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J Gandhara Med Dent Sci
ORIGINAL ARTICLE
:
:
July - September 2025
A QUASI-EXPERIMENTAL STUDY ON EFFECTS OF 3.2MM SUPRATEMPORAL CLEAR
CORNEAL INCISION DURING PHACOEMULSIFICATION ON PREOPERATIVE ASTIGMATISM:
BRIDGING THEORY AND SURGICAL PRACTICE
Junaid Sethi1, Fawad Ahmad2, Nuzhat Rahil3
ABSTRACT
OBJECTIVES
This study aimed to evaluate the effect of 3.2 clear corneal superotemporal
incisions on postoperative astigmatism in patients surgically treated with
phacoemulsification for cataract extraction, thereby bridging the gap
between theory and surgical practice.
METHODOLOGY
This quasi-experimental study was conducted in the ophthalmology
department of the Medical Teaching Institute, Lady Reading Hospital,
Peshawar, from February 2024 to August 2024, following ethical approval
and informed consent from the patients. Seventy-three patients presenting
with non-complicated and non-traumatic cataracts between the ages of 20
and 85 years were enrolled. Phacoemulsification surgery was performed on
these patients of both genders. A 3.2 super temporal clear corneal incision is
used during phacoemulsification surgery. Using the Keratometer and
comparing the corneal dioptric power along the horizontal and vertical
meridians, the pre-and post-operative astigmatism at 3- and 6-month follow-
ups was assessed. The data was entered and analyzed using SPSS version 25.
RESULTS
A total of 73 patients with cataracts were enrolled in this study. The patients'
mean age was 61.6 ± 11.9 years. The ratio of male to female was in the ratio
of 2:1. The mean pre-operative astigmatism was 0.88±0.4947D. The
mean astigmatism after surgery was 1.15±0.748 D, and after 6 months, it
decreased to 0.67 D. Following the study, the young surgeons in years 3 and
4 learned about the negating effect of this incision.
CONCLUSION
There was no significant difference in astigmatism when followed
postoperatively over an extended period of 6 months with a 3.2 mm
supratemporal clear corneal incision during phacoemulsification. The
practical aspect of the study yielded more satisfactory results during the
training of Postgraduate residents (PGRs).
KEYWORDS: PGRS, Clear cornea, Cataract, Phacoemulsification, and With
and Against the Rule of Astigmatism
How to cite this article
Sethi J, Ahmad F, Rahil N. A Quasi-
Experimental Study on Effects of 3.2mm
Supratemporal Clear Corneal Incision
during Phacoemulsification on Preoperati
ve Astigmatism:Bridging Theory and
Surgical Practice.J Gandhara Med Dent
Sci. 2025;12(3):3-7.https://doi.org/10.37
762/jgmds.12-3.731
Date of Submission: 23-05-2025
Date Revised: 04-05-2025
Date Acceptance: 05-06-2025
1Assistant Professor, Department of
Ophthalmology, Lady Reading Hospital,
Peshawar
2Ex-Post Graduate Resident, Department
of Ophthalmology, Lady Reading
Hospital, Peshawar
Correspondence
3Nuzhat Rahil, Assistant Professor and
Head of Department Ophthalmology,
Lady Reading Hospital, Peshawar
+92-321-9036959
nuzhatrahil@gmail.com
INTRODUCTION
As evidenced by multiple studies, the prevalence of
cataracts in Pakistan is the same as in the rest of the
world, and the best surgical techniques are the need of
the day. Phacoemulsification is a surgical method used
to treat cataracts, the primary cause of reversible
blindness.1 It has emerged as one of the most well-liked
and safest methods for cataract removal worldwide, and
in Pakistan, it is considered superior to alternative
surgical techniques. Even in low-income countries, the
advantages of early visual recovery compelled the use
of this particular surgical technique. At one end of the
spectrum, cataract is the primary cause of vision
dimness; on the other end, astigmatism -a type of
corneal asymmetry that causes poor image quality in
patients with cataracts -exacerbates the visual handicap
2of these patients, increasing their discomfort.
