Q: What is astigmatism and how does it affect vision?
The cornea (front window of the eye) is almost always shaped like a football (oval) rather than a basketball (round). This football shape creates astigmatism which distorts and blurs vision at all distances, near and far. Both myopic (nearsighted) and hyperopic (farsighted) eyes also have astigmatism.
Q: How do I know if I have astigmatism?
There is no way of knowing without specific testing. Astigmatism arises from two sources: the cornea and the lens. Cataract surgery eliminates the lens component of astigmatism. Any amount remaining in the cornea contributes to the reduced quality of vision following surgery. Some people have no astigmatism in their eyeglass measurements, yet they have astigmatism in their corneas. The only way of knowing if corneal astigmatism is present is by testing for it using advanced diagnostic tools such as corneal topography. The cost of this testing is included in the Astigmatism Management Fee.
Q: How is astigmatism corrected?
There are three methods. The first involves making incisions in the cornea at the time of cataract surgery. During the planning process, one of our surgeons will determine the length, depth, location and number of incisions required to reduce the astigmatism. These incisions can be made manually or with a femtosecond laser under imaging guidance. Femtosecond laser incisions can be made with a higher level of precision than manual incisions. The second involves implanting a Toric intraocular lens once the cataract is removed. This type of special lens requires marking of the eye just before and during the surgical procedure. Once the Toric lens is placed in the eye, the surgeon must precisely orient the lens to maximally reduce the astigmatism. If one of our surgeons recommends a Toric intraocular lens, the patient will pay an additional charge to the hospital for the purchase of the lens. The cost of a Toric lens is NOT included in the Astigmatism Management Fee. The final method is using an excimer laser (PRK and LASIK) at some time after the cataract surgery. The surgeon will typically use these procedures if the astigmatism could not be fully corrected at the time of cataract surgery using one of the first 2 methods. If The surgeon determines that a PRK or LASIK procedure could improve the vision following cataract surgery, the cost of this procedure is included in the Astigmatism Management Fee.
Q: What if I have no astigmatism or only a small amount?
All corneas have at least some astigmatism. Cataract surgery involves making incisions in the cornea to allow the surgeon to remove the cataract from the eye. The incisions will change the cornea’s astigmatism. There is no way of avoiding this change. A corneal topography measurement helps the surgeon plan the location and size of the incisions to minimize post-operative astigmatism. If a corneal topography is not performed prior to surgery, the changes in astigmatism induced by the surgical incisions will be random, resulting in an unpredictable amount of astigmatism following the surgery.
Q: What if I don’t have it corrected?
If you have postoperative astigmatism, you will need glasses or contact lenses to see the clearest.
Q: Are there other options?
The other option is to perform the surgery without addressing the astigmatism. Astigmatism can be treated after surgery if a patient does not like the vision and the surgeon determines that correcting the astigmatism will improve the vision. The correction will be performed using PRK or LASIK which is not be covered by Medicare or other Health insurance. In this case, the cost will be significantly higher than if the astigmatism management was performed during the initial surgery. It is possible to discount the cost of astigmatism correction at the time of initial surgery because the surgeon is already in the operating room to perform the cataract surgery.
Q: Will I need astigmatism correction in both eyes?
Yes. Separate pre-operative evaluation, including corneal topography, must be performed on each eye to determine the surgical correction of astigmatism specific to each eye.
Q: Will I see 20/20 if my astigmatism is corrected?
We hope so, but as with all surgery, we cannot guarantee outcomes. There are many variables that affect visual outcomes besides astigmatism (the power of the lens implant, the health of your retina and optic nerve, etc). The chance of achieving 20/20 visual acuity without glasses or contact lenses are significantly higher if we evaluate and correct your astigmatism than if we do not.
Q: Will it take longer to recover from surgery if my astigmatism is corrected?
If you have a small amount of astigmatism or of a Toric lens is implanted, recovery will be the same as cataract surgery without astigmatism correction. If additional incisions are required to correct the astigmatism, your eye may be a little more irritated the day of surgery. Either way, recovery is quick. Most eyes feel fairly normal the day after surgery.
Q: Is it recommended for every patient?
Nearly all patients would benefit from having astigmatism evaluated and managed. Only if your potential vision is very poor (because of advanced macular degeneration, an ischemic central retinal vein occlusion, previous macula-off retinal detachment, macular hole, or other similar eye problems) correcting the astigmatism may not be as beneficial. It is our general feeling that you will likely benefit from astigmatism management if your potential visual acuity is 20/200 (the big E on the eye chart) or better.
Q: Should I have my astigmatism corrected if my visual potential is poor?
It depends on your eye condition. If you will not be able to see the big “E” on the eye chart after eye surgery, it will likely not help to have your astigmatism corrected. If you are not sure what your visual potential is, it is best to choose astigmatism management. If you have a reduced potential vision, ask the surgeon what he believes your potential vision will be after cataract surgery to assist you in making your decision.
Q: Should I have my astigmatism corrected if I am having surgery in one eye only?
