Introduction

Cataract and pre-existing corneal astigmatism commonly coexist in the elderly population, posing a frequent refractive challenge in modern cataract surgery1. Multiple studies have demonstrated that a considerable proportion of patients scheduled for cataract extraction present with clinically significant corneal astigmatism. For instance, 26.2% of eyes in Iran exhibited astigmatism greater than 1.5 diopters (D)2, while in western China, 39.1% of cases had astigmatism of 1.25 D or more3. These epidemiological findings emphasize the clinical necessity of addressing astigmatism concurrently with cataract removal. If left uncorrected, corneal astigmatism can significantly compromise uncorrected distance visual acuity (UDVA) and diminish patients’ overall quality of life. Moreover, a progressive shift in astigmatism axis occurs with age. Younger adults typically present with with-the-rule astigmatism, while older individuals tend to develop against-the-rule patterns4. This shift further complicates refractive planning and highlights the critical importance of achieving precise astigmatic correction at the time of cataract surgery to ensure optimal postoperative visual outcomes5.

Surgical strategies for correcting pre-existing corneal astigmatism have undergone significant refinement in the context of modern cataract surgery. Among the earliest approaches were limbal relaxing incisions (LRI), which remain in use today, particularly in resource-constrained settings, owing to their technical simplicity, low cost, and minimal instrumentation requirements6. Despite these advantages, LRI are often associated with less predictable refractive outcomes and a propensity for postoperative regression.

By contrast, toric intraocular lenses (toric IOL), introduced in the early 2000 s, provide a more precise and stable lens-based solution by incorporating a cylindrical power component directly into the IOL optic. Their adoption has grown substantially over the past two decades, driven by enhanced refractive accuracy, improved rotational stability, and consistently higher levels of postoperative patient satisfaction7.

These two techniques differ fundamentally in their mechanisms of action. LRI achieve astigmatic reduction by physically modifying the corneal curvature, whereas toric IOL deliver internal refractive correction without altering the corneal structure. However, the broader adoption of toric IOL is often constrained by their higher cost compared to non-toric IOL, which may limit accessibility in certain healthcare systems8. In addition, their effectiveness is highly dependent on precise axis alignment, as even minor deviations can significantly diminish the intended astigmatic correction9. Postoperative rotational misalignment remains another critical concern, with the extent of rotation varying considerably based on IOL design characteristics10. These limitations—when considered alongside issues such as cost-effectiveness, patient-specific anatomical factors, and surgeon experience—have sustained ongoing debate regarding the optimal strategy for managing moderate regular corneal astigmatism (1.0–2.5 D) in the context of cataract surgery11.

Although both LRI and toric IOL are commonly employed in cataract surgery, high-quality comparative data focusing specifically on patients with moderate regular astigmatism remain limited. To address this gap, the present study was designed to prospectively compare the clinical outcomes of LRI and toric IOL under standardized surgical conditions, all procedures being performed by a single experienced surgeon. By minimizing procedural variability and implementing a consistent operative protocol, this investigation aims to generate clinically relevant evidence to guide astigmatism management strategies in routine cataract surgery.

Methods

Study design and patient selection

This study was conducted at Yuyao Maternity and Child Health Care Hospital (Yuyao Second People’s Hospital) between January 2024 and December 2024. Ethical approval was obtained from the Institutional Ethics Committee of Yuyao Maternity and Child Health Care Hospital (Approval No. 2023Y74), and all participants provided written informed consent prior to enrollment. The study was conducted in accordance with the principles outlined in the Declaration of Helsinki.

Participants were eligible for inclusion if they met all of the following criteria: aged between 55 and 80 years; clinically diagnosed with age-related cataract; nuclear sclerosis graded as Emery II to III on slit-lamp biomicroscopy; presence of regular preoperative corneal astigmatism ranging from 1.0 to 2.5 diopters (D), primarily originating from the anterior corneal surface, with exclusion of posterior asymmetric astigmatism; central corneal thickness ≥ 500 μm; symmetric corneal topography with no evidence of keratoconus or other structural abnormalities; and stable intraocular pressure (≤ 21 mmHg) without active ocular inflammation or infection within three months prior to surgery.

