APPROACH TO A PATIENT WITH

ASTIGMATISM

PRESENTER: DR NARENDRA N
MODERATOR: DR SANDEEP K
 OVERVIEW

• INTRODUCTION
• HISTORY
• CLINICAL FEATURES
• EXAMINATION
• TREATMENT
• REFERENCES
 INTRODUCTION

Astigmatism is a type of refractive error wherein the refraction varies in

different meridian.
The rays of light entering the eye cannot converge to a point focus but form
focal lines
Incidence
Infants- About 50% of full term infants have astigmatism of over 1D
Adults- Incidence of astigmatism decreases as the child grows
 By adulthood, 15% of people have astigmatism >1D and only 2% have
astigmatism >3D
Most common type- Compound myopic astigmatism
 BASIS FOR ASTIGMTISM

SPHERICAL SURFACE TORIC SURFACE

 The curvatures are same in all  Curvatures are not same in all
meridians meridians. One meridian is steep,
 When light rays pass through a the other is flat
transparent spherical surface,  When light rays pass through a
each meridian focuses the rays transparent toric surface, each
at the same distance from the meridian will focus it at a
lens different distance from the lens
 Astigmatism
CLASSIFICATION
The orientation of the steepest (myopic) and flattest
(hypermetropic) meridians

Perpendicular Not No definite pattern

to each perpendicula or
other r to each
other regularity

Correspond to Correspond to 450

1800 and 900 and 1350 meridia
meridia of the of the cornea
cornea

Bi-
Regular Oblique oblique Irregular
astigmatism Astigmatism astigmatis astigmatism
m
 Regular
Astigmatis
m

Both Both
One meridia meridia
meridian is have the have
Emmetropic same different
refractive refractive
error errors

The other is The other Both Both are

myopic is are hypermetro
hypermetro myopi pic
pic c

Simple Simple Compoun Compound Mixed

Myopic Hypermetro d Myopic Hypermetro astigmatis
Astigmatis pic Astigmatis pic m
m Astigmatism m Astigmatism
 Regular Astigmatism

Vertical meridian is more steeper Horizontal meridian is more

than horizontal steeper than vertical

With the rule Astigmatism Against the rule Astigmatism

 HISTORY

COMPLAINTS
Symptoms
Blurring of vision
Asthenopic symptoms- Tiredness of eyes, headache, dizziness, irritability and fatigue
Burning and itching
Constant rubbing of eyes
Distortion of objects
Polyopia

Signs
Tilting of head
Squinting
Reading material may be held close to eyes
 PAST HISTORY
Lid swellings in the past
Previous history of ocular surgeries
Pre-existing refractive errors like myopia and hypermetropia
Diabetes
Family history of astigmatism
Preterm birth/low birth weight
History of spectacle and contact lens usage
 Etiology of Regular astigmatism
1. Corneal astigmatism- abnormalities of curvature of cornea.
Usually congenital
2. Lenticular astigmatism
Types
a. Curvatural- Lenticonus
b. Positional- Subluxation of lens
c. Index- Refractive index varies
3. Retinal astigmatism- due to oblique placement of macula
REFRACTIVE TYPES OF REGULAR ASTIGMATISM
 I R R E G U L A R A S T I G M AT I S M

Whenever the two principal meridians are not symmetric and do not lie 90
degrees apart (orthogonal) the astigmatism is considered irregular. 
 It is always a pathologic condition. 

Etiology
Corneal-corneal epithelial basement membrane dystrophy, corneal
degeneration, corneal scarring, keratoconus, prior corneal surgery.
Lenticular- due to variations in refractive index
Retinal- Tumors of retina or choroid pushing the macular area 
Dry eye, pterygium, trauma
 PHYSIOLOGICAL ASTIGMATISM

 Vertical corneal meridian is more curved than the horizontal

 Seen in children and young adults
 Gradually decreases with age
 Constant pressure of the upper lid over the globe
 In old age-Inverse astigmatism-Horizontal
meridian is more curved than the vertical
 EXAMINATION

Uncorrected
distant and near
vision

Snellens’s chart
37
for vision
 Slit lamp examination
Look for
• Lids- Meibomitis, blepharitis, dry eye syndrome
• Conjunctiva- Scarring, conjunctivochalasis, chemosis
• Cornea- Scarring, keratoconus
• Lens- Nuclear sclerosis, lenticonus

IOP measurement- Rule out glaucoma

Dilated fundoscopy
• Posterior segment- Retinal tears, retinal breaks, optic nerve(glaucoma)
RETINOSCOPY
• In the presence of astigmatism, with its principal axis horizontal and
vertical, one axis is neutralised with spherical lens and the plane of second
axis is determined and corrected with cylindrical lens

Retinoscopy
 KERATOMETRY
Astigmatism is characterized by
• Difference in the power between two principal meridians
• Horizontally oval mires are seen in WTR astigmatism
• Vertically oval mires are seen in ATR astigmatism
• In oblique astigmatism, the principal meridians are between 30-60
degree and 120-150 degree

