Multifocal IOL (MIOL)
Splits light into multiple foci
Bifocal (distance+near) or trifocal (distance+intermediate+near) design. Highest spectacle independence rate. More prone to halos and glare. Representative products: PanOptix, FineVision
Multifocal Intraocular Lens (Presbyopia Correction)
1. What is a Multifocal Intraocular Lens? (Definition)
Section titled “1. What is a Multifocal Intraocular Lens? (Definition)”Multifocal intraocular lenses (presbyopia-correcting IOLs, PC-IOLs) are a type of intraocular lens inserted to replace the natural lens removed during cataract surgery. They provide multiple focal distances (far, intermediate, near) to achieve presbyopia correction. While standard monofocal IOLs focus at only one distance, multifocal IOLs offer uncorrected vision at multiple distances through designs such as bifocal, trifocal, extended depth of focus (EDOF), and accommodating IOLs.
In Japan, these lenses became available sequentially from 2007, were approved as advanced medical care in 2008, and are currently handled as elective medical treatment (the cataract surgery itself is covered by health insurance, but the additional cost of the multifocal IOL is borne by the patient).
According to the classification in ISO 11979-7:2024 (SVL classification), multifocal IOLs are divided into three categories: MIOL (multifocal), EDF (extended depth of focus), and FVR (full visual range)1).
EDOF (Extended Depth of Focus)
Extends focus without splitting
Covers distance to intermediate continuously. Fewer halos and glare than multifocal IOLs. Near vision may be inferior to trifocal IOLs. Representative products: TECNIS Symfony, Clareon Vivity
Accommodating IOL
Utilizes ciliary muscle contraction
The lens moves forward and backward to adjust focus. Optical properties similar to monofocal IOLs with fewer halos. Accommodative effect is limited. Representative product: Crystalens
Q
Which patients are suitable for multifocal intraocular lenses?
A
They are suitable for cataract patients who want to significantly reduce dependence on glasses. Particularly suitable for those who need both computer work and reading for work or hobbies, and want to expand their daily life without glasses as much as possible. On the other hand, patients with macular degeneration, diabetic macular edema, high irregular astigmatism (keratoconus), advanced glaucoma, or those who require night driving professionally are cautious indications or relative contraindications. Thorough preoperative counseling with the attending physician is essential.
2. Classification and Postoperative Visual Phenomena
Section titled “2. Classification and Postoperative Visual Phenomena”Classification by Number of Foci
Section titled “Classification by Number of Foci”| Type | Focus Characteristics | Representative Products | Near Visual Acuity | Spectacle Independence Rate | Halos and Glare |
|---|---|---|---|---|---|
| Bifocal | Distance + Near | ReSTOR | ○ | High | Many |
| Trifocal | Distance + Intermediate + Near | PanOptix, FineVision | ◎ | Highest (>85%) 2) | Moderate |
| EDOF | Continuous focus from distance to intermediate | TECNIS Symfony, Clareon Vivity | △ | Moderate | Few |
| Enhanced monofocal | Monofocal + slight extension | EyHance, RayOne EMV | × | Low | Minimal |
Classification by optical principle
Section titled “Classification by optical principle”Refractive multifocal IOL: Concentric distance and near zones are arranged on the optic. Energy distribution varies with pupil size; small pupils may result in insufficient near vision. Theoretically, there is 0% light loss.
Diffractive multifocal IOL: Light is split by concentric microscopic step structures (diffraction grating). The 0th-order diffracted light is for distance, and the 1st-order diffracted light is for near. Stable energy distribution is possible regardless of pupil size. Higher-order diffracted light (2nd order and above) does not form an image and causes a decrease in high-frequency contrast sensitivity.
Postoperative visual phenomena
Section titled “Postoperative visual phenomena”Dysphotopsia is reported with all multifocal IOLs, but in most patients the impact on daily life is minimal and decreases with neuroadaptation over 3–6 months. Reported incidence varies widely from 1% to 93% depending on the study2).
- Halo: A ring-shaped light circle seen around a light source at night. More common with diffractive IOLs
- Glare: Increased glare from light sources
- Starburst: Radial light rays seen from a light source
- With multifocal IOLs, even mild decentration can easily lead to decreased visual function
Q
What is the difference between an EDOF intraocular lens and a multifocal intraocular lens?
A
Multifocal IOLs “split” light into multiple focal points for distance, intermediate, and near vision. This provides vision over a wide range of distances, but part of the light that is split into focal points becomes out of focus, causing decreased contrast sensitivity and halos/glare. In contrast, EDOF lenses are designed to “extend” rather than “split” the focal point, providing a continuous depth of focus from distance to intermediate. EDOF lenses produce fewer halos and glare, and nighttime vision tends to be more stable, but uncorrected near vision (within 40 cm) may be inferior to trifocal IOLs.