Exclusion criteria included any significant retinal or optic nerve pathology that could potentially compromise postoperative visual outcomes, such as diabetic retinopathy, macular hole, age-related macular degeneration, or optic atrophy. Patients were also excluded if they experienced major intraoperative complications or presented with systemic comorbidities that might interfere with surgical safety or adherence to postoperative follow-up. These included poorly controlled diabetes, Parkinson’s disease, post-stroke sequelae, cognitive impairment, psychiatric disorders, or severe hearing or language deficits.

Group allocation and sample size calculation

Patients were allocated into two groups based on their informed and voluntary selection of the surgical intervention: the LRI group (n = 45) and the toric IOL group (n = 48). This study employed a prospective, non-randomized design where treatment allocation was determined by patient choice following comprehensive preoperative counseling. All surgeries were performed by a single senior cataract surgeon with over 20 years of clinical experience, thereby ensuring procedural consistency across both groups.

Prior to enrollment, all patients participated in a standardized preoperative counseling session conducted by the operating surgeon. The counseling session followed a structured protocol lasting approximately 30 min and was conducted in a private consultation room. During this session, the respective advantages, disadvantages, anticipated visual outcomes, costs, and potential risks associated with both LRI and toric IOL implantation were comprehensively discussed. Specifically, patients were informed that LRI offered a cost-effective approach with good astigmatic reduction but potentially less predictable outcomes and possible regression over time. In contrast, toric IOL provided more precise and stable astigmatic correction with higher patient satisfaction rates, but at significantly higher cost and with dependence on precise axis alignment. Illustrated brochures and a short educational video were utilized to facilitate patient understanding. The educational materials included visual diagrams showing the anatomical differences between the two procedures, expected recovery timelines, and realistic examples of postoperative visual outcomes. Patients were explicitly informed that while both procedures aimed to reduce pre-existing corneal astigmatism in conjunction with cataract extraction, LRI involved peripheral corneal incisions at a lower cost, whereas toric IOL implantation provided a lens-based correction offering more predictable refractive outcomes albeit at higher expense. Patients were given detailed cost breakdowns for both procedures, including potential additional expenses for spectacles or enhancement procedures if needed. They were strongly encouraged to discuss the decision with their family members and were offered a minimum 48-hour consideration period before finalizing their choice. Patients were encouraged to carefully consider their visual expectations, occupational visual requirements, and financial circumstances, and to consult with their family members before making an informed, voluntary decision regarding the choice of surgical technique. No financial incentives or pressures were applied to influence patient decisions, and patients were assured that their choice would not affect the quality of their surgical care or follow-up.

To maintain scientific rigor despite the non-randomized design, recruitment was conducted consecutively among eligible patients. When enrollment in one treatment group approached the predetermined sample size threshold, subsequent eligible patients received additional information about the potential benefits of the underrepresented procedure to encourage balanced recruitment. However, the final decision remained entirely with the patient, and no patient was denied their preferred treatment option. This balanced recruitment strategy helped minimize potential selection bias while respecting patient autonomy and maintaining adequate statistical power for both study arms.

Phacoemulsification was performed using the Compact Intuitiv platform (Abbott Medical Optics, USA), with intraoperative visualization provided by a Leica M822 F20 surgical microscope (Leica Microsystems, USA). Preoperative biometric parameters—including axial length, anterior chamber depth, and keratometric values—were obtained using the IOLMaster 500 optical biometer (Carl Zeiss Meditec, Germany). The surgically induced astigmatism (SIA) was assumed to be 0.3 D at 180° for all toric IOL calculations, based on the surgeon’s historical data from over 200 previous cases using the standardized temporal clear corneal incision approach. The main corneal incision was standardized as a 2.8 mm temporal clear corneal incision for both groups, with two 1.2 mm side ports placed at the 10 and 2 o’clock positions. In the LRI group, paired arcuate corneal relaxing incisions were manually created prior to the construction of the main corneal incision. The steep corneal meridian was identified based on corneal topography (SW-6000, Tianjin Suowei), and axis marking was performed manually using a reference ring in the upright position. A limbal relaxing knife preset to a depth of 550 μm—approximately 85% of peripheral corneal thickness—was used to create incisions along the marked axis. Incision arc length and location were determined using the Donnenfeld online nomogram (www.lricalculator.com) with surgeon-specific adjustments based on over 20 years of clinical experience, incorporating age-related modifications and individual healing response patterns observed in the patient population.

