Accepted Manuscript

Multifocal Intraocular Lenses: An Overview

Jorge Alio, MD, PhD, FEBO, Ana B. Plaza-Puche, MsC, Roberto Férnandez-
Buenaga, MD, PhD, Joseph Pikkel, MD, Miguel Maldonado, MD, PhD

PII: S0039-6257(16)30063-7
DOI: 10.1016/j.survophthal.2017.03.005
Reference: SOP 6712

To appear in: Survey of Ophthalmology

Received Date: 25 April 2016

Revised Date: 28 February 2017
Accepted Date: 3 March 2017

Please cite this article as: Alio J, Plaza-Puche AB, Férnandez-Buenaga R, Pikkel J, Maldonado
M, Multifocal Intraocular Lenses: An Overview, Survey of Ophthalmology (2017), doi: 10.1016/
j.survophthal.2017.03.005.

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 ACCEPTED MANUSCRIPT
MULTIFOCAL INTRAOCULAR LENSES: AN OVERVIEW
Authors:
Alio Jorge MD, PhD, FEBO1,2
Plaza-Puche Ana B MsC1
Férnandez-Buenaga Roberto MD, PhD1
Pikkel Joseph. MD3

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Maldonado Miguel MD, PhD4

1.Vissum Instituto Oftalmologico de Alicante, Alicante, Spain

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2. Division of Ophthalmology, Universidad Miguel Hernández, Alicante, Spain
3. Department of ophthalmology Ziv medical center, Safed, Israel

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4. IOBA, Universidad de Valladolid, Spain

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Corresponding author:
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Jorge L. Alio, MD, PhD
Avda de Denia s/n, Edificio Vissum
03016 Alicante
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Spain
jlalio@vissum.com
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The authors have no proprietary or commercial interest in the medical devices that are
involved in this manuscript.
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This publication has been carried out in the framework of the Red Temática de
Investigación Cooperativa en Salud (RETICS), reference number RD12/0034/0007,
financed by the Instituto Carlos III – General Subdirection of Networks and
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Cooperative Investigation Centers (R&D&I National Plan 2008-2011) and the European
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Regional Development Fund (Fondo europeo de desarrollo regional FEDER)

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ABSTRACT:
Multifocal intraocular lenses (MfIOLs) are increasingly used in the management of
pseudophakic presbyopia. After MfIOL implantation, most patients do not need
spectacles or contact lenses and are pleased with the result. Complications, however,
may affect the patient’s quality of life and level of satisfaction. Common problems with
multifocal lenses are blurred vision and photic phenomena associated with residual

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ammetropia, posterior capsule opacification, large pupil size, wavefront anomalies, dry
eye, and lens decentration. The main reasons for theseare failure to neuroadapt, lens

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dislocation, residual refractive error, and lens opacification. To avoid patient
dissatisfaction after MfIOLs implantation, it is important to considerer preoperatively

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the patient’s life style, perform an exhaustive examination including biometry,
topography and pupil reactivity, and explain the visual expectations and possible
postoperative complications .

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Key words: Multifocal IOLs, patient dissatisfaction, complications, indications, visual
outcomes
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INTRODUCTION:
Modern lens surgery aims to accomplish ambitious goals in visual and refractive
outcomes . Particularly in highly-developed societies with well-educated individuals,
cataract surgery outcomes are more than just visual restoration and aim to improve the
patient’s quality of life by achieving spectacle independence for all distances. Reduced
spectacle dependence is an increasingly common expectation among those wanting to

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take advantage of newer surgical options, particularly among those with active
lifestyles. Nowadays, many middle aged and older patients are involved in sports,

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reading, as well computer usage, activities much improved by spectacle independence.
This is why addressing pseudophakic presbyopia has become such an important topic in
the practice of modern cataract surgery and, specifically, in refractive lens exchange.13.

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One of the main treatment modalities of pseudaophakic presbyopia are modern
multifocal intraocular lenses (MfIOLs)8. The main challenge for multifocal lenses is that

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they use a non physiological optical method to improve near vision9. Multifocal lenses,
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by definition, separate light into different foci, and this causes a dispersion of the energy
of the light entering into the eyei1,12,30,109,146,188,191. This results in a change in the
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physiology of vision as the light follows a different focal performance at the level of the
visual axis and, consecutively, at the level of the retina. It is necessary to activate a
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process of neuroadaption, the capability of the brain to adapt to changes, to adjust the
neurophysiology of the changes that are induced in the quality of the retinal image by
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the dispersion of light. Moreover, the overlapping of different foci is neither normal nor
physiological in the evolution of humans or animals. To the best of our knowledge, no
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visual system is multifocal in nature in any mammal.

The new and emerging multifocal optical technologies recently developed have aimed
to make a much more physiological division of light. However, the adventages of these
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optical technologies have to be proven by a demostrated improvement in the quality of

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the patient’s vision and life. Since this is the challenge and as there is no existing perfect
solution for the light division in multifocality, there is still a great technological
challenge ahead of us until the real restoration of accommodation in pseudophakia is
accomplished as these lenses, when properly developed , will be more physiological for
near vision restoration27.
Even though not perfect, todays existing intraocular multifocal lenses do provide in
most of the cases a satisfactory solution for good vision at different distances149.
Evidence exits about that when careful patient selection is performed and the surgeon is
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familiar with the implanted lens and knows how to control complications, intraocular
multifocal lenses are today useful and provide good visual results. The existing lenses
currently available in the market provide a large range of solutions and a variety of
possibilities to tackle various clinical situations. According to the optical design of the
lens, they may have a dependency or independency of the pupil size and dynamics.
Even though all designs are made for “in the bag” implantation, sulcus placement is

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becoming a possibility for patients already implanted with a monofocal IOL or when
bag implantation is not feasible due to surgical complications. MfIOLs may be bifocal

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or even trifocal offering different performances for different distances to be better
adapted to the style of life of the patients65. Choosing the right intraocular multifocal

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lens is a process influenced by many factors and considerations, the five most
influencing factors in choosing a multifocal IOL to implant are:
• Patient’s age, needs, lifestyle, and psychological profile

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• Patient’s clinical ophthalmic condition and associated eye comorbidities,
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especially those with a potential negative impact on contrast sensitivity function
• Pupil reactivity and size in different light environments
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• Evidence, published in peer review literature and independent from industry

bias, supporting outcomes of the tentatively selected multifocal intraocular lenses,
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especially the defocus curve of the lens.

• Surgeon’s attitude, education and experience.
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A successful MfIOL will have to have a balance among all these factors and other
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requirements in order to be clinically rewarding and avoid related complications

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1. Modern Multifocal IOLs: technological designs and models:

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Aiming to provide good vision for different distances, different optical solutions for
multifocality have been proposed. A multifocal intraocular lens must incorporate optical
designs to focus light from distant objects and light from near objects at the same time.
Some light is dispersed to no particular focus due to chromatic aberrations, corneal
optical quality, diffraction by the pupil edge and total refractive error of the implanted
eye, among others. These factors are prone to influence the successful outcome of
MfIOL8.
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Multifocal intraocular lenses can be refractive, diffractive, or a combination of both
designs.
The previous and some recent models of refractive MIOLs are rotationally symmetric
and they work by providing annular zones of different refractive powers to provide
appropriate focus for objects near and far. Some newer versions are rotationally
asymmetric with an inferior segment with the refractive power required to provide good

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near vision. They are also called varifocal as they offer a continuous change in power
along a given meridian. Refractive multifocal intraocular lenses may be affected by

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pupil size dynamics and decentration. Refractive multifocal lens implants provide
adequate intermediate and distance vision while near vision is typically adequate, but
may not be sufficient or may affect the quality of the retinal image creating distortion99.

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Limitations of refractive multifocal intraocular lenses are:
• Pupil dependence, variable depending on the design
• High sensitivity for lens centration
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• Intolerance to kappa angle which varies from patient to patient
• Potential for halos and glare due to rough areas between the zones.
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• Loss of contrast sensitivity

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Diffractive lenses are based on the principle that every point of a wavefront can be
thought of as being its own source of secondary so-called wavelets, subsequently
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spreading in a spherical distribution (Huygens-Fresnel principle). The amplitude of the

optic field beyond this point is simply the sum of all these wavelets. When a portion of
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a wavefront encounters an obstacle, a region of the wavefront is altered in amplitude or

phase, and the various segments of the wavefront that propagate beyond the obstacle
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interfere and cause a diffractive pattern. By placing diffractive microstructures in

concentric zones and decreasing the distance between the zones as they get further from
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the center, a so-called Fresnel zone plate is produced that can produce optic foci.
Achieving multifocality in these types of lenses is accomplished for far vision by the
combination of the optical power of the anterior and posterior lens surfaces, the zero
order of diffraction and the near power by combining the power of the anterior and
posterior surfaces and the first order of diffraction.
The diffractive multifocal lens implant usually provides good reading vision and very
good distance vision. The intermediate vision is acceptable, but not as good as the far
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and near vision. Diffractive multifocal intraocular lenses are less pupil size dependent
and are more tolerant to the kappa angle and decentration8. However, their main
disadvantage has been the energy lost caused by light scattering at the diffractive
surfeces.
Diffractive bifocal/multifocal lenses have a high potential of producing halos and glare
due to more non-transition areas. Diffractive cause approximately 18% loss of light in

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transition. These disadvantages may decrease quality of vision especially in mesopic
and scotopic conditions. However, modern diffractive trifocal intraocular lenses

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provide, through different mechanisms, intermediate vision by a redistribution of the
diffracted light to other foci.

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Some models of multifocal intraocular lenses modify the index of refraction so that it
changes from the periphery to the center of the lens, providing a multifocal optical
performance different depending on pupil size. Some aspheric lenses are designed to

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eliminate spherical aberration in the IOL, leaving the corneal spherical aberration to
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introduce extended depth of focus. In order for a multifocal lens to be efficient,
astigmatism must be completely eliminated or reduced to a minimum and therefore the
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ability to use toric multifocal intraocular lenses is of great importance. Visual

performance after MfIOL implantation is negatively influenced by the presence of
significantly increased corneal high order aberrations178.
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2. Patients Selection for MfIOL implantation

Aiming a successful outcome, and in order to avoid complications when implanting
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multifocal intraocular lenses, a variety of influencing factors should be considered and

analyzed. A cataract surgeon should take into consideration the patient’s life style as
well as to detect any ophthalmic comorbidities.
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Patient selection is very important and therefore we will try to describe criteria for a
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successful indication and detecting evidence that could lead to postoperative failure, as
we have learnt from our own experience as well as from others. Patient information
provided and the expected outcomes will avoid further misunderstandings and patient
dissatisfaction.
Inquiring about the patient’s main visual labour activities, hobbies and other daily
activities provides information about the visual requirements to accomplish. The
patient’s tolerance to nightime dysphotopsia and decreases in visual quality should be
taken also into consideration by the surgeon when recommending a multifocal
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intraocular lens. Patient’s personality is important in estimating the patient’s ability to
neuroadapt in cases of postoperative dysphotopsia, halos, and glare and the patient’s
ability to risk a small loss of contrast sensitivity or temporary glare in exchange for a
broader range of vision and spectacle-free near vision. Patient’s personality plays an
important role in preoperative considerations – one should avoid patients with
unrealistic expectations and those with an overly critical personality62.

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Contrast sensitivity function might be significantly affected postoperativelly due to ligh
division ocurred in the MfIOLs design41,133,142, especially in low mesopic environments.

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Night vision is also a major concern when implanting any MfIOL. Patients that already
suffer from night vision problems other than those that are caused by cataract and

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patients that work at night, drive at night, or suffer from other night vision disturbances
should be warned that postoperatively contrast sensitivity might be reduced and halos
and glare may appear or worsen134.

