visual outcomes.
et al10 (34.8%), Hoffman et al11 (36.0%), and Khan et al12 While ATR and OB astigmatism may increase with age, our
(40.41%). The higher figure in this study is likely to be findings show that OB astigmatism decreases relative to the
concurrent to higher mean age of 72.28 years. Similarly, magnitude of astigmatism (Figure 3c). A summary of key
the mean corneal astigmatism of 1.08 D was higher than findings from other papers relating to the population
the aforementioned studies as shown in Figure 2. Patients demographics, magnitude, and axis of corneal astigmatism
with 41 D of astigmatism should be considered for can be seen in Tables 2a and b.
surgical correction of astigmatism at the time of surgery Finally, we also assessed the relationship between ocular
for improvement of visual outcomes postoperatively. dimensions and corneal astigmatism. AL is arguably one of
It is already known that the prevalence of corneal the most important factors in preoperative assessment for
astigmatism increases relative to age, and our study is IOL calculations, to ensure correct use of lenses and to

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 Astigmatism and ocular dimensions in eyes with cataract
O Collier Wakefield et al
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Figure 3 (a) Correlation between mean corneal astigmatism in the WTR/ATR/OB groups and age. (b) The prevalence of WTR/ATR/
OB astigmatism by age. (c) The prevalence of WTR/ATR/OB by different magnitudes of astigmatism. (d) Correlation between
magnitude of preoperative astigmatism and ACD with reference to WTR/OB/ATR. (e) Correlation between magnitude of preoperative
astigmatism and AL with reference to WTR/OB/ATR.

reduce postoperative astigmatism. Analysis of this cohort should be assessed collectively preoperatively to decide
showed that the magnitude of ATR astigmatism negatively the best method to correct astigmatism during cataract
correlated to AL (Figure 3e), meaning that smaller eyes surgery with improved visual outcomes.
have a larger degree of ATR astigmatism in patients As the likelihood of a patient requiring astigmatic
undergoing cataract surgery. Conversely, ACD showed no correction at the time of cataract surgery increases with
significant correlation with corneal astigmatism (Figure 3d). age, it is useful to factor the cost of astigmatic corrective
AL is commonly regarded as the most significant determinant procedures when estimating expenses for cataract surgery
of refractive error.22 The key findings of other papers relating in an ageing population. This is particularly relevant in
to AL and ACD can be seen in Table 2c; however, to our countries where majority of cataract surgery is performed
knowledge no paper has reported a significant correlation in the publicly funded government hospitals such as in the
between AL and the magnitude of preoperative corneal United Kingdom with National Health Service (NHS),
astigmatism. In light of this, AL and corneal astigmatism compared with other countries. Furthermore, treatment

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 Astigmatism and ocular dimensions in eyes with cataract
O Collier Wakefield et al
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Table 2a Comparison of patient demographics

Study for comparison (first author)

Parameter
This study Ferrer-Blasco10 Chen9 Guan1

Eyes (n) 2247 4540 4831 1430

Patients (n) 2247 2415 2849 827

Age (years)
Mean ± SD 72.28 ± 13.84 60.59 ± 9.87 70.56 ± 9.55 72.27 ± 11.59
Range 10, 109 32, 87 40, 95 16, 98

Astigmatism (D)
Mean ± SD 1.11 ± 0.88 0.90 ± 0.93 1.01 ± 0.69 1.07 ± 0.73
Range 0.02, 13.71 0.25, 6.75 0.05, 6.59 0.06, 5.52

K1 (D)
Mean ± SD 43.18 ± 1.64 43.48 ± 1.61 43.76 ± 1.53 43.57 ± 1.56
Range 32.19, 48.98 — — 38.09, 51.76

K2 (D)
Mean ± SD 44.29 ± 1.70 44.08 ± 1.59 44.76 ± 1.56 44.64 ± 1.65
Range 36.97, 52.53 — — 39.61, 52.98
Abbreviations: K1, flat keratometry, K2, steep keratometry.