In the toric IOL group, toric IOL power and axis calculations were performed using the IOLMaster 500 integrated calculation software (Carl Zeiss Meditec, Germany), incorporating keratometric values, axial length, and the assumed 0.3 D SIA. Preoperative axis marking was performed manually using reference rings in the upright position, and intraoperative axis verification was conducted using the surgical microscope’s built-in axis markers. Posterior corneal astigmatism measurements were not routinely obtained as advanced corneal imaging was not available in our facility. Standard phacoemulsification techniques were applied through a temporal clear corneal incision. Toric IOL implantation followed, with axis alignment guided by manual preoperative reference marking.

Sample size estimation was based on the primary endpoint of residual refractive cylinder measured at 6 months postoperatively. Assuming a standard deviation of 0.4 (D) and a minimal clinically important difference of 0.25 D7, a minimum of 40 participants per group was required to achieve 80% statistical power at a two-sided significance level of 0.05. The calculation was performed using the `pwr` package in R software. Both groups in this study met the sample size requirement. Although patients ultimately self-selected the surgical procedure after receiving standardized counseling, recruitment was conducted consecutively, and proactive measures were taken to achieve balanced group sizes. Specifically, when enrollment in one group approached the predetermined sample size threshold, subsequent eligible patients were encouraged to carefully consider the alternative procedure to maintain approximate parity between cohorts. This approach helped minimize potential group size imbalances and supported the statistical power requirements of the study.

Outcome measures and assessment techniques

The primary outcome of this study was the residual refractive cylinder at 6 months postoperatively, hereafter referred to as “residual cylinder.” Secondary outcomes included corneal astigmatism (K2–K1), spherical power, UDVA, best-corrected visual acuity (BCVA), and subjective visual satisfaction.

All refractive and visual acuity parameters were assessed at four time points: preoperatively, and at 1, 3, and 6 months postoperatively. Visual acuity was recorded in logarithm of the minimum angle of resolution (LogMAR) units, using standardized 5-meter LogMAR visual charts.

Postoperative refractive measurements were performed by a single experienced optometrist using comprehensive subjective refraction. The protocol included initial objective refraction as baseline, followed by systematic subjective refinement. Cylinder power and axis were determined using cross-cylinder technique, and sphere power was optimized using maximum plus to maximum visual acuity principle. All measurements were conducted under standardized conditions to ensure consistency.

Corneal astigmatism was calculated as the difference between steep and flat anterior keratometry values, measured via corneal topography (SW-6000, Tianjin Suowei). Baseline biometric parameters—including axial length, anterior chamber depth, central corneal thickness, and intraocular pressure —were collected for demographic and biometric profiling purposes, but were not included as primary or secondary outcomes.

Subjective visual satisfaction was assessed at the 3-month follow-up using a self-designed, single-item, five-point Likert-type scale. Patients independently completed a printed questionnaire by rating their overall satisfaction with postoperative visual performance. The survey item was phrased: “How satisfied are you with your current vision?” with response options ranging from 1 (very dissatisfied) to 5 (very satisfied). Although this measure was not formally validated, it was selected for its clarity, simplicity, and practicality in a predominantly elderly patient population.

Statistical analysis

Statistical analyses were conducted using SPSS software, version 22.0. Variables that followed a normal distribution were expressed as mean ± standard deviation. Between-group comparisons at each time point were performed using independent-samples t-tests, while within-group changes over time were analyzed using repeated-measures analysis of variance. The P values presented in the results tables follow a consistent format: values in individual time point columns represent between-group comparisons at that specific assessment, while values in the rightmost column of longitudinal data tables represent within-group changes from baseline to the final follow-up visit using repeated-measures analysis. Subjective satisfaction scores, treated as ordinal data derived from the five-point Likert scale, were compared between groups using the Mann–Whitney U test. A two-tailed P value of < 0.05 was considered statistically significant for all analyses.

Results

Baseline characteristics

Baseline demographic and ocular characteristics were comparable between the LRI (n = 45) and toric IOL (n = 48) groups, with no statistically significant differences in laterality, age, or sex distribution (all P > 0.05; Table 1). Similarly, ocular biometric parameters—including axial length, anterior chamber depth, central corneal thickness, and intraocular pressure—did not differ significantly between groups. Preoperative visual acuity (UDVA and BCVA) and refractive measures (corneal astigmatism, refractive cylinder, and spherical power) were also similar across groups, with no significant baseline differences observed (all P > 0.05).