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In summary, the preoperative combination of proper patient selection and proper lens
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selection eventually results in a goos judgement and correct indication of multifocal
IOLs leading to obtain a satisfied patient.
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Postoperativelly, vision degradation may result from ocular surface dryness, blepharitis,
basement membrane dystrophy, corneal scaring, corneal edema, macular edema, other
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retinal diseases, lens decentration, posterior capsular opacification, and residual

refractive error or astigmatism. These variables if exist prior to the surgery , should be
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diagnosed and treated previously to the surgeons should avoid patients who have an
ocular comorbidity that precludes normal visual potential or a chance of a satisfactory
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multifocal spectacle independent outcome. Caution should be taken in patients that have
a long-standing history of monovision contact lens wearing – implanting a multifocal
intraocular lens is a different solution to the refractive error from what the patient is
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already used to. This may cause a neuroadaptive problem. Although we have described
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possible complications of multifocal intraocular lens implants and a long list of

preliminary considerations, overall, the value of multifocality for patients far exceeds
the temporary discomfort and the short-term dysphotopsia that few experience with
multifocal intraocular lenses. Patient selection is of even greater importance in certain
clinical comorbidities that are quite common. Among other factors, the patient’s ocular
condition in addition to his or her personality and lifestyle is a factor that the surgeon
should be aware of when choosing the specific multifocal intraocular lens that best fits
the individual patient150.
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As an example, the use of MfIOLs is still debatable in some clinical situations. MfIOLs
in children raises the problem of IOL calculation in the ongoing growth of the child
resulting in a change of the refractive power of the eye, hence raising the question of
lens150
how to calculate the power of the implanted . Concerns such as reduced contrast
sensitivity and intermediate vision that can exacerbate amblyopia85 , changes of
refractive power and daily tasks whilst growing - the growth of the eye between the

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ages of 10 and 20 may lead to a change of 4.0 diopters174 or more. However, some
authors have reported positive outcomes of MfIOL in children including some
restoration of stereoacuity55.

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Patients with glaucoma have a certain degree of contrast sensitivity reduction and

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mesopic visual function. Multifocal intraocular lenses may reduce contrast sensitivity
and mesopic visual function as well, and therefore they might cause significant vision
disturbances in these patients100,112. While established glaucoma is to be considered a

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contraindication for MfIOL implantation, ocular hypertension may not be a
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contraindication.
Patients affected by any maculopathy are another debatable indication group. There is
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no doubt that patients that suffer from diabetic maculopathy or from age-related macular
degeneration may benefit from cataract surgery and intraocular lens implant. However,
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patients that already suffer from maculopathy have reduced contrast sensitivity which is
additive to the contrast sensitivity reduction from the implanted lens. Nevertheless, the
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overall result of implanting an intraocular lens in these patients is beneficial. Most

multifocal pseudophakic patients without an active retinal disease are satisfied from
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being free from spectacles even though a certain amount of contrast sensitivity is still
lost. Patients with maculopathy and some visual loss are more tolerant to image defocus
and might adapt more rapidly. However, in some of these patients, contrast sensitivity is
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an important measure of their reading ability. Therefore, patients that suffer from
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maculopathy should be carefully selected and assessed preoperative for multifocal

intraocular lens implant8. It is noteworthy than some studies have found that multifocal
intraocular lenses were used to serve as a visual aid in patients that suffer from age-
related macular degeneration. In an article published in 2012, Gayton et al. reported
their experience in implanting multifocal intraocular lenses in patients with age-related
macular degeneration and concluded that multifocal lenses can serve as a low-vision
aid. Targeting the implanted lens for a spherical equivalent of about −2.00 diopters
yielded a +5.20 near addition. Replacing the crystalline lens with this myopia-targeted
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multifocal intraocular lens improved or maintained near vision without severely
compromising corrected distance vision86.
Dry eye syndrome is also a doubtful indication for MfIOL implants. A healthy ocular
surface is a key factor in achieving a successful result in multifocal intraocular lens
implantation. The corneal tear film is the first refractive plane of the eye, therefore its
healthiness and integrity is important. A cataract operation with a multifocal intraocular

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lens implant, but with interference with irregulairties in tear film will result in an
unfavorable refractive result and an unhappy patient. Inadequate tear film might be due

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to the small amount of tear production (dry eyes) or due to poor-quality tears. In both
cases, the result is a disruption of the ocular surface causing a disturbance in vision and

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interference with quality of life. About 15% of unsatisfied multifocal intraocular
patients suffer from dry eyes, reporting of blurred vision and photic phenomena in
addition to irritation, redness, and excessive tearing9.

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Categorization the dry eye into aqueous deficiency state or to poor tear quality or a
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combination of both is helpful in choosing the treatment strategy70. Dry eye should be
diagnosed and treated conveniently preoperatively.
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Proper mechanical lid function, lack of presence of any anterior or posterior blepharitis
(such as seborrheic anterior blepharitis and meibomianitis) and other diseases of the
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ocular surface should be diagnosed and treated as they are a risk factor for postoperative
infection and inflamation59,127,136.
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3. Monocular implantation of Multifocal Intraocular Lenses

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As multifocal intraocular lenses are prone to reduce contrast sensitivity, in cases where
only one eye is operated, the amount of light finely reaching the retina might be less
when compared to the unoperated eye. A relevant difference in the quality of the retinal
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image between both eyes may be inconvenient and could take time to get used to.
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Neuroadaptation to this difference is a time-consuming procedure, but eventually the

brain neuroadapts and the perceived image from both eyes is clear and integrated in the
vast majority of patients. Opponents to multifocal intraocular lenses warren from
monocular supression124 while others suggest that multifocal intraocular lenses should
be implanted in unilateral cataract patients and the overall outcome is satisfactory.
Several reports on monocular multifocal lenses suggest that results in these cases are
good and multifocal intraocular lenses in one eye provides better stereopsis, higher
spectacle independence rate and satisfactory functional vision compared to monofocal
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lens implant in unilateral cataract patients55. Although bilateral multifocal intraocular
lens implant is probably the most favorable, unilateral implantation of multifocal lenses
may also provide patients with high levels of spectacle independence without
compromising contrast sensitivity114, especially in young patients.

4. Neuroadaptation and Multifocal Intraocular Lenses:

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Due to the fact that the division of light caused by the particular optical design of
MfIOLs induces different focal points, the brain receives simultaniously different

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images which have to be processed and used to focus objects at different distances. The
visual function is developed processing only one image which, in case of

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accommodation, changes the focal point to adapt the focus to the distance to which we
want to get a focused image. This is the reason that a visual neuroadaptation process is
necessary for the brain to use properly the different images which are provided by

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multifocal optics. Failure in this neuroadaptation may cause the perception of glare,
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confusion, distorsion and the feeling of poor vision.
Neuroadaptation is an acquired process and our brain gets used to correct the visual
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input according to what the brain already knows as learnt. Neuroadaptation is a process
in which the human nervous system adjusts to changes in neural inputs. In the case of
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MFIOLs, it is actually a process in which the brain learns how to “correct” the image to
properly use it so that the final perception is as real as possible. Due to aberrations
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caused by the cornea and the crystalline lens, the image on the retina is not perfect and
is somewhat blurred. When implanting an intraocular lens, the aberrations of the cornea
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change due to the surgical incisions and the lens’ aberrations change as well. Multifocal
intraocular lenses, due to their design, induce a further change since at least one focus
(intermediate vision or near vision) is blurred, thus creating a more complex challenge
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for the brain to adapt to the new image on the retina89.

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At first, the brain will correct the new image as it used to correct the previous
(preoperative) image, thus creating an “additive” mistake. After neuroadaptation occurs
(new adjustment to the new situation), the perceived image will be similar to the real-
world image. Visual neuroadaptation in MfIOLs is more difficult and may be a time-
consuming process. It is dependent on individual factors, some are dependent on the
particular type of multifocal optic and the intraocular lens associated optical higher
order aberrations, while others depend on the individual patient. One of these variables
is age, younger patients find it easier to neuroadapt than older ones. The diffractive or
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refractive character of the MfIOL implanted causes differences in the neuroadaptation
process, which may influence the outcome.
A young active patient will probably want neuroadaptation to be as short as possible,
but they have to understand that this process cannot be rushed. It is important for the
surgeon to take the time to discuss this issue prior to the operation – patients should
know that it takes time to achieve a good vision. Some authors propose that

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neuroadaptation can be hastened by visual training. Hovewer, there is no consistent
evidence to confirm whether training helps or not , even though some evidence indicates
that visual training might be a possible solution for the non-adapting patients38,96.

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Neuroadaptation can occur in response to either a monocular or binocular visual

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disturbance, and is dependent on a great extent on visual awareness. Neuroadaptation is
a major concern when implanting multifocal intraocular lenses since these lenses, in
order to achieve multifocality, superimposse images and reduce in variable degrees

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contrast sensitivity.
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Eventhough multifocal intraocular lenses are a challenge related to the negative aspects
of neuroadaptation, they offer an opportunity to improve patient’s satisfaction related to
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the possibility to use different focal distances in daily life, which is a beneficial process
that may foster positively neuroadaptation. According to this balance, neuroadaptation
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is a problem and a solution at the same time, and as most surgeon’s experience, the vast
majority of patients experience visual improvement and enjoy doing visual daily tasks
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with no problem, usually within a short time after the operation, hence proving once
again the superiority of the human mind and the brain’s flexibility which
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neuroadaptation is part of. The typical neuroadaptation process after multifocal IOL
implantation involves a minimum of approximately three months for photic phenomena
to lessen significantly, reaching this continuous process its maximum improvement one
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year after surgery95.

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5. Multifocal IOL visual outcomes

A scientific literature search was performed in Medline from 2000 to January 1st 2016.
The key search terms were “multifocal intraocular lens” and “visual outcomes”.
Abstracts and full papers were examined. A total of 102 were found and 74 abstracts
and full papers were selected. The inclusion criteria were papers published in English
and studies reporting multifocal IOL visual outcomes. Exclusion criteria were case
reports, studies involving patients with ocular pathologies with an expected negative
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positive effect of the surgery on the visual outcome, eyes with previous ocular surgeries
and studies with mix and match multifocal IOL implantation.
The main outcomes extracted from the papers revised included the type of multifocal
IOL implanted, number of patients and eyes, uncorrected distance visual acuity
(UDVA), uncorrected near visual acuity (UNVA), uncorrected intermediate near visual
acuity (UIVA), refractive outcomes, patient satisfaction, spectacle independence and

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frequency of photic uncomfortable phenomena by the patient such as glare and halos
rate. The data compiled in this way from the different reports selected for this review

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are summarized in Table 1.

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Uncorrected distance visual acuity
Table 1 shows the UDVA outcomes published with different multifocal IOL models.
For the multifocal IOL models analysed the mean monocular UDVA was better than

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0.30 LogMAR in 100% of the papers examined. Monocular UDVA was better than 0.10
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logMAR in 70.6% of IOL groups evaluated.
In all studies collected with binocular UDVA data, a binocular UDVA of 0.30 logMAR
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was achieved in 100% of them. Binocular UDVA was better than 0.10 logMAR in 77.3
% of IOL groups analysed.
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Monocular UDVA was better than 0.10 logMAR in 57.1 % of refractive IOL groups
evaluated. Monocular UDVA was better than 0.10 logMAR in 73.7% of diffractive IOL
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groups evaluated.
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Uncorrected near vision

Table 1 shows the UNVA outcomes published with different multifocal IOL models.
For the multifocal IOL models analysed the mean monocular UNVA was better than
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0.30 LogMAR in 92.6% of the papers examined. Monocular UNVA was better than
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0.10 logMAR in 38.3% of IOL groups evaluated.

Binocular UNVA of 0.30 logMAR was achieved in 97.3% of IOL groups analysed.
Binocular UNVA was better than 0.10 logMAR in 62.16 % of IOL groups analysed.
Monocular UNVA was better than 0.10 logMAR in 19.23% of refractive IOL groups
evaluated. Monocular UNVA was better than 0.10 logMAR in 47.3% of diffractive IOL
groups evaluated.

