Cataract Surgery and Astigmatism: Can Both Be Corrected at Once?

Astigmatism is a common condition that affects around 1 in 3 people, according to the American Association of Ophthalmologists. If you also have cataracts and are approaching the time when surgery is due, then we have great news for you:

Cataract surgery and astigmatism correction can be performed in the same short operation…

Indeed, having correction or a special astigmatism lens implant brings a life far less dependent on eyeglasses or contact lenses—or might even mean you won’t need any visual support whatsoever!

There are three ways that surgeons can approach astigmatism correction alongside cataract surgery, as leading cataract surgeon, Dr. Brent Bellotte explains. 

How Can Cataract Surgery Fix Astigmatism?

Astigmatism occurs when the cornea (the eye’s clear front surface) is irregularly shaped—more like a football than a basketball. This causes light to focus unevenly on the retina, which leads to blurred or distorted vision. It often gets worse with age.

The condition can be mild, moderate, or high and, depending on the category, your surgeon has different treatment options available. The severity is measured in diopters (D), with mild being up to 1.00D, moderate 1.00D-2.00D, and severe/high being anything over 2.00D.

The three options for astigmatism correction are:

1. Limbal relaxing incisions (LEI): for mild to moderate astigmatism
2. Laser-assisted astigmatic keratotomy (AK): for irregular or subtle astigmatism
3. Toric intraocular lenses (IOLs): the gold standard for those with moderate to high astigmatism

1. Limbal Relaxing Incisions

This involves making small, partial-thickness cuts in the peripheral cornea, where it meets the white of the eye. These allow the cornea to relax and become more spherical, reducing astigmatism.

How it works

• Incisions are placed at the steepest part of the cornea to flatten it and balance curvature.
• Depth, length, and location are calculated based on pre-op measurements.
• It’s performed manually with a diamond blade during traditional cataract surgery, either at the start or the end of the procedure.

This is a great option for those with low-to-moderate astigmatism who prefer not to use a premium lens.

Benefits and limitations

Having limbal relaxing incisions during cataract surgery is often covered under standard surgical fees, although it’s generally considered additional to any Medicare procedure, meaning you’ll need to pay the difference. However, it doesn’t require a premium lens or a laser-assisted cataract procedure, meaning that out-of-pocket expenses are less. 

It’s suitable for those with astigmatism of up to 1.50 – 2.00 diopters.

The healing response can vary, meaning that there’s potential for over or under-correction. However, it’s generally extremely successful at reducing astigmatism in the vast majority of cases—or even curing it completely for many. 

2. Laser-Assisted Astigmatic Keratotomy (AK)

This also involves making incisions in the peripheral cornea. However, in AK, these are done using a femtosecond laser, rather than manually, for maximum precision.

How it works

• The laser uses real-time imaging to plan and place incisions with micron-level precision
• Incisions are made at exact depth, length, and location—an accuracy that’s unachievable when performed manually
• It’s combined with the standard steps during cataract surgery (capsulotomy, lens fragmentation)

Benefits and limitations

AK is minimally invasive with rapid recovery. The highly accurate incisions offer superior results and are ideal for eyes with subtle, or irregular, astigmatism.

However, it’s a more premium service than LRI, meaning out-of-pocket expenses are higher than the manual procedure. 

Toric IOL Cataract Surgery

These are FDA-approved to correct astigmatism up to 4.00D but are generally used for those that are 1.00D and higher (so moderate to severe). They’re either monofocal or multifocal lenses that are specially designed to counteract the irregular curvature of the cornea. Unlike standard lenses, they have extra power in specific areas to balance out the uneven focus.

How it works

• The eye is mapped pre-surgery using advanced imaging that determines the exact axis and magnitude of astigmatism
• The lens is implanted and carefully rotated to align with the precise axis needed for correction
• Digital markers are used to ensure accurate alignment

Benefits and considerations

Toric lenses are highly predictable and offer long-lasting results—often bringing clear vision without the need for eyeglasses, especially if you choose multifocal or extended depth of focus (EDOF) ones. Toric lenses are more expensive than standard IOLs and, as a premium option, aren’t covered by Medicare (and many insurance policies), so incur an additional fee.

In some cases, a surgeon might also use AK in combination with implanting a toric lens, if required.

FEATURE                     TORIC IOL                                LRI                               AK

Best for                           Moderate to high                        Mild ≥1.5D                            Mild-moderate astigmatism

                                         astigmatism ≥1.0D                                                                     irregular corneas

Precision                         Very high                                      Moderate                              Very high

Glasses-free results      High likelihood                            May still need glasses          Improved independence

Cost                                  Premium (out-of-pocket)          Often included in                   Premium (laser fee)

                                                                                                surgery

Recovery                          Same as premium cataract      Similar                                        Similar

                                           surgery

FDA-approved                  Yes                                                Yes (as part of procedure)    Yes

Comparison table

Astigmatism Correction Choices: A Surgeon’s Perspective.

All of the above procedures provide improved or cured astigmatism after cataract surgery. The key to success is driven by careful pre-surgical considerations that match your needs to the choice of procedure, along with precision during the surgical process. 

From a surgical standpoint, managing astigmatism during cataract surgery isn’t simply about convenience—it’s about maximizing visual quality. Uncorrected astigmatism is a leading cause of blurred vision after cataract surgery. Even a small amount, say 1.0 diopter, can degrade image quality as much as a mild cataract. Correcting it during the cataract operation has so many advantages, including:

• Single recovery period: Treating astigmatism during surgery avoids the need for further procedures later on
• Enhanced predictability: Modern tools allow for real-time adjustments and alignment
• Integrated planning: Your IOL power and astigmatism correction are calculated together for optimal results
• Long-term stability: Corrections made during cataract surgery are permanent and stable

In short, correcting astigmatism during cataract surgery isn’t just possible—it’s highly recommended. While the exact option will depend on the level of the astigmatism and your personal choice, it’s a decision that is made in partnership with your cataract surgery.

Tired of astigmatism glasses? Ask Dr. Bellotte whether your cataract surgery can correct both at once.