Table 1 Baseline demographic and ocular characteristics of the LRI and toric IOL groups.
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Visual acuity outcomes

Changes in UDVA and BCVA, measured in LogMAR, are summarized in Table 2. UDVA improved significantly over time in both the LRI and toric IOL groups. At baseline, mean UDVA was similar between groups (0.55 ± 0.08 vs. 0.54 ± 0.08; P = 0.706). At 1 month postoperatively, both groups showed substantial improvement, with no significant difference. However, by 3 months, the toric IOL group demonstrated significantly better UDVA than the LRI group (0.19 ± 0.03 vs. 0.22 ± 0.02; P < 0.001), and this difference remained significant at 6 months (0.15 ± 0.03 vs. 0.20 ± 0.03; P < 0.001) (Fig. 1).

Table 2 Changes in uncorrected and best-corrected distance visual acuity from preoperative to 6 months postoperative.
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Fig. 1
Fig. 1
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Postoperative UDVA over time in the LRI and Toric IOL groups.

BCVA also improved significantly within each group over the 6-month period. Although baseline values were comparable (0.40 ± 0.06 vs. 0.39 ± 0.07; P = 0.665), no statistically significant differences in BCVA were observed between the two groups at any postoperative time point (all P > 0.05).

Refractive and corneal astigmatism parameters

Table 3 summarizes the longitudinal changes in refractive cylinder, spherical power, and corneal astigmatism from baseline to 6 months postoperatively.

Table 3 Refractive and corneal astigmatism parameters from preoperative to 6 months postoperative.
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Residual refractive cylinder decreased significantly in both groups following surgery. At baseline, values were comparable (1.74 ± 0.39 D in the LRI group vs. 1.70 ± 0.42 D in the toric IOL group; P = 0.619). Although both groups showed reductions by 1 month, the difference became statistically significant at 3 months (0.97 ± 0.27 vs. 0.73 ± 0.30 D; P < 0.001) and remained so at 6 months (0.94 ± 0.30 vs. 0.67 ± 0.28 D; P < 0.001), with the toric IOL group consistently demonstrating lower residual cylinder (Fig. 2).

Fig. 2
Fig. 2
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Residual refractive cylinder over time in the LRI and Toric IOL groups.

Spherical power also changed significantly postoperatively. Preoperative values were similar between groups (–1.10 ± 1.29 D vs. − 1.02 ± 1.44 D; P = 0.801). By 6 months, the toric IOL group achieved a significantly more precise refractive target closer to emmetropia compared to the LRI group (–0.17 ± 0.39 vs. 0.01 ± 0.25 D; P = 0.011).

Corneal astigmatism (K2–K1) followed different trajectories between groups, reflecting the distinct mechanisms of action. In the LRI group, K2–K1 significantly decreased from 1.83 ± 0.45 D at baseline to 1.01 ± 0.21 D at 6 months (P < 0.001), indicating substantial corneal flattening induced by peripheral incisions. In contrast, the toric IOL group showed minimal change over time (1.79 ± 0.39 D to 1.69 ± 0.34 D; P = 0.326), consistent with lens-based correction that does not alter corneal architecture.

3-Month subjective satisfaction

Table 4 summarizes the distribution of patient-reported visual satisfaction scores at 3 months postoperatively, as assessed using a five-point Likert scale (1 = very dissatisfied; 5 = very satisfied). No patients in either group reported being “very dissatisfied.” In the LRI group, most patients rated their satisfaction as either “satisfied” (40.0%) or “neutral” (26.7%). Only 15.6% reported being “very satisfied” while 17.8% expressed dissatisfaction. In contrast, the toric IOL group exhibited a more favorable distribution: 58.3% were “satisfied” and 22.9% were “very satisfied” with no patients reporting dissatisfaction. The overall satisfaction distribution differed significantly between the two groups (P = 0.009), indicating that patients in the toric IOL group were more likely to experience higher postoperative satisfaction at 3 months.