Numerous studies also conclude that 53.7% and 68.2%
of patients who develop cataracts in their eyes have
preexisting astigmatism.2 Modern cataract surgery aims
to achieve early visual rehabilitation, best-corrected
visual acuity, and minimal postoperative astigmatism.3
The type, dioptric power, and correction, as well as the
type of cylinder used for preoperative astigmatism,
affect the type and amount of postoperative
astigmatism. After surgery, astigmatism may be
lessened with a small incision. That small incision can
now be used for removing cataractous lenses due to
phacoemulsification and the use of foldable intraocular
lenses (IOLs). Significant changes in corneal curvatures
are avoided by various techniques, which can hasten
visual recovery. A small incision technique pioneered
4 J Gandhara Med Dent Sci July - September 2025
by D.I. Howard for the first time, not only eliminated
surgically created astigmatism but also reduced
postoperative inflammation. In most cases, the surgeons
opt for a temporal or superior incision for different
reasons.4 However, for patients with significant
preoperative astigmatism, the steeper corneal meridian
is chosen for incision to decrease the likelihood of
postoperative astigmatism. The risk of postoperative
astigmatism is further nullified if the clear corneal
incision is small, posterior, and within the limbus.5 The
site and the size of a 3.2mm transparent supratemporal
corneal incision are advantageous (5), as injecting the
foldable IOL via the 3.2 mm does not cause an increase
in the size of the wound (5) and does not alter the
curvature of the cornea. The position, dimensions, and
arrangement of incisions also greatly influence surgical
astigmatism. Astigmatism benefits from incision at the
supratemporal location in the oblique meridian.
Moreover, postoperative astigmatism is minimized by
flattening the horizontal corneal axis with a clear
corneal supratemporal incision.6 Compared to anterior
incisions, posterior incisions are less likely to cause
astigmatism.7 It is very effective to make the incision in
the steep meridian of the astigmatism because nearly all
wounds eventually relax post-operatively. However, the
question arises as to why the temporal approach should
be preferred, and it is justified because most elderly
patients with age-related cataracts have against-the-rule
astigmatism (ARA). A temporal approach can help
reduce postoperative astigmatism more effectively than
other approaches.8 The alternative approach can be a
temporal scleral tunnel, but additional bleeding from a
temporal scleral incision may require cautery due to the
anatomy of the scleral blood supply. On the other hand,
excessive cautery to combat the bleeding steepens the
cornea's meridian by causing the collagens to shrink
excessively. This short steepening typically disappears
in four to six weeks. When treating against-the-rule
astigmatism (ARA), temporal clear corneal incisions
are beneficial and are associated with less bleeding and,
ultimately, less use of cautery.8 The supratemporal
clean corneal incision technique is considered a reliable
method with minimal side effects in
phacoemulsification. Unfortunately, local studies
comparing the degree of astigmatism in these patients
before and after surgery are scarce, particularly when
assessing the degree of astigmatism to delayed best-
corrected visual acuity. This study aims to bridge that
gap by providing practical information that can inform
clinical procedures. In addition to educating PGRs on
the practical aspects of surgery, we also need to use
evidence-based practice to illustrate these aspects. To
improve interventions and update current treatment
protocols, the results will be incorporated when
designing practical guidelines in our teaching setup for
young surgeons. To evaluate the effect of 3.2 clear
corneal superotemporal incisions on short and long-
term postoperative astigmatism in patients surgically
treated by phacoemulsification for cataract extraction.
To close the gap between theory and surgical practice
by teaching the PGRs. After the study, we will be able
to answer the following questions. How does the
supratemporal clear corneal incision affect post-
operative astigmatism after 6 months of follow-up?
What particular changes in the current surgical
guidelines for PGRs are we expecting as a result of our
findings?
METHODOLOGY
A Quasi-experimental study was conducted at the
Department of Ophthalmology, Lady Reading Hospital,
Peshawar, over six months. February 2024 and August
2024. Using the OpenEpi calculator, the sample size
was calculated based on a reference preoperative
astigmatism of 0.78 ± 0.70 D and postoperative
astigmatism of 1.20 ± 1.07 D (11), with a 95%
confidence level and 10% absolute precision. Based on
this, the sample size is 73 patients in the group. A non-
probability consecutive sampling Technique was used.