3. Epidemiology and Indications
Section titled “3. Epidemiology and Indications”Usage and Costs in Japan
Section titled “Usage and Costs in Japan”Multifocal IOLs were introduced in Japan in 2007 and approved as advanced medical care in 2008. Currently, they are treated as selected medical treatment; cataract surgery itself is covered by health insurance, but the additional cost of multifocal IOLs is borne by the patient.
Indication Assessment
Section titled “Indication Assessment”Recommended Indications
Characteristics of patients suitable for multifocal IOLs
Strong desire to significantly reduce dependence on glasses. Good macular function (normal OCT). Regular corneal shape (no irregular astigmatism or keratoconus). Realistic expectations and mental stability. Younger age (tendency for higher neuroadaptation ability) 6). No serious ocular diseases other than cataract.
Relative Contraindications / Cautious Indications
Conditions requiring careful judgment
Macular degeneration, diabetic macular edema. High irregular astigmatism (e.g., keratoconus). Night driving is occupationally essential. Advanced glaucoma. History of corneal refractive surgery (LASIK/PRK). Unrealistic expectations or mental instability. Dry eye (re-evaluate after preoperative treatment).
Multifocal IOLs are recommended with “thoughtful use” (careful indication assessment). EDOF/monovision are positioned as options that prioritize intermediate vision and have fewer dysphotopsias 1).
4. Preoperative Evaluation and Indication Assessment
Section titled “4. Preoperative Evaluation and Indication Assessment”Essential Evaluation Items
Section titled “Essential Evaluation Items”| Evaluation Item | Content | Importance |
|---|---|---|
| Corneal Shape | Topography/tomography, exclusion of irregular astigmatism and keratoconus | Very high |
| Macula/Fundus | OCT, evaluation of macular degeneration, epiretinal membrane, diabetic macular edema | Very high |
| Pupil Diameter | Measurement under photopic and scotopic conditions (refractive type depends on pupil diameter) | High |
| Intraocular Pressure/Visual Field | Evaluation of glaucomatous changes | High |
| Tears and cornea | Presence and severity of dry eye (preoperative treatment may be needed) | High |
| Contrast sensitivity | Baseline assessment of preoperative visual function | Medium |
| Lifestyle | Occupation, hobbies, visual expectations, need for night driving | Extremely high |
IOL power calculation
Section titled “IOL power calculation”For IOL power calculation, use third-generation or newer formulas (e.g., Barrett Universal II, Holladay 2). High-precision measurement of axial length and corneal curvature is key to improving accuracy. In multifocal IOLs, residual refractive error has a greater visual impact than in monofocal IOLs, so corneal shape evaluation using anterior segment OCT is also important.
AAO criteria for EDOF designation
Section titled “AAO criteria for EDOF designation”The AAO defines EDOF IOLs based on the following criteria3):
- Depth of focus at logMAR 0.2 is at least 0.5 D greater than that of a monofocal IOL
- Distance-corrected intermediate visual acuity (DCIVA) at 66 cm is statistically superior to that of a monofocal IOL
- Distance-corrected distance visual acuity (BCDVA) is non-inferior to monofocal IOLs
Astigmatism management strategy
Section titled “Astigmatism management strategy”| Residual astigmatism | Recommended approach |
|---|---|
| <0.75 D | Adjust incision site or perform limbal relaxing incisions (LRI) |
| 0.75–1.5 D | Consider toric PC-IOL (taking posterior corneal astigmatism into account) |
| >1.5 D | Toric PC-IOL recommended |
EDOF IOLs have higher tolerance to astigmatism than multifocal IOLs, and even moderate residual astigmatism has relatively little impact on visual function 5).
Q
Can multifocal IOLs be used even with astigmatism?
A
Regular astigmatism (astigmatism along the principal meridians of the cornea) can be corrected with toric multifocal IOLs. For astigmatism of 0.75 D or more, consider using a toric IOL; for 1.5 D or more, it is recommended. On the other hand, high irregular astigmatism (e.g., keratoconus) is a relative contraindication for multifocal IOLs. EDOF IOLs tend to have higher astigmatism tolerance than multifocal IOLs, and EDOF may be chosen for patients with moderate astigmatism.
5. Standard treatment and clinical outcomes
Section titled “5. Standard treatment and clinical outcomes”Surgical technique and intraoperative management
Section titled “Surgical technique and intraoperative management”During cataract surgery using phacoemulsification, a multifocal IOL is selected and inserted. The accuracy of continuous curvilinear capsulorhexis (CCC) and intraoperative centration of the capsular bag and optic are particularly important for multifocal IOLs. Even slight decentration can easily lead to decreased visual function.