Table 4 Distribution of 3-month subjective satisfaction scores between LRI and toric IOL groups.
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Discussion

Summary of principal findings

This prospective study evaluated and compared the clinical performance of toric IOL and LRI for the correction of moderate regular corneal astigmatism in patients undergoing cataract surgery. Both surgical strategies led to significant improvements in UDVA and reductions in refractive cylinder. However, from the third postoperative month onward, the toric IOL group consistently demonstrated superior visual acuity outcomes and significantly lower residual astigmatism compared to the LRI group. BCVA remained comparable between groups throughout follow-up, indicating equivalent corrected visual potential. Notably, patient-reported satisfaction was significantly higher in the toric IOL group, with no cases of dissatisfaction, whereas the LRI group included patients expressing suboptimal visual experience. These findings suggest that although both techniques are clinically effective, toric IOL may offer more predictable refractive outcomes and greater subjective visual satisfaction in the correction of moderate regular astigmatism during cataract surgery.

Visual and refractive outcomes

Both toric IOL and LRI significantly improved UDVA following cataract surgery, consistent with expected patterns of refractive recovery in pseudophakic eyes12,13. However, a statistically significant separation in visual outcomes became evident by the third postoperative month, with the toric IOL group achieving better UDVA and lower residual cylinder compared to the LRI group14. This divergence is primarily attributable to fundamental differences in the mechanisms of astigmatic correction. Toric IOL provide internal, lens-based optical correction that remains unaffected by corneal wound healing or peripheral biomechanical variability. When rotational alignment is maintained within 5°, they yield high refractive precision and long-term stability15,16, as the embedded cylindrical component maintains axis fidelity and reduces postoperative fluctuation17.

By contrast, LRIs function by inducing peripheral corneal remodeling through arcuate incisions, making their efficacy more susceptible to inter-individual variability in healing responses and corneal biomechanics18. In this study, the LRI group showed an early reduction in refractive cylinder that stabilized by three months, with minimal subsequent change. The absence of regression in our LRI cohort may be attributed to our standardized technique employing consistent incision depth (85% peripheral corneal thickness) and precise topography-guided axis alignment, though the six-month follow-up period may be insufficient to detect gradual regression typically reported over 12–24 months in other studies. This plateau pattern is consistent with previous findings suggesting that LRI-induced astigmatic correction typically reaches a steady state in the early postoperative period19. Although some studies have reported mild regression over time19, this trend was not observed in our cohort, likely due to standardized incision depth, precise meridional alignment, and favorable wound healing.

The progressive reduction in residual cylinder observed in the toric IOL group from 1 to 6 months differs from the expected pattern where toric IOLs typically achieve stable refractive outcomes within weeks of implantation. This continued improvement likely reflects the resolution of postoperative factors affecting refractive measurements: complete resolution of subclinical inflammation that can influence the optical interface, normalization of tear film stability and corneal surface irregularities that affect measurement accuracy, and gradual maturation of capsular fibrosis that may optimize IOL-capsule relationships without affecting rotational position. While the IOL itself maintains positional stability early postoperatively, these secondary factors may contribute to refinement in measured refractive outcomes over the healing period. In comparison, the Toric IOL group demonstrated a continuous decline in residual cylinder from 0.93 ± 0.27 D at 1 month to 0.67 ± 0.28 D at 6 months. These findings align with prior studies demonstrating the superior refractive accuracy and vector-based astigmatic correction of Toric IOLs20,21. Moreover, the long-term rotational stability and refractive consistency of modern Toric IOLs have been validated across multiple clinical trials22,23.

The significant difference in residual spherical power between groups at 6 months reflects the distinct mechanisms of astigmatic correction. While LRI theoretically maintain spherical equivalent neutrality through 1:1 corneal coupling, the slight myopic shift observed in our LRI cohort may result from incomplete coupling or individual variations in corneal healing response24. In contrast, toric IOL provide internal optical correction without altering corneal curvature, thereby avoiding coupling-related effects on spherical equivalent refraction.

Subjective satisfaction and patient expectations

In this study, patients who received toric IOL reported significantly higher levels of postoperative visual satisfaction compared to those in the LRI group, with no cases of dissatisfaction in the toric cohort. This subjective advantage closely mirrored objective clinical outcomes, including superior UDVA, lower residual refractive cylinder, and greater spectacle independence, particularly from the third postoperative month onward17,22. These findings are consistent with prior research indicating that patient satisfaction is strongly associated with refractive precision, visual quality, and reduced reliance on corrective eyewear25,26. While LRI also led to meaningful visual improvements, the relatively higher residual astigmatism and plateau in refractive gains may have contributed to comparatively lower satisfaction rates.