Uncorrected intermediate visual acuity

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Table 1 shows the UIVA outcomes published with different multifocal IOL models. For
multifocal IOL models analysed the mean monocular UIVA was better than 0.30
LogMAR in 95% of the papers examined. Monocular UIVA was better than 0.10
logMAR in 22.5% of IOL groups evaluated.
Binocular UIVA of 0.30 logMAR was achieved in 96.0% of IOL groups analysed.
Binocular UIVA was better than 0.10 logMAR in 32 % of IOL groups analysed.

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Monocular UNVA was better than 0.10 logMAR in 19.23% of refractive IOL groups
evaluated. Monocular UNVA was better than 0.10 logMAR in 47.3% of diffractive IOL

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groups evaluated.

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Spectacle independence
Of the reviewed articles that have not been differentiated between distance and near
vision to study the independence of glasses, a global spectacle independency of 80% or

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higher in 48.7% were found. When the authors differentiated distance, intermediate or
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near vision, spectacle independence was 80% or more in 91.6% of reports for distance,
for intermediate vision in 100% and 70% for near vision from the different IOL groups
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studied (table 1).

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Patient satisfaction
Many quality of life questionnaires are available to evaluate patient satisfaction, these
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outcomes are shown in table 1. Overall patient satisfaction was found to be good with
multifocal IOLs.
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Two principal studies were found that analyzed the patient dissatisfaction after
multifocal IOL implantation. De Vries et al.61 encountered that the most common
symptoms of dissatisfaction with multifocal lenses are: 94.7% eyes presented blurred
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vision, 38.2% eyes presented photic phenomena. The principal findings associated with
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these symptoms are residual ammetropia in 65.5% of eyes, posterior capsule

opacification (PCO) in 15.8%, large pupil size in 14.5% of eyes, wavefront anomalies in
11.8% of eyes. Woodward et al174 found that principal symptoms of patients with
dissatisfaction were blurred vision in 95% of eyes and photopic phenomenon in 42% of
eyes. In this study, the blurred vision was in relation with residual ammetropia in 29%
of eyes, with dry eye in 15% of eyes and with PCO in 54% of eyes. Photopic
phenomena was associated with dry eye in 5% of eyes, with IOL decentration in 11% of
eyes and PCO in 67% of eyes.
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Visual symptoms
Halos and glare at night were the most commonly reported visual symptoms57,61,94,175.
There are several methods to evaluate the presence of halos and glare and very few of
them are validated. The studies that evaluate the presence and severity of glare and
halos are listed in table 1.

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6. COMPLICATIONS FOLLOWING MULTIFOCAL IOL SURGERY AND

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CLINICAL MANAGEMENT OF THE PATIENT WITH DISTURBING VISUAL
SYMPTOMS.

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Reasons for patient’s dissatisfaction:
Implantation of multifocal IOLs offer the possibility to achieve spectacle independence

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at all distances. The overall evidence indicates that multifocal IOLs achieve frequently
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high patient satisfaction48,49 , with scores of 8.3±1.6 (over of 10) and 8.5±1.2 (out of 9),
respectively101. However, complications sometimes occur that influence the quality of
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life and the level of patient’s satisfaction.

In a paper from our research group we found correlations between some clinical
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parameters and the quality of life, such as driving (especially at night) and contrast
sensitivity or eyesight quality and uncorrected distance visual acuity24.
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In a recent publication, an interesting correlation between positive dysphotopsia

complaint and personality type was found. In this study, 82.2% of the patients would
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opt for a multifocal IOL again, 3.7% would not and 14.1% were uncertain. The overall
satisfaction achieved with the procedure was correlated to low astigmatism, good visual
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performance, low halos and glare perception and low spectacle dependence. The
personality characteristics of compulsive checking, orderliness, competence, and
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dutifulness were statistically significantly associated to subjective disturbance by glare

and halos116.

Blurred vision is the leading cause of dissatisfaction among patients with multifocal
IOLs.175 Woodward et al. reported that blurred vision was the main complaint in 30 (41
eyes) out of 32 patients (43 eyes). 15 patients (18 eyes) reported photic phenomena and
13 patients (16 eyes) reported both blurred vision and photic phenomena. The etiology
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of blurred vision was attributed to ametropia and PCO in the majority of cases. Despite
overall success with less invasive interventions, 7% of eyes required IOL exchange to
resolve symptoms175.
In a different study focused on the same issue, blurred vision (with or without photic-
phenomenon) was reported in 72 eyes (94.7%) and photic phenomena (with or without
blurred vision) in 29 eyes (38.2%). Both symptoms were present in 25 eyes (32.9%).

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Residual ametropia and astigmatism, posterior capsule opacification, and a large pupil
were the 3 most significant etiologies. Intraocular lens exchange was performed in 3
cases (4.0%)61.

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A Cochrane review about multifocal IOLs, found that photic phenomena are 3.5 times
more likely with multifocal IOLs than with monofocal IOLs107. Most of the times there

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is an identifiable reason. In a publication mentioned above, it was shown that causes of
blurred vision included ametropia (29% of cases), dry eye (15%), posterior capsule

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opacification (PCO) (54%) and unexplained etiology (2%). Regarding the photic
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phenomena, its causes included IOL decentration (12%), retained lens fragment (6%),
PCO (66%), dry eye (2%) and unknown etiology (2%). In this paper, the authors
achieved an improvement in 81% of eyes with conservative treatment175. In a similar
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study, 84.2% of eyes were amenable to therapy, with refractive surgery, spectacles, and
laser capsulotomy as the most frequent treatment modalities61. In a very recent paper
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over more than 9300 eyes implanted with a multifocal IOL patient satisfaction was very
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high: 93.8% of the patients reported to be satisfied or very satisfied while only 1.7% of
the patients were dissatisfied or very dissatisfied170.
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Complications following multifocal IOL surgery

1-IOL decentration:
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Several clinical studies have determined the decentration of IOLs after

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cataract34,63,92,98,122,123,127,152,162-164. In general, the mean decentration (after uneventful

cataract surgery) in the studies is 0.30 ± 0.16 mm (range 0 to 1.09 mm). When a
multifocal IOL is displaced from its center, it may lose its ability to achieve optimal
optical properties thus decreasing the visual function (Figure 1). There are three main
factors that determine how visual function is affected by IOL decentration:
• Amount of IOL decentration,
• Multifocal IOL technology design,
• Pupil size
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In a recent study 4 different multifocal IOL models (2 diffractive and 2 refractive)
performance was studied at increasing degrees of decentration in an eye model with a 3
mm pupil. For the ReSTOR (+4), the near MTF (modulation transfer function)
deteriorates with increasing degrees of decentration while the far MTF tends to
improve. This is explained by the specific design of this IOL with a monofocal design
in its peripheral part. In other IOL models like the ZM900 the entire optical surface has

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a diffraction structure, therefore a slight decrease in both far and near MTF starting at
decentrations of 0.75 mm was observed. For the refractive models (ReZoom and SFX-

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MV1), even when the decentration was 1mm, the near MTF did not change. However
the far MTF decreased starting at decentrations of 0.75 and 1mm, respectively. In

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conclusion, the MTFs and near images are affected, but clinical relevant effects are not
to be expected up to a decentration of 0.75mm using this eye model with a 3mm pupil
and the previously mentioned IOLs160.

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In a different report comparing refractive multifocal and monofocal IOL performance
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depending on the pupil size and decentration, it was found that in the multifocal group
smaller pupils correlated with worse near visual acuity while decentration was
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significantly correlated with worse distance and intermediate visual acuity. However, in
the monofocal group, pupil size and IOL decentration did not affect the final visual
acuity84.
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It has been also shown by other authors that the more optically sophisticated the IOL
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optic, the more sensitive to decentration and tilt it is. This issue is supported by a report
comparing aberration-correcting, aberration-free and spherical IOLs, after decentration,
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the performance of the IOL was more affected in the aberration-correcting group
followed by the aberration-free IOLs while the spherical IOLs were not affected by
decentration at all66.
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Another interesting consideration is the presence of a large kappa angle. Although it is

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not very common, some patients may have a large kappa angle. It should be suspected
and checked in every patient with a perfectly pupil centered multifocal IOL, but
complains about poor vision130.
Management: The first important message is that multifocal IOL decentration that
occurs after an uneventful cataract surgery can be managed without IOL explantation in
the majority of cases. We advocate performing Argon laser iridoplasty as the treatment
of choice. The Argon laser settings for the iridoplasty are 0.5 sec, 500 mW and 500 µm.
Other authors have also recommended this approach (E.D. Donnenfeld, MD, et al.,
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‘‘Argon Laser Iridoplasty to Improve Visual Function After Multifocal IOL
Implantation,’’ presented at the ASCRS Symposium on Cataract, Intraocular Lens and
Refractive Surgery, Chicago, Illinois, USA, April 2008).

2-IOL tilt:
The material and biocompatibility of the haptics have been shown to play a role in IOL

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centration56,153. Hydrophilic IOLs have several advantages because of its pliable and
scratch resistance nature allowing these IOLs to be implanted through small corneal

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incisions. The combination of hydrophilic material with soft C-loop haptics may
facilitate IOL decentration and tilt when capsule bag contraction starts to develop.

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Rotationally asymmetric refractive IOLs are sensitive to decentration and tilt because
their inherent design caracteristics17,21,167.
Our group has recent publications on this issue especially regarding our experience

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with the Oculentis Mplus IOL17,21,23. To date, there are two different platform versions
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of the Lentis Mplus, the LS-312 and the LS-313. The former one was the first to be
marketed and it has a C-loop design while the latter one has a plate-haptic design. Also,
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we published the first paper evaluating this IOL performance “in vivo” and comparing
it with a monofocal spherical IOL17. It was discussed in this manuscript that the
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multifocal IOL group showed larger amounts of intraocular tilt. This suggested that the
Lentis Mplus LS-312 might be tilted and perhaps decentered in the capsular bag in a
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significant number of cases. Capsular tension rings (CTR), have been shown to inhibit
posterior capsule opacification97, play a role in the stability and positioning of IOLs106
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and prevent IOLs movements caused by capsular bag contraction150.

Based on the outcomes showed in this study, we tried to to ascertain also whether the
use of a capsular tension ring positively affects the refractive and visual outcomes as
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well as the intraocular optical quality of eyes implanted with the rotationally
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asymmetric multifocal Lentis Mplus LS-312 IOL (Oculentis GmbH, Berlin, Germany).
Two different groups of patients were compared, one group with the Mplus LS-312 plus
CTR and the second group implanted without CTR. It was found that refractive
predictability and intermediate visual outcomes with the Lentis Mplus LS-312 IOL
improved significantly when implanted in combination with a capsular tension ring23. In
another study12, the effectiveness of a capsular tension ring to stabilize a diffractive
multifocal IOL model was also demonstrated.
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Due to all these inconveniences discussed above, Oculentis GmbH, Berlin, Germany,
decided to introduce a new plate-haptic design for the Mplus IOL, the LS-313, in an
attempt to achieve a greater IOL stability when capsular bag contracts. We tried to
verify whether that purpose was achieved with the new design21, confirming the more
consistent behaviour of this lens design in the capsular bag based on its improved
optical design.