Basic Principles of IOL Selection
Section titled “Basic Principles of IOL Selection”- Multifocal IOL (e.g., trifocal): For patients who strongly desire spectacle independence for distance, near, and intermediate vision (ESCRS recommendation) 1)
- EDOF: For patients who prioritize intermediate vision and wish to reduce dysphotopsia (ESCRS recommendation) 1)
- Individualized counseling is essential 1)
Design and Features of Representative Lenses
Section titled “Design and Features of Representative Lenses”PanOptix (Alcon) Trifocal
Overall length 13 mm, optic diameter 6 mm, 15 diffractive zones
Central 4.5 mm diffractive region plus refractive rim. Light distribution: near 25%/intermediate 25%/distance 50%. Focal points: near 40 cm/intermediate 60 cm/distance infinity. Anterior aspheric surface (-0.10 μm SA). The intermediate focal point of 60 cm is a distinctive feature compared to 80 cm in many competing products 2).
Gemetric/Gemetric Plus (HOYA) Trifocal
Overall length 13 mm, optic diameter 6 mm, central 3.2 mm diffractive zone
Addition power: +1.75 D (intermediate)/+3.50 D (near). G: more distance and intermediate; GPlus: more near. Customization strategy possible by using different types in the fellow eye. Toric version corrects up to 2.6 D of astigmatism 4).
TECNIS Symfony/Synergy (J&J) EDOF
Echelette diffractive EDOF
Symfony: Chromatic aberration reduction design extends depth of focus and improves intermediate vision. Synergy: Hybrid design combining diffractive bifocal and EDOF. Most widely studied as a representative EDOF 2).
Clareon Vivity (Alcon) Non-diffractive EDOF
X-WAVE technology (radial curvature discontinuity)
No light splitting. Theoretically no light loss, and because there is no diffractive structure, halos and glare are minimal. Near vision is the most limited among EDOF lenses10).
IC-8 Apthera (AcuFocus) is a small-aperture type (pinhole effect) that significantly extends depth of focus, but caution is needed for reduced low-light vision. EyHance/RayOne EMV (enhanced monofocal type) extends focus through continuous power change from center to periphery; the extension range is limited but it has the least photic phenomena1).
Visual outcomes of representative lenses
Section titled “Visual outcomes of representative lenses”Kohnen et al. (PanOptix, n=27, 3 months)2):
- UDVA: 0.00 ± 0.094 logMAR
- UIVA (60 cm): 0.00 logMAR
- UNVA: 0.01 ± 0.087 logMAR
Lawless et al. (PanOptix, n=33 retrospective)2):
- UDVA: 0.01 ± 0.10 logMAR
- UIVA: 0.30 ± 0.14 logMAR (88.9% ≥ 0.20)
- UNVA: 0.11 ± 0.04 logMAR
NINO Study (Gemetric/GPlus, n=124, 6 months)4):
- Achieved visual acuity of 0.1 logMAR or better at all distances
- Defocus curve: maintains 0.15 logMAR or better from 0.0 D to -3.50 D
- With G/GPlus contralateral eye customization, 92% are spectacle-independent for near vision
EDOF vs Trifocal Meta-Analysis
Section titled “EDOF vs Trifocal Meta-Analysis”In the meta-analysis by Karam 2023 (22 studies, 2,200 eyes) 2):
| Outcome | Trifocal vs EDOF | Statistics |
|---|---|---|
| Uncorrected distance visual acuity (UDVA) | No difference | MD=0.00, P=0.84 |
| Uncorrected intermediate visual acuity (UIVA) | No difference | MD=0.01, P=0.68 |
| Corrected distance visual acuity (CDVA) | EDOF slightly better | MD=-0.01, P=0.01 |
| Uncorrected near visual acuity (UNVA) | Trifocal significantly better | MD=0.12, P<0.00001 |
| Distance-corrected near visual acuity (DCNVA) | Trifocal better | MD=0.12, P=0.002 |
| Halo incidence | No difference | OR=0.64, P=0.10 |
| Glare incidence | No difference | No significant difference |
| Spectacle independence rate | Trifocal significantly higher | OR=0.26, P=0.02 |
| QoV score | Slightly better with trifocal | MD=1.24, P=0.03 |
| Patient satisfaction | No difference (both high) | — |
| Contrast sensitivity | No difference (7 of 10 studies) | — |
Trifocal vs bifocal comparison
Section titled “Trifocal vs bifocal comparison”In the meta-analysis cited by the ESCRS guidelines (Wisse et al.), trifocal IOLs compared to bifocal IOLs 1):
- UDVA: MD −0.03 logMAR (trifocal superior)
- UIVA: MD −0.07 logMAR (trifocal superior)
- No significant difference in spectacle dependence, contrast sensitivity, or glare incidence
A systematic review of multifocal vs monofocal IOLs (Khandelwal 2019) also showed superiority of multifocal IOLs for intermediate and near vision 8).