Importantly, patient-reported outcomes are not determined solely by refractive efficacy. Psychological factors, especially preoperative expectations regarding spectacle independence, visual clarity, and night vision, play a substantial role in shaping perceived outcomes. Patients anticipating complete unaided vision may express dissatisfaction even in the presence of objectively acceptable results. Prior studies have confirmed that misalignment between expected and actual visual function is a significant driver of dissatisfaction, underscoring the importance of comprehensive preoperative counseling and expectation management27. Aligning surgical goals with individual patient priorities remains essential to achieving optimal subjective outcomes.

Economic and clinical considerations

Toric IOL entail higher upfront costs due to their specialized optical design and the need for precise preoperative planning, biometric calculation, and axis alignment. Nevertheless, they may offer long-term economic benefits by reducing dependence on spectacles, lowering the likelihood of postoperative corrective interventions, and enhancing overall quality of life. In contrast, LRI are technically simpler and more cost-effective, making them an attractive option in resource-limited settings or healthcare systems where toric IOL are not covered by insurance. These economic disparities underscore the importance of a personalized approach to astigmatism management.

Femtosecond laser-assisted arcuate keratotomy (FLAK) represents an emerging alternative in contemporary astigmatism correction28. Recent systematic reviews demonstrate that while FLAK achieves meaningful astigmatism reduction with excellent safety profiles, clinical outcomes remain comparable to manual limbal relaxing incisions29. The technology’s substantial economic burden restricts widespread adoption primarily to high-volume premium practices30. Current evidence suggests FLAK may be most appropriately reserved for specific clinical scenarios rather than serving as a first-line treatment for moderate regular astigmatism as evaluated in our study31.

Optimal technique selection should consider not only biometric criteria and the severity of astigmatism, but also patient-specific factors such as visual expectations, occupational visual demands, financial capacity, and access to advanced surgical technologies. Incorporating shared decision-making frameworks that integrate clinical data with individual values is essential to achieving satisfactory visual and functional outcomes. In this context, both cost and expected benefit must be carefully weighed to align surgical choices with patient priorities and systemic constraints.

Limitations

Several limitations should be acknowledged. First, this study employed a non-randomized design where patients self-selected their treatment option following standardized counseling, which may introduce selection bias despite comparable baseline characteristics between groups. Although our balanced recruitment strategy and comprehensive preoperative counseling helped minimize systematic differences, the potential for unmeasured confounding variables that could influence both treatment choice and outcomes cannot be entirely excluded. Second, the sample size was moderate, and although adequate for detecting group differences, larger multicenter trials are needed to confirm generalizability. Third, the follow-up period was limited to six months, which may not capture long-term stability, particularly in relation to toric IOL rotational behavior and LRI-induced corneal remodeling. Fourth, our study utilized conventional astigmatic analysis rather than vector analysis methods such as the Alpins method or Double Angle Plot Tool. While our approach adequately addressed the primary research question, vector analysis would have provided more detailed insights into the accuracy, precision, and predictability of astigmatic correction, including systematic over- or undercorrection patterns for both techniques. Additionally, subjective satisfaction was assessed using a non-validated, self-designed single-item Likert scale. This simplified format was selected to enhance response compliance among elderly participants, although it may limit generalizability and restrict comparison with established instruments such as the NEI VFQ-25. Future studies should incorporate randomized controlled designs, extended follow-up durations, astigmatism axis stratification, validated patient-reported outcome measures, and formal economic evaluations to enhance the robustness and translational relevance of the findings.

Conclusion

This study demonstrates that both toric IOL and LRI are effective in reducing corneal astigmatism and improving UDVA in patients with moderate regular astigmatism undergoing cataract surgery. While BCVA remained similar between groups, toric IOL provided significantly superior UDVA and lower residual refractive cylinder at both three and six months postoperatively. Moreover, patients receiving toric IOL reported higher levels of subjective satisfaction, reflecting not only objective optical benefits but also enhanced perceived visual quality. Although LRI offer a lower-cost and accessible alternative, particularly in resource-constrained settings, toric IOL may yield greater long-term value for patients who prioritize visual precision and spectacle independence. These findings support a personalized, evidence-based approach to astigmatism correction during cataract surgery. Clinical decisions should carefully balance surgical efficacy, patient expectations, and financial feasibility to optimize both visual outcomes and patient satisfaction.