What is the best approach toward treating patients with high degrees of astigmatism?  Extremely high degrees of corneal astigmatism (>5D) are usually insufficiently managed with corneal relaxing incisions, soft or toric contact lenses, or even toric IOLs and are “off label” when it comes to LASIK for the treatment of high astigmatism treatment.  Ruling out keratoconus and minimizing the future risk of corneal ectasia is essential particularly in this patient population.  Corneal topography along with elevation based corneal tomography are helpful in evaluating high degrees of corneal astigmatism and minimizing the risk of future ectasia.  Hinge position is also more important when it comes to the sphero-cylindrical ablation pattern.  Anzor has offered a video testimonial discussing his experience of having both eyes treated 16 hours previously for a large refractive error that included 6 diopters of refractive cylinder.  Fortunately, our equipment, staff, and capabilities at the Duke Center for Vision Correction allow us to manage the most complex patients with the safest and most effective treatment options.  Link to patient interview = http://www.youtube.com/watch?v=HcPtzDwMDtY