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3-Inadequate pupil size:
Postsurgical pupil size is a very important parameter that definitely determines the IOL

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performance. The main challenge regarding this issue is that it is very difficult to predict
the pupil size that will be found after the surgery because it usually changes in

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comparison with the preoperative measurements. Thus a very small pupil after the
surgery will limit the near vision performance of most of the multifocal lenses. On the
other hand, large postoperative pupils are associated with increased photic phenomena

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referred by the patients.
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Visual acuity correlates with pupil size; a larger pupil permits greater use of the
multifocal IOL optic with zonal models and improved contrast sensitivity with
diffractive models84,119
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Management:
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-In patients with poor near vision outcomes due to very small pupils we advocate to use
cyclopentolate to enlarge the pupil, if a clear improvement is noticed, the patient may
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keep using the cyclopentolate as described by other authors175 or an 360º Argon

iridoplasty (0.5 sec, 500 mW and 500 µm) can be planned.
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-The other side of the spectrum is comprised by patients with pupils that are too large
and complain of increased photic phenomena. In these cases, brimonidine tartrate 0.2%
to decrease mydriasis at night is a classical solution in refractive surgery. This has been
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also recommended by other authors30,47,175. It decreases the pupil size, thus improving
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the photic phenomena at night.

4-Residual refractive error:

Despite new advances in cataract surgery, unsatisfactory visual outcomes as a result of a
residual refractive error occasionally occur. A recent report analyzing refractive data
from more than 17000 eyes after cataract surgery showed that emmetropia was only
reached in 55% of eyes planned for that goal35. These outcomes highlight that refractive
error after cataract surgery is an important issue.
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Postoperative refractive errors may be due to different causes, such as inaccuracies in
the biometric analysis136,144,159 , inadequate selection of the IOL power, limitations of
the calculation formulas especially in the extreme ametropia, or IOL positional errors67.
Previous studies have shown good efficacy, predictability and safety for myopic and
hyperopic laser in situ keratomileusis (LASIK) and photorefractive keratectomy (PRK)
enhancements after cataract surgery3,32,120,126,139,142. Lens based procedures are also

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useful alternatives to consider82,91. It should be noticed that some surgeons do not have
easy access to excimer laser, thus lens procedures become the only possible option in

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these cases. We have recently reported a study that aimed to present and compare the
results assessing the efficacy, predictability and safety of three different procedures to

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correct residual refractive error after cataract surgery: LASIK, IOL exchange and
piggyback lenses implantation. Although this study only included monofocal IOLs, the
outcomes could be extrapolated to multifocal IOLs. The results of this study showed

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that the three procedures were effective, but LASIK achieved the highest efficacy index,
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the best predictability with 100% of the eyes within ± 1 diopters of final spherical
equivalent and 92.85% of eyes showed a final SE within ±0.50D. LASIK also showed
lower risk of losing lines of corrected vision compared to the other two procedures69.
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Regarding laser enhancement after multifocal IOL implantation, some authors have
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reported improvement in distance vision with limited effect on photic phenomena after
PRK re-treatments in patients implanted with refractive multifocal IOLs105, while others
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have reported excellent predictabilit3.

In another study performed by our research group, we evaluated efficacy, predictability,
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and safety of LASIK to correct residual refractive errors following cataract surgery,
comparing the outcomes of patients implanted with multifocal and monofocal IOLs. We
found that laser in situ keratomileusis refinement after cataract surgery with monofocal
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IOL implantation provides a more accurate refractive outcome than after multifocal IOL
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implantation. Predictability of LASIK correction is limited in hyperopic eyes implanted

with multifocal139 IOLs. It should be noted that residual spherical ametropia (myopia
and hyperopia) should be assessed properly by performing a compete defocus curve,
otherwise, a serious mistake can arise from refracting solely either the far or near foci of
the multifocal IOL.

5-Posterior capsule opacification:

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The most common long-term complication of IOLs implanted is posterior capsule
opacification (PCO).29,31,161
A Cochrane Review74 showed significantly higher PCO rates after hydrogel IOL
implantation than after implantation of IOLs of other materials, significantly lower PCO
rates with sharp posterior optic edge IOLs than with round-edged IOLs, no difference
between 1-piece and 3-piece IOLs, lower PCO rates with IOLs placed in the capsular

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bag than in the sulcus, and lower PCO rates in eyes with a small capsulorhexis than with
a large capsulorhexis.

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In a study comparing the frequency of posterior capsulotomies in patients receiving a
multifocal or monofocal intraocular lens (IOL) of a similar design showed that the use

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of multifocal IOLs in clinical practice may result in more frequent Nd:YAG laser
capsulotomies. After an average 22-month postoperative follow-up (range: 2 to 41
months), 15.49% of eyes in the multifocal group underwent posterior capsulotomies

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compared to 5.82% of eyes in the monofocal group163.
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The main complaints in patients with multifocal IOLs implanted and PCO are blurred
vision and increased photic phenomena175. In fact, in this study, blurred vision and
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photic phenomena were attributed to PCO in 54% and 66% of eyes, respectively.
Other authors have studied the capsulotomy rate after the implantation of different
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multifocal IOL models to see if there is a difference in this rate related to the IOL
material or design. The authors compared a hydrophobic lens (AcrySof ReSTOR) with
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a hydrophilic IOL (Acri.LISA) and they found that 24 months after the surgery the
capsulotomy rates were 8.8% in the hydrophobic group and 37.2% in the hydrophilic
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group (P< 0.0001). Eyes in the hydrophilic group had a 4.50-fold (2.28 versus 8.91)
higher risk for Nd:YAG laser capsulotomy (P<.0001)79.
Management: The best treatment to resolve a PCO is Nd:YAG laser capsulotomy.
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However, we encourage surgeons to reserve Nd:YAG capsulotomy until all other

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causes of patient complaints are treated or ruled out. Although IOL exchange is
necessary in rare cases, it is significantly more challenging and associated with higher
risk of complications when the posterior capsule has been previously opened. Surgeons
should be especially aware of patient complaints arising from elements intrinsic to IOL
design, which should generate complaints in the immediate postoperative period before
PCO formation.

6- Photic phenomena and contrast sensitivity:

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In a very recent literature review about multifocal IOL benefits and side effects, photic
phenomena was detected as one of the most important drawbacks after multifocal IOL
implantation63. Halos and glare are more often reported by patients with a multifocal
IOL than with a monofocal IOL45,83. Refractive multifocal IOLs appear to be associated
with more photic phenomena than diffractive multifocal IOLs49. Photic phenomena are
among the most frequent reasons for dissatisfaction after multifocal IOL

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implantation61,175.
Multifocal IOLs are associated with a lower contrast sensitivity than monofocal IOLs49,
especially in mesopic conditions6. It has been demonstrated that patients with a

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diffractive multifocal IOL have a relevant reduction in contrast sensitivity, especially in

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the low mesopic range, as assessed with standard automated perimetry for size III and
size V stimuli in comparison with phakic patients and with monofocal implanted
patients33.Modern diffractive multifocal IOLs appear to be equal or superior to

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refractive multifocal IOLs with respect to contrast sensitivity112,113,115, with the
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exception of the MPlus Oculentis group of lenses in which one of our studies
demonstrated they induce no changes in CSF, especially in low mesopic
environments140, a finding probably related to the large amount of the optical profile tha
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these lenses offer for distance vision.

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Management:
The photic phenomena management starts before the cataract surgery with adequate
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patient’s education. The patient candidate to MfIOL implantation should be informed

that they will notice some degree of glare and halos after the surgery, although in most
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of the cases, the photic phenomena will be mild to moderate and most of the patients
will get used to it with time (neuroadaption process). However, it is generally not
recommended to implant multifocal IOLs in night professional drivers, even more so if
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the patient has a large scotopic pupil size which will increase the perception of halos
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and glare at night.

7-Dry eye:
Dry eye is a multifactorial disease of the tear film and the ocular surface that results in
symptoms of discomfort, visual disturbance, and tear-film instability.
Dry eye and cataract formation are very common in the elderly population. In addition,
cataract surgery can induce dry eye or exacerbate a pre-existing disease. The incisions
created during surgery may damage the cornea’s neuro-architecture, reduce corneal
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sensation, and induce dry eye disease64. A study found a significant increase in the
incidence of dry eye in patients after having cataract surgery108. In another study,
patients with pre-existing dry eye had decreased tear production and tear breakup time
(TBUT) after cataract extraction, leading to ocular discomfort and irritation143.

ºManagement:

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Dry eye treatment is not the purpose of this chapter, but as general guidelines the
treatment should be started by improving the eyelid hygiene and using artificial tears. In

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more resistant cases cyclosporine has proven to be a very useful treatment improving
patient symptoms and tear break-up time and decreasing conjunctival staining64.

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Another alternative to consider is to implant punctal plugs, especially in those patients
with aquous deficiency and lack of associated inflammation. We have a very positive
experience with the use of PRP (platelet rich plasma) drops in patients presenting with

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severe dry eye. We have conducted several studies which show that platelet rich plasma
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has very good outcomes in treating dry eye, dry eye ocular surface syndrome after
LASIK surgery, dormant corneal ulcers and even perforated corneas in its solid
form9,10,15,26,87.
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7. MULTIFOCAL IOL EXPLANTATION AND EXCHANGE

Multifocal IOL explantation and replacement represents the major failure of the
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intended MfIOL surgery. It is always disappointing for both patient and surgeon.
Furthermore, IOL explantation surgery is not always easy to be performed and may be
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followed by new complications. Due to of all these reasons, multifocal IOL explantation
and exchange should only be performed when there is no other alternative and all the
causes leading to patient dissatisfaction have been properly ruled out. MfIOL exchange
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or explantation may be associated with new complications. Several studies show that
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the rate of multifocal IOL exchange among dissatisfied patients is 0.85%170, 4%61, and
7%175.
In a study analyzing the main reasons for pseudophakic IOL explantation, the failure to
neuroadapt in patients with multifocal lenses implanted was the fourth main cause of
explantation after IOL dislocation (first cause), refractive error (second cause) and IOL
opacification (third cause)68. Explantation surgery is always challenging, however,
explantation of a multifocal lens is usually easier (especially with a capsular tension
ring) than explantation due to the other causes. First, because the decision of
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explantation is made only a few months after the cataract surgery, hence the scarring
process has not occurred yet and second because the ocular structures are undamaged,
therefore, the surgery is less risky. On the contrary, when performing IOL explantation
due to other causes, such as dislocation or IOL opacification, the surgery is associated
with more complications due to the ocular structure damage in the former and the
presence of fibrotic tissue in the latter especially because in these cases the IOL

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explantation is performed a long time after the original cataract surgery70,71.
The main issue about multifocal IOL explantation is if it is worth doing or not. Is the

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satisfaction rate higher after the explantation and exchange surgery?; Is it associated to a
high complications incidence? Surprisingly, to date, there are only two papers77,94

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answering these questions.
In the first publication, Galor et al78, retrospectively studied the outcomes after
refractive IOL explantation in 12 eyes of 10 dissatisfied patients. The main symptoms

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before surgery were blurry vision, glare/halos and contrast sensitivity loss. The
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conclusions of this paper were the improved symptoms leading to the explantation
surgery in most of the patients (8 out of 10). Second, after the exchange surgery the
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refractive deteriorated. Third, there were severe complications in 2 eyes, such as corneal
decompensation and IOL dislocation requiring scleral suturing having steroid response
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with elevated IOP and cystoid macular oedema in the postoperative course.
The other publication is more recent and larger. Kamiya et al.94shows a retrospective
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study that included 50 eyes that required multifocal IOL explantation. Of the explanted
multifocal IOLs, 84% were diffractive and 16% were refractive. Monofocal IOLs
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accounted for 90% of the new implanted IOLs. The most common complaints before
the explantation surgery were waxy vision (58%), followed by glare and halos (30%),
blurred vision for far (24%), dysphotopsia (20%), blurred vision for near (18%) and
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blurred vision for intermediate (6%).

