Trifocal Intraocular Lenses Best Preserve Distance Acuity for Patients With Presbyopia

Trifocal IOLs can provide optimal outcomes for patients with presbyopia, without compromising distant visual acuity.

Patients with presbyopia who undergo cataract removal and receive trifocal intraocular lens (IOL) implants experience superior visual quality compared with patients who receive monofocal IOLs, according to a meta-analysis published in JAMA Ophthalmology. However, the report shows some subjective visual quality measures between patients who received the 2 lens types are comparable.

Researchers conducted a bayesian network meta-analysis (NMA) that included 2605 patients from 27 studies. The studies analyzed a total of 8 types of IOLs implanted following bilateral cataract extraction. The researchers analyzed records of subjective visual quality, such as  binocular visual acuity, contrast sensitivity (under photopic and mesopic conditions), and patient-reported outcomes (glare, halos, and spectacle independence). 

The study authors classified IOLs in the analysis as either monofocal, bifocal diffractive (old and new), bifocal refractive (old and new), accommodative, trifocal, or extended depth of focus (EDOF).

All multifocal IOLs showed consistently better performance than monofocal IOLs for near and intermediate vision, consistent with previous reports.

Patients implanted with trifocal (MD, -0.32 [95% CrI, -0.46 to -0.19]) and old bifocal diffractive IOLs (mean difference, -0.33 [95% CrI, -0.50 to -0.14]) experienced better uncorrected near visual acuity than patients implanted with monofocal IOLs. 

Those implanted with EDOF IOLs experienced superior uncorrected intermediate visual acuity compared with those given monofocal IOLs; however, pairwise comparisons found no differences between EDOF and trifocal diffractive IOLs. 

In measuring uncorrected distance visual acuity (UDVA), there were no statistical differences between multifocal and monofocal IOL in terms of contrast sensitivity, glare, or halos, according to the report. However, the report indicates that prior investigations found lower contrast sensitivity in multifocal IOLs than monofocal IOLs (primarily in mesopic conditions), potentially due to structural characteristics of multifocal IOLs which divide light power in 2 or more foci.

“For binocular UDVA, most multifocal IOLs were comparable with monofocal IOLs,” the researchers explain. “All multifocal IOLs showed consistently better performance than monofocal IOLs for near and intermediate vision, consistent with previous reports.”

Limitations include the inability to analyze some metrics, such as defocus curves, and higher-order aberrations, inconsistencies in data gathering, and differences in how the studies analyzed measured visual acuity.


Cho JY, Won YK, Park J, et al. Visual outcomes and optical quality of accommodative, multifocal, extended depth-of-focus, and monofocal intraocular lenses in presbyopia-correcting cataract surgery a systematic review and bayesian network meta-analysis. JAMA Ophthalmol. Published online September 22, 2022. doi:10.1001/jamaophthalmol.2022.3667