Table 2b Summary of clinical studies relating to the magnitude and axis of astigmatism

Study (first author) Country Number (n) Age, in years Findings

Eyes/patients

Hashemi17 Iran a
/5020 40–65 Prevalence of ATR/OB astigmatism increased with age.
Higher education inversely correlated to magnitude of
astigmatism (P ≤ 0.001).
Astigmatism was higher in men.
Guan1 China 1430/827 ≥ 16 45.45% of eyes had 41.00 D of astigmatism.
The magnitude of corneal astigmatism was positively correlated
with age.
Corneal astigmatism shifts with age from WTR to ATR.
Chen9 China 4831/2849 40–95 41.3% of eyes had 41.00 D of astigmatism.
Corneal astigmatism shifts with age from WTR to ATR.
Ferrer-Blasco10 Spain 4540/2415 32–87 34.8% of eyes had 41.00 D of astigmatism.
Corneal astigmatism o1.25 D was present in most cataract surgery
candidates (78%).
13% of cataract surgery candidates do not have corneal astigmatism.
Khan12 UK 1230/746 ≥ 30 40.41% of eyes had 41.00 D of astigmatism.
Nemeth24 Hungary 1092/a ≥ 15 32.78% of eyes had 41.00 D of astigmatism.
ATR astigmatism prevalence positively correlated to age.
Hoffmann11 Germany 23 239/15 448 a
8% of eyes had corneal astigmatism 42.00 D, and 2.6% had 43.00 D.
This study UK 2247/2247 10–109 44.2% of eyes had 41.00 D of astigmatism.
ATR astigmatism is more prevalent with increasing magnitude of
astigmatism, whereas OB astigmatism is less prevalent.
a
Not mentioned.

should arguably be more aggressive during cataract on prevalence of corneal astigmatism in our population is
surgery, because astigmatism will develop with age and very useful for further design of local protocol and analysis
increasing astigmatism is implicated with higher costs.23 of potential costs for the local NHS trust and NHS England.
As 44.2% of this cohort have 41 D of astigmatism and toric With reference to potential costs, an American study23
IOLs are affective for treating 41 D of astigmatism at concluded toric IOLs (where astigmatism 41.5 D) reduce
the time of surgery, this data is also useful to assess the lifetime economic costs by reducing the need for glasses
necessity for use of toric IOLs in this population.6 The data or contact lenses, following cataract removal.

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 Astigmatism and ocular dimensions in eyes with cataract
O Collier Wakefield et al
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Table 2c Summary of clinical studies relating to AL/ACD

Study (first author) Country Number (n) Age (in years) Findings

Eyes/patients

Nemeth24 Hungary 1092/a ≥ 15 Age correlates to both ACD and AL.

Hoffmann11 Germany 23239/15448 a
AL, corneal radius, ACD, and WTW length were correlated with one other.
Leighton25 UK b
/72 — AL decreases with increasing age.
Olsen26 Iceland 723/723 ≥ 55 AL significantly correlated with corneal power (r = − 0.44, Po0.0001).
AL significantly correlated with lens power (r = −0.44, Po0.0001).
Grosvenor18 USA 271/271 19–61 AL/ACD decrease with increasing age, concurrently with an increase
refractive power of both the cornea and the lens.
This study UK 2247/2247 10–109 The magnitude of ATR astigmatism inversely correlates to AL (Po0.0001).
a b
Age in years; Not mentioned.

The limitation of this study is that it is a retrospective Conflict of interest

cross-sectional study. Patient selection may account for The authors declare no conflict of interest.
some of the disparities between different international
studies. Patient age ranged from 10 to 109 years in our
study, compared with Chen et al9 (40–95), Ferrer-Blasco Author contributions
et al10 (32–87), Guan et al1 (16–98), Khan et al12 (30–104),
OCW: Data collection, analysis, manuscript drafting,
Hashemi et al17 (40–65), and Nemeth et al24 (≥15).
statistical analysis and interpretation. RA: Data collection,
Nonetheless, our data has a very wide range capturing a
analysis, manuscript drafting. MAN: Concept and design,
real picture of astigmatism in the cataract surgery
analysis, manuscript editing, drafting, and critical review.
population.
In summary, our study supports an increasing trend
from WTR to ATR preoperative corneal astigmatism with References
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