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The main objective reasons for explantation were decreased contrast sensitivity (36%),
photic phenomena (34%), unknown origin including neuroadaption failure (32%) and
incorrect lens power (20%). After the IOL exchange surgery, patient satisfaction
significantly increased. The UDVA, CDVA, contrast sensitivity improved with the IOL
explantation. Regarding complications, anterior vitrectomy was necessary in 3 cases
(6%). The IOL was placed in the bag in 38 eyes (76%), out of the bag in the sulcus in
11 eyes (22%) and sulcus placement with scleral suture in 1 more eye (2%).
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DISCUSSION:
Cataract surgery with multifocal IOL implantation aims to achieve a complete spectacle
independence visual rehabilitation for all viewing distances. The advantage of this
complete visual rehabilitation is to provide a better quality of life related to spectacle
independence IOLs. However, the disadvantages, such as optical side effects,
neuroadaptation, etc. obtained after implantation of multifocal IOLs, are well known.

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The aim of this review is to offer to the opthalmic clinician and surgeons an updated
and integrated perspective about the visual, refractive outcomes, patient satisfaction,

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complications and causes of failure leding to explanation in patients implanted with
multifocal IOLs.

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In this review, the visual acuity data were collected for different viewing
distances. With this visual acuity information it is important to define an index of
success after implantation of multifocal IOLs to assess the favorable visual

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rehabilitation in the last years with these kind of IOLs. In this review, the index of
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success was defined as UDVA, UNVA better than 0.10 LogMAR. In the IOL groups
analyzed in this study, 39.60% of the groups obtained a successful outstanding visual
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rehabilitation according to the index of success as previously defined. This index shows
a low-medium visual rehabilitation after implantation of multifocal IOLs. In contrast,
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72% of the IOL groups analyzed show a spectacle independence of 70% or higher.
These indexes demonstrate that a medium percentage of eyes implanted with multifocal
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IOLs do not have a complete visual rehabilitation due to a residual refractive error.
The patient satisfaction analysis is difficult due to the different quality of life
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questionnaires and scales used to measure this parameter. In this review this information
is collected and the outcomes observed show a high patient satisfaction, but is important
to analyze what causes patient dissatisfaction after multifocal IOL implantation. The
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main causes of patient dissatisfaction observed in this review are blurred vision and
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photic phenomena. Blurred vision is associated in the publications reviewed to residual

ammetropia, PCO, dry eye, large pupil size and wavefront anomalies. Also, photopic
phenomena were associated to dry eye, with IOL decentration and PCO.
Residual refractive error is one of the most common reasons of patient complaints after
cataract surgery with multifocal IOL implantation. Previous studies have shown the
effectiveness to treat the refractive errors with LASIK and PRK enhancements after
cataract surgery3,32,105,120,126,138,141 or IOL exchange and piggyback lenses implantation.
Hence, it is extremely important to make sure, prior to the cataract surgery with
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multifocal IOL implantation, that the patient has normal topography and pachymetry
that will permit a laser enhancement in case it is needed.
The PCO is another important reason of blurred vision and patient dissatisfaction, this
complication is frequent after long term multifocal IOL implantation. Patients with PCO
complain of decreased visual acuity, contrast sensitivity and increased photic
phenomena, such as glare. PCO is especially important in multifocal IOLs because due

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to their designs and the patients higher visual demands, these lenses might be more
sensitive to PCO than the monofocal ones. The treatment is fast and safe using the

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Nd:YAG laser. However, although rare, there may be some associated complications
like optic IOL damage, increased intraocular pressure, cystoid macular edema, and
retinal detachment increased risk90. Furthermore, the procedure has a noticeable

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economic impact (250 millions of dollars/per year in USA).
Dry eye is a very frequent complication in older patients and given the inherent

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importance of the ocular surface and tear film to the quality of vision, dry eye may
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significantly degrade visual outcomes after multifocal IOL implantation64.The presence
of dry eye after multifocal IOL implantation produce blurred vision and photic
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phenomena. For this reason, postoperative cataract surgery topical medications may
also play a role in triggering dry eye or exacerbate a pre-existing one. Therefore, it is
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mandatory to use preservative-free drops and avoid very long and unnecessary
antibiotic prescriptions.
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The main symptoms when multifocal IOL decentration occurs are photic phenomena
including glare and halo. A sub-optimal visual acuity is also detected in these cases.
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Several studies demonstrated that visual outcomes and optical quality degradation are
higher in postoperative multifocal IOL decentrations than in monofocal IOLs.
Another important complication detected after multifocal IOL implantation is the IOL
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tilt due to capsular bag contraction, which is more prone to occur in lenses made of soft
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materials especially in combination with C-loop haptics. IOL tilt determines increased
high order optical aberrations, thus poorer optical quality and limited performance also
related to a worse refractive predictability. IOL tilt should be prevented using robust
IOL designs resistant to the normally occurring capsular bag scarring.
Another cause of patient dissatisfaction after multifocal IOL are the photic phenomena
6,58,61,175
and loss of contrast sensitivity . Refractive multifocal IOLs appear to be
associated with more with photic phenomena than diffractive multifocal IOLs49. An
explanation for the lower contrast sensitivity could be that multifocal IOLs result in
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coexisting images, because the light is shared between 2 (or more) different foci.
Therefore, there are 2 images, 1 sharp and 1 out of focus, with the light from the latter
reducing the detectability of the former image. Although contrast sensitivity in
individuals with multifocal IOLs is diminished compared with individuals with
monofocal IOLs, it is generally within the normal range of contrast in age-matched
phakic individuals6,119.

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Multifocal IOL explantation and exchange should only be performed when there is no
other alternative and all the causes leading to patient dissatisfaction have been properly

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ruled out. The main reasons for pseudophakic IOL explantation are: IOL dislocation
(first cause), refractive error (second cause), IOL opacification (third cause) and failure
to neuroadapt68. Multifocal IOL explantation and exchange by a monofocal implant

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with monovision in dissatisfied patients is a feasible option that significantly improves
patient satisfaction. It emphasizes the importance of performing specific tests for the

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accurate assessment of the visual function, especially in patients with good visual acuity
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who complaint of having poor vision. Decreased contrast sensitivity was found in most
of these cases. However, it is important to keep in mind that IOL exchange is not
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exempt of complications. In this series, the IOL had to be placed in the ciliary sulcus in
24% of the cases and anterior vitrectomy was performed in 6% of the eyes.
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In conclusion, the general recommendations to be considered in the indication of

multifocal IOLs are:
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• The patient life style: is very important to know the visual requirements
of the patient before multifocal IOL implantation to indicate the most
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adequate IOL design to obtain high levels of patient satisfaction.

• A complete and comprehensive preoperative examination is crucial to
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discriminate ocular pathologies that could influence negatively the

postoperative outcomes. The preoperative treatment of the pathologies,
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such as dry eye should be considered previously to implant the multifocal

IOL to achieve better patient satisfaction.
• It is crucial to study the biometry, topography and pupil reactivity to
avoid patient dissatisfaction due to residual refractive or photic
phenomena due to a poor pupil reaction or extreme pupil size, either
large or small.
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• Is very important to explain to the patient the visual expectation, possible
postoperative complications and solutions in the preoperative visit to
avoid patient surprises in the postoperative period.
• Multifocal IOL explantation is a feasible approach that should be
considered as the last option, in the management of patient´s
disatisfaction.

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In summary, MfIOL implanation may be considered, today as a good option for the

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correction of pseuphakic presbyopia, achieving spectacle independence in most of the
cases, especially the newer designs. Patient’s satisfaction with the recent models is high

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and visual and refractive outcomes are good, according to the most recent reports. The
complications related to its use may be avoided in most of the cases using adequate
preoperative patient selection criteria. If complications finally happen, they can be

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managed with an adequate knowledge of the alternatives available. If in spite of all of
AN
this patient dissatisfaction finally happens, the last feasible option is intraocular lens
exchange, which in experienced hands offers adequate outcomes. Due to all these
M

reasons, modern MfIOLs should be considered as a major achievement in the progress

of the intraocular lens industry in the benefit of cataract and refractive lens exchange
D

patients.
TE
C EP
AC
 ACCEPTED MANUSCRIPT

Average Average Average Questionnair %

IOL Patients/eye Residual UDVA UNVA, UIVA, e/ Spectacle Halos/glare
Study

PT
name s refractive error (logMAR (logMAR (logMAR Satisfaction Independe (scale)
) ) ) rate (scale) nt

RI
VF -14/ 85.8

SC
(0: Very
Brydon Array SE -0.45D
15/30 --- --- --- dissatisfied, ---- ---
200046 SA40N

U
100: very

AN
satisfied)

M
58.8%

D
Slagsvold 815 LE within ±0.25D
72/97 ---- --- --- --- 54 ---
2000158 (3M) 91.8% within
±1.00D
TE
EP
SE -0.02±0.49D Self/ 100 (0:
C

(–1.50 to Very
Sasaki ArrayT
AC

31/58 +0.75D) --- --- --- dissatisfied, 70.4 ---

2000152 PA154N
100: very
satisfied)
 ACCEPTED MANUSCRIPT

Average Average Average Questionnair %

IOL Patients/eye Residual UDVA UNVA, UIVA, e/ Spectacle Halos/glare
Study

PT
name s refractive error (logMAR (logMAR (logMAR Satisfaction Independe (scale)
) ) ) rate (scale) nt

RI
SC
Javitt Array SE -0.27 to
89
64/128 0.02 0.10 --- --- 41 yes
2000 SA40N -0.51 D

U
AN
Cataract
TyPE/ 8.4 (0:

M
Javitt Array SE -0.27 to -0.36 Very
88
127/254 0.02 0.11 --- 32

D
2000 SA40N D dissatisfied,
10: very

TE satisfied)
EP
Self/ 4.49 (0:
C

Walkow SE –0.17±0.43D Very

811E lens 50/64 0.07 0.10 --- 80 0.44/0.45
AC

2001172 84.2% of eyes dissatisfied, 5:

within ±0.5D very satisfied)
Mean
 ACCEPTED MANUSCRIPT

Average Average Average Questionnair %

IOL Patients/eye Residual UDVA UNVA, UIVA, e/ Spectacle Halos/glare
Study

PT
name s refractive error (logMAR (logMAR (logMAR Satisfaction Independe (scale)
) ) ) rate (scale) nt

RI
astigmatism

SC
0.64±0.59 D
54.1% of eyes

U
0.50D or less

AN
M
D
SE 0.71±0.68 D
(range,
TE Distance 65
EP
Jacobi Array 0.00–2.50D)
54/54 0.25 0.18 --- ---- Near 91 25/29%
200286 SA40N cylindrical error
C

0.63±0.58D
AC

(range, 0.00–
2.50D)
 ACCEPTED MANUSCRIPT

Average Average Average Questionnair %

IOL Patients/eye Residual UDVA UNVA, UIVA, e/ Spectacle Halos/glare
Study

PT
name s refractive error (logMAR (logMAR (logMAR Satisfaction Independe (scale)
) ) ) rate (scale) nt

RI
SC
TyPE
instrument/
SE -0.03 (0.74)

U
distance 8
88% eyes within

AN
Array near 6 (0:
29/58 ±1.00D 0.06 0.43 --- 24 ---
SA40NB Very

M
Cylinder 0.20
dissatisfied,
(0.53)

D
10: very
Leyland
satisfied)

TE
2002107 EP
SE +0.22 (0.61) TyPE
83% eyes within instrument/
TrueVista
C

15/30 ±1.00D 0.10 0.46 --- distance 8 7 ----

68STUV
AC

Cylinder 0.38 near 7 (0:

(0.64) Very
dissatisfied,
 ACCEPTED MANUSCRIPT

Average Average Average Questionnair %

IOL Patients/eye Residual UDVA UNVA, UIVA, e/ Spectacle Halos/glare
Study

PT
name s refractive error (logMAR (logMAR (logMAR Satisfaction Independe (scale)
) ) ) rate (scale) nt

RI
10: very

SC
satisfied)