Keratometry
 Irregular anterior corneal surface is characterized by Irregular mires and
doubling of mires

Keratoconus is characterised by
• Inclination and jumping of mires is seen while attempting to adjust the
mires(jumping mires)
• Minification of mires, Irregular, wavy and distorted mires indicate advanced
keratoconus(K>52D)
• Oval mires are seen due to large astigmatism
 CORNEAL TOPOGRAPHY

PLACIDO DISC
PRINCIPLE
• Use of first purkinje image
• Consists of equally spaced alternating white and
black lines
• A luminous object(target rings) is placed in front of patient’s cornea

• Image size is produced in the corneal reflection is measured

 CLINICAL INTERPRETATION
• Circular rings- Spherical cornea
• Oval rings- Regular astigmatism
• WTR astigmatism
• ATR astigmatism

With long vertical axis-

Against the rule astigmatism
With long horizontal axis- With the rule astigmatism
OBLIQUE ASTIGMATISM
CORNEAL TOPOGRAPHIC PATTERNS

ASTIGMATIC PATTERNS:
Symmetrical & Orthogonal : (Bow-Tie Effect)
• With or without skewed axis
Asymmetrical & Orthogonal:
• With superior steepening
• With inferior steepening
• Bow-tie with skewed radial axis
• Irregular : no pattern and non-orthogonal
 Round Oval Sup. Steep Inf.
Steep

Asym. Bow-Tie with Asym. Bow-Tie with Sup.

Sym. Bow-Tie
Symm. Bow Inf. Steep Steep
with Skew
tie

Asym. Bow-Tie with skew

 CORNEAL PACHYMETRY
 Corneal thickness is an important criterion for determining adequacy
for keratorefractive surgery.
 If CCT< 480micrometers, it is difficult to perform LASIK refractive
surgeries
 JACKSON’S CROSS CYLINDER

• Cross cylinder is a type of toric lens used during refraction.

• Also known as ‘flip’ cylinder.
• Its use was popularized by Edward Jackson and it is
referred to as Jackson’s cross cylinder
• The cross cylinder is a combination of two cylinder of equal strength
but opposite sign placed with their axis at right angle to each other
and mounted on a handle
• The cross cylinder is a sphero cylindrical lens in which the power of
the cylinder is twice the power of the sphere and of the opposite sign
• The lens is mounted on a handle which is placed at 45 degrees to the
axes of the cylinders
• The most commonly used cross cylinders are of +/- 0.25D and +/-
0.50D

• Colour code
Minus axis- White dot
Plus axis- Red dot
1. Refinement of the axis
2. Refinement of the cylinder power
Power of the correcting Estimated
initial cylinder (DC)
required (0.25 JCC)
0.25 30°
0.50 20°
0.75 15°
1.00–2.00 10°
2.25
05°
 ASTIGMATIC FAN TEST

 The fan block test consists of series of radiating lines spaced at

10° interval & arranged after the manner of the rays of rising sun
 There is a central panel carrying a ‘V’ & two sets of mutually
perpendicular lines (the blocks)
 The V & block simultaneously can be rotated through 180°
 Steps of fan & block technique:
•Obtain best visual acuity using sphere only
-Add positive sphere equal to half of estimated amount of
astigmatism
-Refer patient to fan chart, ask which group of lines appear
clearest & darkest
-Directing attention to maddox arrow
-Directing attention now to blocks, add negative cylinder at
appropriate axis until both blocks are equally clear
 OPTICAL TREATMENT

LENSES
 Cylindrical lenses in the form
of spectacles
 Full correction usually
 Under-correction if intolerable
symptoms

Contact lenses
 In small errors- spherical
equivalent
 In large errors- toric /rigid
contact lens 39
CONTACT LENS FITTING IN ASTIGMATISM

RGP LENSES FOR ASTIGMATISM

 Spherical RGP lens- Corneal astigmatism as high as 4D can be corrected
 RGP lens with toric peripheral curves- In patients with 1.5-2.5 D corneal astigmatism.
The standard peripheral curves are used in the flattest meridian, and in the steepest
meridian the peripheral curves are made steeper by an amount of equal to the dioptres
of corneal astigmatism.
 Bitoric lens- Has anterior and posterior toric curves. In patients with >2.5 D corneal
astigmatism.
 Front surface toric RGP lenses- In patients having spherical corneas with significant
amount of astigmatism
SOFT LENSES FOR ASTIGMATISM
 Spherical soft contact lenses- May correct astigmatism upto 1 D, provided the
total astigmatism is not more than one-third of the spherical correction. Thinner
spherical lenses correct less astigmatism than standard thicker lenses.
 Toric soft contact lenses for astigmatism- When astigmatism is >1 D and the
spherical lens is not able to correct it and the patient is unable to tolerate rigid
lenses.
 INCISIONAL REFRACTIVE PROCEDURES

 ASTIGMATIC KERATOTOMY (AK)

Pre-op Evaluation :
• Astigmatism (specially asymmetric)
• Calculating best position & configuration of relaxing incision
Post-op evaluation reveals:
• Longer incision : more steepening of un-incised meridian
• Incision closure to limbus: less flattening
• Deeper incision : more effect
• Making transverse or arcuate cuts in the mid periphery
perpendicular to the steepest corneal meridian.
• Incised meridian flattens while the meridian perpendicular
to it steepens by nearly the same amount.
• Transverse or arcuate incision can be given.
• Upto 4-6 D
 Limbal relaxing incision

-To correct mild(-1 to -2) astigmatism.

