Extending the Standard Temporal Incision

I very much enjoyed the editorial “Opposite Clear Corneal Incisions,”1 which discussed the important findings in the article by Lever and Dahan2 that was published in that same issue. I have long believed that when it comes to refractive surgery in our cataract surgery population, “less is better.” I agree with the conclusions, and I believe that the editorial beautifully summarized most of the options available for correcting preexisting astigmatism along with cataract. However, I would like to add an option that was not discussed. Our group has presented data3 describing our variation on the theme of the “astigmatically beneficial cataract incision” concept that was originally suggested to me by David M. Dillman, MD (course presentations and personal communications). Our technique is, to paraphrase your comments, “merely stating the obvious” as we know that incisions made in the steep axis of astigmatism flatten that axis preferentially. Our technique involves extending a temporal clear corneal incision, differentially, to treat higher degrees of preexisting astigmatism. In our study, we were able to correct up to 3.5 diopters of against-the-rule (ATR) astigmatism by extending our “standard” 3.5 mm temporal incision to 5.5 mm. Incisions greater than 4.5 mm were closed with sutures, which were removed selectively as needed to manage residual astigmatism, while incisions less than 4.5 mm were closed with stromal hydration alone. Our case series, which now includes over 30 patients, is being prepared for publication. In summary, I would urge surgeons who have patients with high preexisting ATR astigmatism to consider simply extending their standard temporal clear corneal incisions as the simplest means of treating ATR astigmatism. Using this technique does not require making additional incisions in the eye, having extensive preoperative discussions with the patient, or purchasing additional equipment. Most patients have very little postoperative astigmatism, and it is always in the same axis as it was preoperatively. Randy J. Epstein MD aChicago, Illinois, USA