U
AN
SE -0.24±0.52
Cylinder -

M
Pineda-
Array 0.68±0.29
Fernández 35/70 --- --- --- --- 31 ---

D
SA40N 87% eyes within
2004137
±1.00D and 56%
within ±0.50D
TE
EP
VF-14/ 95.1
C

(0: Very
Nijkamp Array
AC

68/68 Sphere 0.13 --- --- dissatisfied, --- ---

2004125 SA40N
+0.20(0.52) 100: very
Cylinder - satisfied)
 ACCEPTED MANUSCRIPT

Average Average Average Questionnair %

IOL Patients/eye Residual UDVA UNVA, UIVA, e/ Spectacle Halos/glare
Study

PT
name s refractive error (logMAR (logMAR (logMAR Satisfaction Independe (scale)
) ) ) rate (scale) nt

RI
0.53(0.56)

SC
95.2% eyes
within ±1.00D of

U
SE

AN
Array

M
Claoué ---
SA40N 22/43 --- --- --- --- 94.1 ---
200451

D
TE VF-7 88.26
EP
Sphere -
(0: Very
Array 0.42±0.55 Moderate
Sen 2004162 35/53 0.18 0.38 --- dissatisfied, ---
C

SA40N cylinder 30.2/13.2%

100: very
AC

0.36±0.35 48.1%
satisfied)
eyes within
±0.50D and 84.6
 ACCEPTED MANUSCRIPT

Average Average Average Questionnair %

IOL Patients/eye Residual UDVA UNVA, UIVA, e/ Spectacle Halos/glare
Study

PT
name s refractive error (logMAR (logMAR (logMAR Satisfaction Independe (scale)
) ) ) rate (scale) nt

RI
within ±1.00D

U SC
Array Sphere +0.2±0.8
Binocular Binocular

AN
SA40N 16/32 cylinder -0.8±0.9 --- --- --- 21.9/6.3
0.30 0.30
SE -0.3±0.9

M
Alio 200428 TwinSet
Sphere +0.2±0.8

D
737D/733 Binocular Binocular
12/24 cylinder -0.8±0.5 --- --- --- 20.8/8.3
D 0.30 0.10

TE
SE -0.2±0.7
EP
Sphere
ReSTOR
Chiam 0.31±0.38
SA60D3 40/80 0.07 0.11 --- --- 85 16.3/21.3
C

200645 Cylinder
AC

-0.46±0.43
Alfonso ReSTOR Monocula Monocula Binocular Self/ 8.6 (0: 2.8/1.3 (1:
325/650 --- ---
20071 SA60D3 r 0.09/ r 0.015/ 0.352 incapacitating; none,
 ACCEPTED MANUSCRIPT

Average Average Average Questionnair %

IOL Patients/eye Residual UDVA UNVA, UIVA, e/ Spectacle Halos/glare
Study

PT
name s refractive error (logMAR (logMAR (logMAR Satisfaction Independe (scale)
) ) ) rate (scale) nt

RI
binocular binocular 9: 4: severe)

SC
0.06 0.013 Excellent)
Monocula Monocula Self/ 8.7 (0:
2.5/1.4 (1:

U
ReSTOR r 0.122/ r 0.057/ Binocular incapacitating;
335/670 --- --- none,

AN
SN60D3 binocular binocular 0.356 9:
4: severe)
0.073 0.041 Excellent)

M
ReSTOR
Vingolo

D
SA60D3 50/100 --- 0.06 0.10 --- --- 92 22/28%
2007171

TE NEI RQL-42)/
EP
81.50 (0: Very
ReSTOR
12/24 --- 0.15 0.14 0.30 dissatisfied, --- ---/72.97%
Pepose SA60D3
C

100: very
2007132
AC

satisfied)
NEI RQL-42)/
REZOOM 14/28 --- 0.07 0.25 0.15 --- ---/69.17%
75.19 (0: Very
 ACCEPTED MANUSCRIPT

Average Average Average Questionnair %

IOL Patients/eye Residual UDVA UNVA, UIVA, e/ Spectacle Halos/glare
Study

PT
name s refractive error (logMAR (logMAR (logMAR Satisfaction Independe (scale)
) ) ) rate (scale) nt

RI
dissatisfied,

SC
100: very
satisfied)

U
ReSTOR SE +0.20±0.25D Binocular Binocular Binocular Survey/ 72%
50/100 86 30/20%

AN
Chiam SA60D3 0.06 0.11 0.32 very satisfied
200746 Binocular Binocular Binocular Survey/ 54%

M
REZOOM 50/100 SE +0.13±0.35 D 70 28/14%
0.00 0.23 0.23 very satisfied

D
Tecnis Binocular
26/52 --- --- --- --- 87 ---
ZM900 0.18

TE
Martínez
REZOOM Binocular
Palmer 32/64 --- --- --- --- 77 ---
EP
0.14
2008110
Twinset Binocular
32/64 --- --- --- --- 44 ---
C

0.16
AC

Binocular Binocular
Chang REZOOM 15/30 --- 0.15 --- 50 66.7/ 58.3
-0.01 0.32
200843
ReSTOR 15/30 --- Binocular Binocular 0.05 --- 72.7 58.3/ 58.3
 ACCEPTED MANUSCRIPT

Average Average Average Questionnair %

IOL Patients/eye Residual UDVA UNVA, UIVA, e/ Spectacle Halos/glare
Study

PT
name s refractive error (logMAR (logMAR (logMAR Satisfaction Independe (scale)
) ) ) rate (scale) nt

RI
SA60D3 0.08 0.14

SC
Acri.Lisa
Alio 200811 52/69 --- 0.12 0.12 --- --- --- ---
366D

U
Modified VF-

AN
7/ 93.8 (0:
Array
Very

M
SA40N 16/32 --- 0.06 0.20 --- 43.7 43.8/ 6.3
dissatisfied,

D
100: very
satisfied)

TE
Cillino
Modified VF-
200849
EP
7/ 94.6 (0:
Very
REZOOM 15/30 --- 0.06 0.21 --- 53.3 60/ 33.3
C

dissatisfied,
AC

100: very
satisfied)
Tecnis 16/32 --- 0.16 0.14 --- Modified VF- 87.5 12.5/ 87.5
 ACCEPTED MANUSCRIPT

Average Average Average Questionnair %

IOL Patients/eye Residual UDVA UNVA, UIVA, e/ Spectacle Halos/glare
Study

PT
name s refractive error (logMAR (logMAR (logMAR Satisfaction Independe (scale)
) ) ) rate (scale) nt

RI
ZM900 7/ 99.1 (0:

SC
Very
dissatisfied,

U
100: very

AN
satisfied)

M
SE +0.09±0.37 Self/ distance
Monocula Monocula

D
90.9% eyes 2.84, near 3.80 (scale 1:
De Vries ReSTOR r 0.097/ r 0.02/ Distance 85/
44/22 within ±0.50 and --- 1.78 (scale 1: severe, 4:

TE
200860 SA60D3 binocular binocular near 75
100% within excellent, none)
0.115 0.058
EP
±1.00D 5:good)
C

ReSTOR SE-0.04±0.05D
23/46 0.03 --- --- --- --- ---
AC

Zelichowsk SA60D3
a 2008176 SE -0.13±0.25D
REZOOM 23/46 0.03 --- --- --- --- ---
 ACCEPTED MANUSCRIPT

Average Average Average Questionnair %

IOL Patients/eye Residual UDVA UNVA, UIVA, e/ Spectacle Halos/glare
Study

PT
name s refractive error (logMAR (logMAR (logMAR Satisfaction Independe (scale)
) ) ) rate (scale) nt

RI
Ferrer ReSTOR SE 0.21±0.19D
15/30 0.07 0.04 --- --- --- ---

SC
200873 SN60D3
Sphere -

U
ReSTOR 0.03±0.25 Binocular Binocular Binocular
18/36 --- --- ---

AN
SN60D3 Cylinder - 0.02 -0.04 0.20
Alfonso
0.21±0.28
20097

M
Sphere -
Acri.Lisa Binocular Binocular Binocular

D
20/40 0.09±0.32Cylind --- --- ---
366D 0.01 -0.05 0.20
er -0.26±0.38
sphere
TE
EP
Palomino Tecnis 0.55±0.67D 90.4% good
129
137/250 0.19 0.24 --- --- 22.4%
2009 ZM900 cylinder - vision
C

0.97±0.65D
AC

100% eyes 100% near/

Alfonso ReSTOR
23/46 ±0.50D of SE 0.02 0.02 --- --- 96% ---
20104 SN60D3
SE +0.14±0.22D intermediate
 ACCEPTED MANUSCRIPT

Average Average Average Questionnair %

IOL Patients/eye Residual UDVA UNVA, UIVA, e/ Spectacle Halos/glare
Study

PT
name s refractive error (logMAR (logMAR (logMAR Satisfaction Independe (scale)
) ) ) rate (scale) nt

RI
SC
100% eyes
Packer Tecnis Self/ 94.6%
125/244 ±0.25D of SE --- 0.30 --- 84.14 22.4/15.5%
2010128 ZM900 satisfied

U
SE 0.02± 0.49

AN
VF-7/ 97.3 (0:

M
Very
Zhao ReSTOR

D
72/72 --- 0.00 0.20 --- dissatisfied, 66.6 43.1/6.9%
2010177 SA60D3
100: very

TE satisfied)
EP
Monocula
SE 0.06±0.49
ReSTOR r 0.04/
C

De Vries 34/68 Cylinder 0.04 0.09 --- --- ---

SN60D1 binocular
AC

201059 -0.57±0.40
-0.03

ReSTOR 23/46 Monocula -0.01 0.24 --- --- ---

 ACCEPTED MANUSCRIPT

Average Average Average Questionnair %

IOL Patients/eye Residual UDVA UNVA, UIVA, e/ Spectacle Halos/glare
Study

PT
name s refractive error (logMAR (logMAR (logMAR Satisfaction Independe (scale)
) ) ) rate (scale) nt

RI
SN60D3 SE 0.12±0.43 r 0.14/

SC
Cylinder binocular
-0.70±0.50 0.05

U
AN
Array
Fujimoto Sphere: -0.20

M
SA40N 41/72 0.00 0.20 --- --- 34.7 44.4%
201076 ±0.63

D
Monocula Monocula Monocula

REZOOM 20/20 SE 0.24±0.15 TE r 0.06/ r 0.07/ r 0.36/

90% 70 35/18.1%
EP
binocular Bincocula Binocular
Mesci -0.05 r 0.05 0.26
C

114
2010 Monocula Monocula Monocula
AC

Tecnis r 0.06/ r 0.15/ r 0.28/

21/21 SE 0.32±0.14 95.4% 86.4 30/22.7%
ZM900 binocular binocular Binocular
-0.05 0.125 0.20
 ACCEPTED MANUSCRIPT

Average Average Average Questionnair %

IOL Patients/eye Residual UDVA UNVA, UIVA, e/ Spectacle Halos/glare
Study

PT
name s refractive error (logMAR (logMAR (logMAR Satisfaction Independe (scale)
) ) ) rate (scale) nt

RI
TyPE

SC
instrument/
Lane ReSTOR 8.5 (0: Very
147/294 SE 0.1±0.4 0.04 0.10 0.17 --- 66.6%/---

U
2010104 SN60D1 dissatisfied,

AN
10: very
satisfied)

M
Sphere -

D
Lentis 0.01±0.60
Alio 201117 12/24 0.25 0.30 --- --- --- ---
Mplus 312 Cylinder -
0.60±0.81
TE
EP
Sphere Monocula
ReSTOR +0.36±0.48 r 0.13/
19/38 0.28 --- --- --- ---
C

SN60D3 Cylinder - Binocular

Alio 201116
AC

0.63±0.44 0.05
Acri.Lisa Sphere Monocula
21/42 0.19 --- --- --- ---
366D +0.15±0.55 r 0.10/
 ACCEPTED MANUSCRIPT