• Incision made at limbus, so , optical quality of cornea is preserved.
• Easy and safe.
 LASE R ABL ATION REF RACTIVE CORNEAL
SURGER IES

Photoastigmatic refractive keratotomy

 Uses a cylindrical rather than a spherical ablation pattern to remove a
tissue in a chosen meridian.
 Chosen in irregular astigmatism
 Upto 3 D
Astigmatic epi-LASIK: preferred over astigmatic PRK.

Astigmatic LASIK:astigmatismof 0.5 to 10.0D is

amenable to correction with LASIK.

Astigmatic C-LASIK: presently the best technique to

treat corneal astigmatism
 M A NA G EM E NT O F P O ST K ER ATO P LA ST Y
ASTIGMATISM

SUTURE REMOVAL:
• Suture removal in steep meridia may improve a
varying degree of both regular & irregular
astigmatism.
• Near a tight suture ,the keratoscopic mires are closer
together and may demonstrate a ‘V’ indentation vector.
 RELAXING INCISIONS:

Arcuate incisions along the steeper meridian in the donor

cornea 0.5mm central to the host-graft junction correct an
astigmatism of 3.5-8.5D.

Two relaxing incisions involving 70% of corneal depth

are made 180 deg. apart.
Relaxing incisions with compression sutures:

 After making relaxing incisions , two or three 10-0 nylon sutures

are applied at the graft host junction 90 deg. away from the
steepest meridian.
 Correct astigmatism of 8.8-16 D
 Corneal wedge resection:
• To correct an astigmatism of 10-20D before repeating the penetrating
keratoplasty.
• Corneal wedge of 1.0-1.5mm wide base and 90 deg. in extent is made.
• Gap is sutured by five to seven deep interrupted 10-0 nylon or prolene
sutures.
Ruiz procedure:

 If a corneal resection fails/ patient has a highly

myopic
spherical equivalent.

 If significant anisometropia exists such as post-

keratoplasty eye with more myopic eye.

 Deep horizontal keratotomy incisions are made with a

guarded diamond blade in a ‘step ladder pattern’ along
the axis of steepest corneal meridian.

 It is important to ensure that the horizontal and

radial incision donot intersect (as this causes
gaping and poor wound healing)
Toric IOL

 Toric IOLs refer to astigmatism correcting

intraocular lenses used at the time of cataract
surgery to decrease post-operative astigmatism.
 Patient should have a visually significant
cataract and astigmatism.
 The toric lenses currently available are
designed to correct regular corneal
astigmatism.
 REFERENCES

• Optics and Refraction- A K Khurana

• Elkington
• Duke and Elders
• Eyewiki
THANK YOU
1. With-the-rule astigmatism: Occurs when the vertical meridian (90°) is the
steepest(between 60 and 120 degrees)
2. Against-the-rule astigmatism: Occurs when the horizontal meridian (180°) is the
steepest(between 0 to 30 and 150 to 180 degrees)
This type of astigmatism is more common in older
patients, due to age related changes.
Oblique astigmatism: The principal meridian are not the horizontal
and vertical, though these are at right angles to one another(31 to 59
degrees and 121 to 149 degrees)

Bi-oblique astigmatism: The two principal meridia

are not at right angle to each other(one may be at
30 degrees and the other at 100 degrees)
 MANIFEST REFRACTION
• To confirm the amount of astigmatism found with retinoscopy,
keratometry, and corneal topography
• To quantify the amount of astigmatism in infrequent cases of almost
total noncorneal (i.e., lenticular or ocular) astigmatism (usually much
greater than that found on keratometry or corneal topography)
• To evaluate the consistency of the corneal topographical cylinder with
reconstruction of the sphero-cylindrical manifest refraction in the
infrequent cases of nonorthogonal astigmatism (i.e., the two steep
meridians differ by more than 180 degrees)
 STRUM’S CONOID

Configuration of rays when they get refracted through a

spherocylindrical surface (toric or compound lens) is like the shape
of a cone hence called the Strum’s Conoid
When parallel rays of light pass through a convex toric lens,
vertical rays get focused at point M and horizontal rays get
focused at point N. Thus these rays have two foci. The distance
between the two foci is called ‘Focal interval of strum’
Clinical Significance
 It explains why an astigmatic patient complains of seeing
distorted objects. Also that a patient having mixed astigmatism
may not complain of defective vision as the circle of least
diffusion falls on his retina and hence his visual acuity is very
good even without glasses.