Both Male and female patients, aged 20 to 80 years,
with non-complicated and non-traumatic cataracts
undergoing phacoemulsification for cataract surgery,
were included in the study. Other causes of
Astigmatism, ocular abnormalities, and corneal
degeneration. Following the Standard Research
Protocol, approval was obtained from
the Ethical Review Board of Lady Reading
Hospital, Peshawar. This study was conducted
at the Department of Ophthalmology at Lady Reading
Hospital, Peshawar. All the patients were assessed
according to defined inclusion and exclusion criteria,
and informed consent was obtained from all
participants after a detailed briefing regarding the
procedure, potential risks, and expected outcomes.
After taking a complete medical and ocular history,
each patient underwent a thorough ocular examination.
This included slit-lamp biomicroscopy, measurement of
intraocular pressure using Goldmann applanation
tonometry, and fundus examination using both direct
and indirect ophthalmoscopy. In cases where fundus
visualization was not possible due to media opacities,
B-scan ultrasonography was employed to evaluate the
posterior segment of the eye. Preoperative astigmatism
was measured and recorded using the Huvitz
Autorefractometer (model number: HRK-8000A).
Keratometric readings were also obtained using the
Huvitz Keratometer, ensuring proper alignment of
mires and precise patient positioning with the forehead
and chin resting in designated supports, as per standard
protocol. The same trained technician took all refractive
A Quasi-Experimental Study on Effects of 3.2MM Supratemporal
5 J Gandhara Med Dent Sci
July - September 2025
measurements to ensure consistency. Routine
preoperative laboratory investigations (complete blood
count, random blood sugar, and serology) were
performed as per hospital policy. On the day of surgery,
after ensuring all aseptic precautions, local anesthesia
was administered, and the operative field was draped
using sterilized material. After administration of
regional anesthesia and properly sterilized draping of
the surgical field, a 3.2 mm clear corneal incision was
made 0.50 mm from the superior limbus. The incision
was placed in the supratemporal quadrant, with careful
consideration of the laterality of the eye:
For the right eye (OD), the incision was made in the
supratemporal quadrant, which lies between
the superior and temporal meridians ( approximately)
at the 10-11 o’clock Position).
For the left eye (OS), the incision was similarly
positioned in the supratemporal quadrant
(approximately at 1-2 o’clock position).
This standardized placement ensured consistent surgical
access, minimized surgically induced astigmatism
(SIA), and optimized wound architecture for self-
sealing incisions. The same technique and orientation
were followed in all patients to maintain uniformity in
outcomes. A foldable acrylic intraocular lens (IOL), a
single piece with an optical diameter of 6.0 mm, was
implanted in the capsular bag. The same surgical
technique, phaco machine (e.g., ZIES), and viscoelastic
material were used in all procedures. To eliminate
surgeon-related variability, all surgeries were
performed by a single experienced surgeon with a
consistent surgical protocol. Postoperative care
included the administration of topical 0.3%
moxifloxacin and 0.1% dexamethasone four times daily
for the first 10 days. This was followed by a tapering
combination regimen of both drugs over the next 30
days. Patients were advised to avoid eye rubbing, heavy
lifting, and exposure to dusty environments during the
recovery period. Follow-up was strictly maintained to
ensure adherence to the protocol. Postoperative
astigmatism was evaluated at 6 weeks, 3 months, and 6
months using the same Huvitz Autorefractometer to
ensure measurement consistency. At each follow-up,
the visual acuity (uncorrected and best-corrected), slit-
lamp examination, intraocular pressure, and IOL
position were assessed. Data regarding the axis and
magnitude of astigmatism were recorded in diopters.