Average Average Average Questionnair %

IOL Patients/eye Residual UDVA UNVA, UIVA, e/ Spectacle Halos/glare
Study

PT
name s refractive error (logMAR (logMAR (logMAR Satisfaction Independe (scale)
) ) ) rate (scale) nt

RI
Cylinder - Binocular

SC
0.53±0.38 0.05
Standardized
92%

U
Monocula Monocula Monocula questionnaire/
distance,

AN
ReSTOR r 0.10/ r 0.30/ r 0.20/ good 100%
12/24 --- 83% 25/47%
SN6AD1 0.00 binocular binocular distance, 75%

M
intermediate
binocular 0.20 0.10 intermediate,
, 92% near

D
Petermeier 91% near
2011135 Standardized

TE
93%
Monocula Monocula Monocula questionnaire/
distance,
EP
ReSTOR r 0.10/ r 0.10/ r 0.40/ good 100%
15/30 --- 80% 47/33%
SN6AD3 0.00 binocular binocular distance, 34%
intermediate
C

binocular 0.00 0.20 intermediate,

, 100% near
AC

100% near
AT Lisa Sphere
Alio 201118 12/23 0.17 0.24 --- --- --- ---
909M +0.37±0.46
 ACCEPTED MANUSCRIPT

Average Average Average Questionnair %

IOL Patients/eye Residual UDVA UNVA, UIVA, e/ Spectacle Halos/glare
Study

PT
name s refractive error (logMAR (logMAR (logMAR Satisfaction Independe (scale)
) ) ) rate (scale) nt

RI
toric Cylinder -

SC
0.67±0.53
Self/ distance

U
Sphere - 1.78, near
Lentis 1.78 (1:

AN
0.09±0.48 2.89 (1:
Mplus 312 13/22 0.27 0.43 0.14 --- excellent, 4:
Cylinder - excellent, 4:

M
MF30 bad/---
0.69±0.79 bad)

D
Alio 201125
Self/ distance

Lentis
Sphere
TE 1.50, near
2.75(1:
EP
+0.13±0.61 2.25 (1:
Mplus 312 13/21 0.25 0.21 0.21 --- excellent, 4:
Cylinder - excellent, 4:
MF15 bad)/---
C

0.77±0.59 bad)
AC

Santhiago RESTOR Monocula Monocula Monocula Self/ 8.50 (1 = 1.05±0.94/

40/20 --- 90
2011151 SN6AD1 r 0.03/ r 0.022/ r 0.172/ least satisfied 0.90±.85 (0,
 ACCEPTED MANUSCRIPT

Average Average Average Questionnair %

IOL Patients/eye Residual UDVA UNVA, UIVA, e/ Spectacle Halos/glare
Study

PT
name s refractive error (logMAR (logMAR (logMAR Satisfaction Independe (scale)
) ) ) rate (scale) nt

RI
0.03 0.027 0.128 and 10 = most no difficulty;

SC
binocular binocular binocular satisfied) 4,severe
difficulty)

U
1.10±0.91/
Monocula Monocula Monocula Self/ 8.35 (1 =

AN
1.00±0.79 (0,
RESTOR r 0.02/ r 0.027/ r 0.232/ least satisfied
40/20 --- 90 no difficulty;

M
SN6AD3 0.02 0.025 0.175 and 10 = most
4,severe
binocular binocular binocular satisfied)

D
difficulty)
100%

TE
VF-14/ 94.7
distance,
(0: Very
EP
Binocular Binocular Binocular 100%
REZOOM 11/22 SE +0.01±0.34 dissatisfied, 18.2/18.2%
0.04 0.26 0.18 intermediate
Gil 201280 100: very
C

, 36.4%
satisfied)
AC

near
ReSTOR Binocular Binocular Binocular VF-14/ 92.0 91.7%
12/24 SE +0.36±0.53 8.3/41.7%
SN6AD1 0.11 0.14 0.14 (0: Very distance,
 ACCEPTED MANUSCRIPT

Average Average Average Questionnair %

IOL Patients/eye Residual UDVA UNVA, UIVA, e/ Spectacle Halos/glare
Study

PT
name s refractive error (logMAR (logMAR (logMAR Satisfaction Independe (scale)
) ) ) rate (scale) nt

RI
dissatisfied, 91.7%

SC
100: very intermediate
satisfied) , 75% near

U
100%
VF-14/ 95.2

AN
distance,
(0: Very
ReSTOR Binocular Binocular Binocular 92.3%

M
13/26 SE +0.47±0.46 dissatisfied, 7.7/38.5%
SN60D3 0.14 0.18 0.22 intermediate
100: very

D
, 92.3%
satisfied)
near

TE VF-14/ 96.8
81.8%
EP
distance,
(0: Very
Tecnis Binocular Binocular Binocular 81.8%
11/22 SE +0.28±0.50 dissatisfied, 18.2/54.2%
C

ZMA00 0.12 0.15 0.17 intermediate

100: very
AC

, 81.8%
satisfied)
near
Muñoz REZOOM 87/174 SE –0.81±0.35 Binocular Binocular --- --- --- ---
 ACCEPTED MANUSCRIPT

Average Average Average Questionnair %

IOL Patients/eye Residual UDVA UNVA, UIVA, e/ Spectacle Halos/glare
Study

PT
name s refractive error (logMAR (logMAR (logMAR Satisfaction Independe (scale)
) ) ) rate (scale) nt

RI
2012121 0.08 0.21

SC
Sphere
+0.38±0.33
Lentis Satisfied

U
45/90 Cylinder - 0.04 0.05 0.40 --- 18.89%/---
Mplus 312 83.3%

AN
0.61±0.53
Van der
SE +0.08±0.31

M
Linden
Sphere
2012168

D
+0.45±0.40
RESTOR Satisfied
72/1473 Cylinder - 0.06 0.05 0.35 --- 18.118%/---

TE
SN6AD1 98.6%
0.66±0.56
EP
SE +0.12± 0.37
100%
Monocula Monocula Monocula
C

distance,
Acri.Lisa r 0.10/ r 0.08/ r 0.16/
AC

Can 201242 16/30 SE -0.30±0.30 --- 96.6% 23.3/ 20%

366D 0.01 0.007 0.11
intermediate
binocular binocular binocular
, 100% near
 ACCEPTED MANUSCRIPT

Average Average Average Questionnair %

IOL Patients/eye Residual UDVA UNVA, UIVA, e/ Spectacle Halos/glare
Study

PT
name s refractive error (logMAR (logMAR (logMAR Satisfaction Independe (scale)
) ) ) rate (scale) nt

RI
100%
Acriva Monocula Monocula Monocula

SC
distance,
Reviol r 0.07/ r 0.02/ r 0.11/
16/30 SE -0.26±0.28 --- 100% 26.6/ 10%
MFM 611 0.007 0.00 0.07

U
intermediate
IOL binocular binocular binocular

AN
, 100% near
VFQ-25/

M
Ramon Lentis 2.080.76 (1:
149
13/26 --- 0.20 0.19 --- --- ---

D
2012 Mplus 312 eccellent, 5:
poor)
Sphere -
TE
EP
Lentis 0.06±0.57
26/45 0.23 0.20 --- --- --- ---
Mplus 312 Cylinder -
C

Alio 201220 0.63±0.61

AC

Sphere
Acri.Lisa
19/38 +0.20±0.44 0.06 0.12 --- --- --- ---
366D
Cylinder -
 ACCEPTED MANUSCRIPT

Average Average Average Questionnair %

IOL Patients/eye Residual UDVA UNVA, UIVA, e/ Spectacle Halos/glare
Study

PT
name s refractive error (logMAR (logMAR (logMAR Satisfaction Independe (scale)
) ) ) rate (scale) nt

RI
0.49±0.38

SC
Sphere -
Lentis 0.22±0.47
--/39 0.26 0.21 --- --- --- ---

U
Mplus 312 Cylinder -

AN
0.69±0.66
Alio 201219
Sphere

M
RESTOR +0.25±0.41
--/35 0.10 0.11 --- --- --- ---

D
SN6AD3 Cylinder -
0.55±0.36

TE
EP
Lentis Binocular Binocular
20/40 --- --- ---- --- ---
Mplus 312 0.03 0.11
Alfonso
C

20122
AC

Binocular Binocular
RESTOR 20/40 --- --- --- --- ---
0.01 0.10
SN6AD1
 ACCEPTED MANUSCRIPT

Average Average Average Questionnair %

IOL Patients/eye Residual UDVA UNVA, UIVA, e/ Spectacle Halos/glare
Study

PT
name s refractive error (logMAR (logMAR (logMAR Satisfaction Independe (scale)
) ) ) rate (scale) nt

RI
SC
Sphere -
Lentis
0.20±0.98
Alio 201222 Mplus 312 20/31 0.26 0.40 0.18 --- --- ---

U
Cylinder -
MF15

AN
0.93±0.57
Self/ 3.78

M
(very dissatisfi
Sphere

D
ed), 2
+0.04±0.49
Chang Tecnis (dissatisfi ed),

TE
29/45 Cylinder -0.10 0.18 0.43 100 78/26%
201244 ZMA00 3 (neutral),
+0.42±0.30
EP
4 (satisfi ed),
SE +0.25±0.52
and 5 (highly
C

satisfi ed)
AC

Sphere Monocula Halometry

Sheppard Binocular Binocular
Finevision 15/30 +0.27±0.36 r 0.19/ NAVQ/ 15.9 --- scotoma
2013156 0.19 0.21
Cylinder - Binocular (0 Z from 0.69 to
 ACCEPTED MANUSCRIPT

Average Average Average Questionnair %

IOL Patients/eye Residual UDVA UNVA, UIVA, e/ Spectacle Halos/glare
Study

PT
name s refractive error (logMAR (logMAR (logMAR Satisfaction Independe (scale)
) ) ) rate (scale) nt

RI
0.48±0.45 0.05 completely 1.03º

SC
satisfied; 100
Z

U
completely

AN
unsatisfied)
Sphere

M
+0.23±0.42
SeeLens

D
25/48 Cylinder - 0.02 0.09 --- 96% satisfied --- 12%
MF
0.41±0.39

TE
Van der
SE 0.03±0.40
Linden
EP
Sphere
2013166
0.29±0.25
RESTOR
C

20/37 Cylinder - 0.04 0.08 --- --- --- 28%

SN6AD1
AC

0.63±0.42
SE 0.07±0.16
Konstantino RESTOR 20/40 --- Binocular Binocular Binocular --- --- ---
 ACCEPTED MANUSCRIPT

Average Average Average Questionnair %

IOL Patients/eye Residual UDVA UNVA, UIVA, e/ Spectacle Halos/glare
Study

PT
name s refractive error (logMAR (logMAR (logMAR Satisfaction Independe (scale)
) ) ) rate (scale) nt

RI
s 2013165 SN6AD3 0.00 0.11 0.08

SC
Lentis
Sphere -
Mplus 312
0.01±0.64

U
without 26/43 0.14 0.21 --- --- --- ---
Cylinder -

AN
CTR
0.45±0.71

M
Sphere
Lentis
Alio 201321

D
+0.16±1.01
Mplus 312 24/47 0.17 0.22 --- --- --- ---
Cylinder -

TE
with CTR
0.53±0.46
EP
Sphere
Lentis +0.16±0.40
27/45 0.16 0.20 --- --- --- ---
C

Mplus 313 Cylinder -

AC

0.39±0.49
Ferreira RESTOR Sphere 1.54/1.21 (0:
19/38 0.07 0.02 0.16 --- 100
201372 TORIC +0.05±0.41 no
 ACCEPTED MANUSCRIPT

Average Average Average Questionnair %

IOL Patients/eye Residual UDVA UNVA, UIVA, e/ Spectacle Halos/glare
Study

PT
name s refractive error (logMAR (logMAR (logMAR Satisfaction Independe (scale)
) ) ) rate (scale) nt