Yes. Your overall vision without glasses will be better even if only one eye is corrected.
Q: What if my astigmatism is not fully corrected at the time of surgery?
You will need glasses or contact lenses for best distance and near vision. If your astigmatism is not fully corrected, the quality of your uncorrected vision will still be better if your astigmatism can be reduced by any amount. If you opt for astigmatism management, the surgeon will recommend whether or not additional procedures would further improve your vision without glasses following the initial cataract surgery. If the surgeon feels that a PRK or LASIK procedure would further improve your vision without glasses, the cost of this procedure is included in the Astigmatism Management Fee. If you did not opt for astigmatism management and wish to have a PRK or LASIK procedure to improve your vision without glasses, the cost will be the full price of PRK or LASIK that is offered at the Santa Monica Eye Medical Group. One of our staff can provide you with this cost.
Q: Will I need reading glasses if I have my astigmatism corrected?
Yes. Astigmatism correction alone does not provide excellent vision at distance and near without glasses. However, if astigmatism correction is combined with certain lens options, useful distance and near vision without glasses can be achieved. These lens options include: multifocal and extended depth of focus lens implantation and monovision lens power targeting. After evaluating your eyes, the surgeon will inform you of your options and make a recommendation as to which options he feels is best for your particular situation.
Q: Are there any risks or side effects?
It is possible that the surgeon is unable to reduce your astigmatism down to a level that affords excellent uncorrected vision with the initial procedure. If PRK or LASIK is recommended and carried out to further improve uncorrected vision, the eye will likely have dryness that persists for at least 3 to 6 months which may require additional eye drops, medications or procedures to improve symptoms of dryness. If a Toric intraocular lens is implanted, there is a small chance that the lens can rotate post-operatively. If this occurs, the surgeon will determine how to handle the rotation.
Q: Can I have surgery if I decide not to have my astigmatism corrected?
Yes, but this will result in a less-than-optimal result requiring glasses or contact lenses to achieve the best vision. State-of-the-art cataract and lens implant surgery involves correcting astigmatism at the time of surgery.
Q: In what situations is Astigmatism Management mandatory?
Astigmatism Management is required when the surgeon performs cataract surgery in the following situations:
- To maximize distance or near vision without glasses
- Eyes with previous LASIK surgery
- Eyes with previous PRK surgery
- Eyes with previous RK surgery
Q: What is NOT included in the astigmatism management fee?
The Astigmatism Management Fee does NOT include the use of the Femtosecond Laser or the ORA Intraoperative Aberrometer, the cost of specialty lenses (e.g. Toric, Multifocal, Extended Depth of Focus, Accommodating IOLs). If the surgeon has recommended one of these specialty lenses, a member of his staff will provide you with the cost of the lens.
The Astigmatism Management Fee does NOT include any of the post-operative procedure that may be required due to medical conditions that can arise following the cataract surgery which are typically covered by insurance (e.g. YAG Capsulotomy for posterior capsular opacity).
Q: Does Medicare or private insurance pay for astigmatism management?
No, Medicare and private health insurance plans do not pay for procedures that treat preexisting corneal astigmatism at the time of cataract surgery.
Q: Why don’t Medicare and private insurance plans pay for astigmatism management?
Medicare sets trends for the insurance industry. Since Medicare distinguishes between what is medically necessary and what is cosmetic, or purely optional, we are required to handle the finances of the cataract removal and the astigmatism management separately. Medicare and private health insurance reimburse for cataract surgery. They do not pay for the refractive procedures that reduce a patient’s dependence on glasses or contact lenses.
Q: Can I submit the astigmatism management invoice to Medicare or another private insurance plan for reimbursement after I pay?
Yes, you can, but they will deny payment on statutory grounds. If Medicare or an insurance company asks this office for justification for the astigmatism management, we will inform them the astigmatism service was done for non-medical or cosmetic reasons and supply copies of our non-covered service waiver and frequently asked questions form.
Q: My friends who have had cataract surgery never mentioned astigmatism management? Why is this?
Many ophthalmologists do not perform refractive cataract surgery. Our surgeons have spent years refining surgical techniques to optimize uncorrected visual acuity (e.g. vision without glasses). Our surgeons believe that correcting astigmatism during cataract surgery is important for achieving the best results.
Q: Does it require additional visits?
No, not typically.
Q: Can I receive a refund if my astigmatism is not fully corrected?
No. As with any surgery, results are subject to individual healing patterns and a host of variables beyond our control. No guarantees can be made with respect to the final result. However, the surgeon will assess your individual situation with great care and recommend additional procedures (e.g. PRK or LASIK) if he feels there is a good chance of further reducing your astigmatism and improving your vision without glasses.
Q: When do I have to decide?
We would like you to decide at the time of the scheduled preoperative visit. At a minimum, you need to let us know one week before surgery.
Q: What do I do if I want astigmatism management?
You should tell one of our office staff. They will have you sign a non-covered service waiver next to a bold YES. If you do not want it, you will sign the waiver next to a bold NO.