The surgically induced astigmatism (SIA) was
calculated using vector analysis methods such as the
Alpins method or the SIA calculator software. All
collected data were entered into a pre-designed
structured proforma. Data were entered into SPSS
version 25, and statistical analysis was performed using
the same software. After assessing the normality of the
data using Skewness and Kurtosis, frequencies and
percentages were calculated for categorical variables,
such as gender. The mean and standard deviation were
calculated for numerical variables, including age,
duration of cataract, preoperative astigmatism, and
postoperative astigmatism. Paired t-tests were used for
the comparison of pre-operative and postoperative
astigmatism; p-value ≤0.05 was considered significant.
The relationship between the pre-and post-operative
dependent variables is analyzed through regression.
Time series analysis is used to identify the mean
difference between pre-and delayed postoperative
astigmatism. Further statistical analysis of the data was
conducted to investigate any correlations between
variables, such as age groups, gender, and duration of
cataract and post-operative astigmatism. A p-value ≤
0.05 was considered statistically significant.
RESULTS
In this study, the patients’ ages ranged from 20 to 80
years. The mean age of the patients was 61.69 ± 11.93
years. The frequency of female to male in this study
was 2:1, with a 65.8 % contribution from female
patients. The duration of cataract presence varied
among patients, and almost 24% of patients had
cataracts for 1 year.
Figure 1: Frequency and Percentage of Patients According to
Disease Duration
Table 1: Pre and Post, 3 & 6-month Astigmatism
Mean
Std. Deviation
Pre-Op
Astigmatism
Post-Op
Astigmatism
3 Months
Post-Op
Astigmatism
6 Months
0.8801 1.1541 0.6267
0.49496 0.74841 0.35630
Table 2: Comparison of Pre-Op and Post Op Astigmatism N = 73
Mean
Std.
Deviati
on
Std.
Error
Mean
95% Confide
nce Interval
of the Differ
ence
Low
er
Upp
er
Pair
Pre-opastig
matism -
post-opasti
gmatism 3
months
0.315
07
0.61524
0.0720
1
0.4586
1
0.1715
2
t df
p-va
lue
4.3
75
72
0.000
1
A Quasi-Experimental Study on Effects of 3.2MM Supratemporal
6 J Gandhara Med Dent Sci July - September 2025
Table 3: Correlation of astigmatism with age (N = 73)
Age pre-op
astigmati
sm
post op
astigmati
sm 3
months
post op
astigmatis
m 6 months
Mean 61.6986 0.8801 1.1541 0.6267
Std.
Deviation
11.9031 0.49496 0.74841 0.35630
Table 4: Correlation of astigmatism with gender (N= 73)
Gender
Male Mean
Std.
Deviation
Fem
ale
Mean
Std.
Deviation
Total Mean
Std.
Deviation
Pre-op
astigmat
ism
Post-op
astigmatis
m 3-month
Post-op
astigmati
sm 6
months
P
Valu
e
0.9200 1.2400 0.7700 0.000
0.47719 0.74120 0.30551
0.8594 1.1094 0.5521 0.000
0.50767 0.75602 0.36084
0.8801 1.1541 0.6267 0.000
0.49496 0.74841 0.35630
DISCUSSION
Over a 6-month follow-up period, our study
demonstrated that a supratemporal 3.2 mm incision
rarely causes astigmatism or substantially alters
preoperative astigmatism, which is typically less than
0.45 to 0.5 diopters —a value that does not significantly
impact vision quality. These results are comparable to
those of Gautam N et al., which was a retrospective
cross-sectional study.5 The results of the study were
similar to those of our research. The mean preoperative
astigmatism in our study was 0.88 with a standard
deviation (SD) of 0.49; 63.3% of patients had WRA
preoperatively. Additionally, a UK-based study found
that 78% of patients had more than 0.5 diopters of
astigmatism preoperatively (12), which is less than our
study. When we assessed the type of astigmatism in our
study, whether WTR or ATR, we found that WTR
astigmatism was more common. The same finding was
observed in another study, where WRA was reported at
a frequency of 35.3% (1). However, the type of
astigmatism differed in another study, where the
prevalence of ATR was higher than that of astigmatism
preoperatively.14 In our studies, the mean postoperative
astigmatism was 1.14 D at 3 months of follow-up and
decreased to 0.62 D at 6 months of follow-up.