RI
Cylinder - trouble; 1:

SC
0.45±0.39 minimal
SE -0.17±0.43 trouble; 2:

U
moderate

AN
trouble;
3:

M
considerable
trouble; 4:

D
overwhelmin

TE g trouble
EP
19% near
Lentis Sphere vision
C

Venter Mplus 0.29±0.43 difficulties

58/89 0.03 0.17 --- --- 20.7/20.7%
AC

169
2013 toric LU- Cylinder - and 10.3%
313 MFT 0.50±0.39 intermediate
vision
 ACCEPTED MANUSCRIPT

Average Average Average Questionnair %

IOL Patients/eye Residual UDVA UNVA, UIVA, e/ Spectacle Halos/glare
Study

PT
name s refractive error (logMAR (logMAR (logMAR Satisfaction Independe (scale)
) ) ) rate (scale) nt

RI
difficulties

SC
Very satisfied

U
68.1%
Sphere

AN
Venter Lentis Satisfied
4683/9366 +0.29±0.61 0.048 0.213 --- --- ---
2013170 Mplus 25.7%

M
SE +0.03±0.60
Neither 4.5%

D
Dissatisfied
1.2%

TE Monocula Monocula
EP
AT Lisa r 0.03/ r 0.04/ 19.48/
42/77 SE +0.09±0.30 --- --- ---
809M binocular binocular 24.68%
Frieling
C

-0.02 0.02
201375
AC

AT Lisa Monocula Monocula

11.54/
toric 26/17 SE -0.13±0.33 r 0.03/ r 0.04/ --- --- ---
26.92%
909M binocular binocular
 ACCEPTED MANUSCRIPT

Average Average Average Questionnair %

IOL Patients/eye Residual UDVA UNVA, UIVA, e/ Spectacle Halos/glare
Study

PT
name s refractive error (logMAR (logMAR (logMAR Satisfaction Independe (scale)
) ) ) rate (scale) nt

RI
-0.01 0.00

SC
AT Lisa
Bellucci
toric 284/142 SE +0.23±0.52 0.16 0.21 0.16 --- --- ---
201336

U
909M

AN
100%
Schmickler Tecnis
104/52 SE 0.01±0.47 0.02 0.15 0.38 --- distance, 4.0/ 8.0%
2013153

M
ZMB00
88% near

D
Sphere
Lentis
+0.11±0.16

TE
Mplus LS- 46/56 0.07 0.15 0.26 --- --- ---
Cylinder -
312
EP
Rosa 0.14±0.17
152
2013 Sphere
C

RESTOR +0.29±0.14
44/44 0.07 0.16 0.26 --- --- ---
AC

SN6AD1 Cylinder -
0.36±0.09
Alio 201314 FineVisio 20/40 Defocus 0.18 0.20 0.26 --- --- ---
 ACCEPTED MANUSCRIPT

Average Average Average Questionnair %

IOL Patients/eye Residual UDVA UNVA, UIVA, e/ Spectacle Halos/glare
Study

PT
name s refractive error (logMAR (logMAR (logMAR Satisfaction Independe (scale)
) ) ) rate (scale) nt

RI
n equivalent

SC
+0.39±0.27
NEI RQL-42/
Sphere

U
RESTOR 99.5 (0: Very
+0.08±0.40

AN
SN6AD3 20/40 0.01 0.05 0.16 dissatisfied, --- ---
Cylinder -
100: very

M
0.20±0.30
satisfied)

D
NEI RQL-42/
Sphere
Cillino RESTOR 99.1 (0: Very

TE
+0.10±0.30
201448 SN6AD1 21/42 0.008 0.02 0.09 dissatisfied, --- ---
Cylinder -
EP
100: very
0.23±0.42
satisfied)
C

Sphere NEI RQL-42/

AC

Tecnis +0.07±0.50 97.2(0: Very

22/44 0.006 0.05 0.11 --- ---
ZMA00 Cylinder - dissatisfied,
0.26±0.32 100: very
 ACCEPTED MANUSCRIPT

Average Average Average Questionnair %

IOL Patients/eye Residual UDVA UNVA, UIVA, e/ Spectacle Halos/glare
Study

PT
name s refractive error (logMAR (logMAR (logMAR Satisfaction Independe (scale)
) ) ) rate (scale) nt

RI
satisfied)

SC
SE within ±0.50:
Alfosno RESTOR 85.2% Binocular Binocular Binocular
49/88 --- --- ---

U
20145 IQ TORIC SE within ±1.00: 0.00 0.10 0.21

AN
95.4%
Self/ 1.43

M
(Excellent (1);

D
Sphere very good (2);
AT Lisa +0.02±0.38 good (3); not

TE
Mojzis
tri 30/60 Cylinder - -0.03 0.20 0.08 completely --- ---
2014118
EP
839 MP 0.28±0.24 satisfied (4);
SE -0.12±0.39 dissatisfied
C

(5); very
AC

dissatisfied (6)
RESTOR Sphere Self/ 7.23 ((1 0.75 (0 =
Guo 201481 20/40 0.04 0.111 0.163 ---
SN6AD1 −0.09±0.40 = none; 1 =
 ACCEPTED MANUSCRIPT

Average Average Average Questionnair %

IOL Patients/eye Residual UDVA UNVA, UIVA, e/ Spectacle Halos/glare
Study

PT
name s refractive error (logMAR (logMAR (logMAR Satisfaction Independe (scale)
) ) ) rate (scale) nt

RI
Cylinder incapacitating; minimal; 2,

SC
−0.17±0.49 10 = 3, and 4 =
excellent) moderate; 5

U
= severe)

AN
RESTOR
SE
Crema Toric

M
44/70 -0.08±0.27 0.02 0.01 --- --- -- ---
201453 (SND1-

D
T2/3/4/5
VF-14/ 9.19

TE (0 not
EP
Lubiński Tecnis Binocular Binocular Binocular satisfied at all]
20/40 --- --- 60%/---
2014109 ZMB00 -0.10 -0.02 0.07 to 10
C

completely
AC

satisfied)
Shimoda Rayner M- Self/ distance
18/34 SE 0.11±0.40 0.03 0.10 0.22 88.9 44.17/38.9%
2014157 flex® toric 9.28
 ACCEPTED MANUSCRIPT

Average Average Average Questionnair %

IOL Patients/eye Residual UDVA UNVA, UIVA, e/ Spectacle Halos/glare
Study

PT
name s refractive error (logMAR (logMAR (logMAR Satisfaction Independe (scale)
) ) ) rate (scale) nt

RI
IOL intermediate

SC
(model 8.97
638F M- near 8.44

U
flex® (from 0 to 10)

AN
NAVQ/ 20.43 Halometry

M
Monocula Monocula
SE -0.13±0.51 (0 = no photopic
Berrow r 0.10/ r 0.18/ Binocular

D
Mplus X 17/34 74% were within difficulty, --- scotomas
201437 Binocular Binocular 0.05
±0.50 100 = extreme between

TE
0.02 0.11
difficulty) 0.47°- 0.69°
EP
SE +0.01±0.76
RESTOR Cylinder
31/31 0.06 0.36 0.21 --- --- ---
C

Pedrotti SN6AD2 -0.37±0.62

AC

2014131
RESTOR SE
31/31 0.04 0.17 0.41 --- --- ---
SN6AD1 0.10±0.73
 ACCEPTED MANUSCRIPT

Average Average Average Questionnair %

IOL Patients/eye Residual UDVA UNVA, UIVA, e/ Spectacle Halos/glare
Study

PT
name s refractive error (logMAR (logMAR (logMAR Satisfaction Independe (scale)
) ) ) rate (scale) nt

RI
Cylinder

SC
-0.43±0.75

U
Sphere

AN
+0.21±0.48 Monocula Monocula Monocula 96%distanc
Cochener FineVisio Cylinder - r 0.01/ r 0.00/ r 0.08/ e and

M
99/198 --- 49/31%
201452 n 0.24±0.31 binocular binocular Binocular intermediate

D
SE+0.11±0.36 0.01 0.00 0.06 80% near

TE QoV
EP
questionnaire
AT Frequency
Maurino Binocular Binocular Binocular 88.1%
C

LISA 84/168 --- 82.1 29 Severity

2015111 -0.03 0.07 0.10 satisfied
AC

809M 22
Bothersome
14
 ACCEPTED MANUSCRIPT

Average Average Average Questionnair %

IOL Patients/eye Residual UDVA UNVA, UIVA, e/ Spectacle Halos/glare
Study

PT
name s refractive error (logMAR (logMAR (logMAR Satisfaction Independe (scale)
) ) ) rate (scale) nt

RI
QoV

SC
questionnaire
Frequency
RESTOR Binocular Binocular Binocular 95.2%

U
84/168 --- 77.4 32 Severity
SN6AD1 -0.03 0.09 0.13 satisfied

AN
22
Bothersome

M
14

D
Light-
distortion

TE
Sphere –
index (%)
AT Lisa 0.03±0.44
EP
---/33 0.022 0.123 --- --- --- Monocular
Brito tri 839M Cylinder –
46.97
201539 0.43±0.36
C

Binocular
AC

29,29
AT Lisa Sphere Light-
---/15 0.042 0.13 --- --- ---
toric +0.28±0.62 distortion
 ACCEPTED MANUSCRIPT

Average Average Average Questionnair %

IOL Patients/eye Residual UDVA UNVA, UIVA, e/ Spectacle Halos/glare
Study

PT
name s refractive error (logMAR (logMAR (logMAR Satisfaction Independe (scale)
) ) ) rate (scale) nt

RI
909MP Cylinder – index (%)

SC
0.41±0.41 Monocular
29.29

U
Binocular

AN
40.49
Self/ 4.22

M
(1 very

D
dissatisfied; 2
dissatisfied; 3

TE
TECNIS
--/23 SE -0.038±0.28 0.07 0.15 0.10 neither 87 39.1/ 43.4%
ZKB00
Kim 201597
EP
satisfied nor
dissatisfied;
C

4 satisfied; 5
AC

very satisfied)
TECNIS Self/ 4.19
--/21 SE -0.097±0.22 0.045 0.14 0.14 85.7 33.3 /47.6%
ZLB00 (1 very
 ACCEPTED MANUSCRIPT

Average Average Average Questionnair %

IOL Patients/eye Residual UDVA UNVA, UIVA, e/ Spectacle Halos/glare
Study

PT
name s refractive error (logMAR (logMAR (logMAR Satisfaction Independe (scale)
) ) ) rate (scale) nt

RI
dissatisfied; 2

SC
dissatisfied; 3
neither

U
satisfied nor

AN
dissatisfied;
4 satisfied; 5

M
very satisfied)

D
Self/ 3.14
(1 very

TE dissatisfied; 2
EP
dissatisfied; 3
TECNIS
--/21 SE -0.036±0.23 0.067 0.15 0.18 neither 76.2 42.9/ 52.4%
ZMB00
C

satisfied nor
AC

dissatisfied;
4 satisfied; 5
very satisfied)
 ACCEPTED MANUSCRIPT

Average Average Average Questionnair %

IOL Patients/eye Residual UDVA UNVA, UIVA, e/ Spectacle Halos/glare
Study

PT
name s refractive error (logMAR (logMAR (logMAR Satisfaction Independe (scale)
) ) ) rate (scale) nt

RI
Sphere Monocula Monocula Monocula

SC
Kretz102 Tecnis +0.31±0.54 r 0.12/ r 0.10/ r 0.21/ 79.3%
38/57 89.5 63.0%
2015 toric ZMT Cylinder Binocular Binocular Binocular satisfied

U
−0.61±0.49 0.04 0.06 0.21

AN
M
D
TE
C EP
AC
 ACCEPTED MANUSCRIPT

PT
RI
U SC
AN
M
D
TE
EP
C
AC
 ACCEPTED MANUSCRIPT
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