Regarding Table 5, the mean difference in astigmatism
between the pre-and postoperative periods in our study
was insignificant. Other studies have revealed that the
same degree of postoperative astigmatism occurs, with
0.51±0.22 in temporal incisions, indicating that the
clear corneal supratemporal incision either caused very
little astigmatism or had no effect on preoperative
astigmatism (15), leading to more early rehabilitation of
vision in these patients. However, a recent study
suggests that a temporal scleral incision yields less
astigmatism than a temporal clear corneal incision
during phacoemulsification.16 Our patients’ mean
WTR astigmatism decreased with time. The flattening
of the cornea along the incisional meridian with time is
evident in multiple studies. A 2020 study aimed to
demonstrate the effect of incision in the four different
meridians concluded that the superotemporal clear
corneal incision yields better and more accepted results
than other incision locations.17 This leads to WTR
astigmatic changes over time with a temporal incision,
which is comparable to the results of our investigation.
In another related study, keratometry analysis of
corneal astigmatism was conducted after surgery on
two groups undergoing phacoemulsification via
superior scleral incision and supratemporal corneal
incision. The keratometry corneal astigmatism did not
increase more with the superior scleral incision than
with the former after three months of surgery.18
Following cataract surgery, changes in the cornea’s
horizontal and vertical meridians depend on the length
and location of the incision. These two factors also
influenced this study. This finding is supported by other
similar studies, which demonstrate that superior
incisions resulted in greater changes than tiny temporal
incisions.19 The experience gained by the PGRs with
the conclusion of this study was satisfactory, and it will
help them in their clinical services to the patients. This
suggests that it is better to plan preoperatively for
temporal incision because the majority of elderly
patients have preoperative ATR astigmatism. Despite
the growing use of 3.2 mm supratemporal clear corneal
incisions, limited literature specifically evaluates their
impact on pre-existing corneal astigmatism. Most
studies have traditionally focused on temporal or
superior incisions, often overlooking quadrant-specific
variations, such as supratemporal placement.
Furthermore, available data vary widely in terms of
incision size, measurement techniques, follow-up
durations, and vector analysis methods, making it
difficult to draw comparative conclusions. This quasi -
experimental study addresses this critical gap by
systematically analyzing the changes in preoperative
astigmatism following standardized 3.2 mm
supratemporal incisions in both right and left eyes,
performed by the same surgeon using consistent
techniques. By employing a single surgeon and
standardized measurement tools (e.g., Huvitz
Autorefractometer), this study reduces procedural
variability and enhances the internal validity of
findings.
LIMITATIONS
There is no comparison of superonasal and
superotemporal incisions with the scleral tunnel.
A Quasi-Experimental Study on Effects of 3.2MM Supratemporal
7 J Gandhara Med Dent Sci
July - September 2025
Belonging to a low-income country, patients who could
not afford foldable intraocular lenses (IOLs) were
excluded from the study, making it difficult to
generalize the results to the entire population.
CONCLUSIONS
Superotemporal, 3.2 mm clear corneal incision is quite
stable and does not significantly increase post-operative
astigmatism when followed over a long (several
months) period. The supratemporal site and the clear
corneal incision have also proved to be superior to
larger and scleral incisions.
CONFLICT OF INTEREST: None
FUNDING SOURCES: None
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AUTHORS CONTRIBUTION
The authors accept responsibility for all aspects of the work
and will ensure that any concerns regarding the accuracy or
integrity of any part are properly investigated and resolved.
Junaid Sethi - Concept & Design; Data Acquisition
Fawad Ahmad - Concept & Design; Data Acquisition; Data
Nuzhat Rahil - Concept & Design; Data Acquisition; Data
Analysis/Interpretation; Drafting Manuscript; Critical
Revision; Supervision; Final Approval
Drafting Manuscript; Final Approval
Analysis/Interpretation; Drafting Manuscript; Final Approval