Multifocal vs Monofocal (Cochrane Review)
Section titled “Multifocal vs Monofocal (Cochrane Review)”A Cochrane review (de Silva et al.) comparing multifocal IOLs to monofocal IOLs found that9):
- Spectacle independence rate: RR 0.63 (95% CI 0.55–0.73), favoring multifocal
- Glare occurrence: RR 1.41 (1.03–1.93), higher with multifocal
- Halo occurrence: RR 3.58 (1.99–6.46), higher with multifocal
Mix-and-Match Strategy
Section titled “Mix-and-Match Strategy”A strategy that combines different lens types in both eyes, such as a trifocal IOL in the dominant eye and an EDOF IOL in the non-dominant eye, to complement the advantages of each lens. This may provide a customized visual profile, but it is important to thoroughly evaluate the impact on stereopsis before surgery6).
Postoperative Follow-up
Section titled “Postoperative Follow-up”- Posterior capsule opacification: Since it affects contrast sensitivity more with multifocal IOLs than with monofocal IOLs, early Nd:YAG laser capsulotomy is recommended.
- Residual refractive error: Consider additional laser correction (touch-up) if necessary.
- Neuroadaptation: Most patients become accustomed to glare and halos within 3–6 months after surgery.
Q
Will I no longer need glasses after surgery?
A
Data show that over 85% of patients with trifocal IOLs become spectacle-independent for distance, intermediate, and near vision. With G/GPlus contralateral eye customization, 92% become spectacle-free for near vision. EDOF IOLs provide good distance to intermediate vision but may require glasses for near vision (within 40 cm). However, individual results vary, and 100% spectacle independence after surgery is not guaranteed. It is important to thoroughly assess the patient’s occupation, hobbies, and expectations before surgery and share realistic expectations.
Q
How bothersome are halos and glare?
A
Meta-analysis (22 studies, 2,200 eyes) found no significant difference in the incidence of halo and glare between EDOF and trifocal IOLs. In many patients, neuroadaptation over 3–6 months postoperatively helps them become accustomed to these photic phenomena. Even if initially bothersome, most cases reduce to a level that does not interfere with daily life. However, some patients may have insufficient adaptation, and quality of life may remain affected. Thorough preoperative counseling is important.
6. Pathophysiology (Optical Principles and Neuroadaptation)
Section titled “6. Pathophysiology (Optical Principles and Neuroadaptation)”Optical Principles of Diffractive Multifocal IOLs
Section titled “Optical Principles of Diffractive Multifocal IOLs”The fine stepped structures (diffraction gratings) arranged concentrically on the optic split the incident light. The 0th-order diffracted light is directed to the far focus, and the 1st-order diffracted light to the near focus, allowing stable energy distribution regardless of pupil size. Higher-order diffracted light (2nd order and above) does not form an image and contributes to reduced high-frequency contrast sensitivity. In apodized designs (e.g., ReSTOR), the depth of the diffractive zones gradually decreases from the center to the periphery, increasing energy distribution to distance in the peripheral area.
Optical Design of EDOF IOLs
Section titled “Optical Design of EDOF IOLs”Diffractive EDOF (echelette type): Uses an echelette diffraction pattern to reduce chromatic aberration while extending depth of focus. Almost all light is concentrated to distance and intermediate.
Non-diffractive EDOF (X-WAVE technology): Vivity IOL. Radial curvature discontinuities on the optic extend depth of focus. No diffractive structure results in less halo and glare10).
Small-aperture (pinhole): IC-8 Apthera. The pinhole effect markedly extends depth of focus, but reduced scotopic visual acuity is a challenge.
Enhanced monofocal: EyHance, etc. Continuous power change in the central optic extends focus. The extension is limited, but abnormal photopsia is minimal.
Impact on Stereopsis
Section titled “Impact on Stereopsis”Stereopsis after bilateral multifocal IOL implantation is significantly better than after unilateral implantation. Bilateral: 84.6% achieved stereopsis of 60” or better; unilateral: 42.8% (P=0.009). Aniseikonia was absent in 92.3% of bilateral cases but present in 21.4% of unilateral cases (P=0.001)6). Refractive IOLs tend to provide better stereopsis than diffractive IOLs (Chang: refractive mean 8.36 points vs diffractive 6.50 points, P=0.017)6).
Neuroadaptation
Section titled “Neuroadaptation”The process by which the brain learns to select and integrate images from each focal point is called neuroadaptation. fMRI studies have shown that cortical activity related to attention, learning, and cognitive control increases 3–4 weeks after multifocal IOL surgery and stabilizes/normalizes after 6 months6). Most patients adapt to glare and halo within 3–6 months.
7. Latest Research and Future Perspectives
Section titled “7. Latest Research and Future Perspectives”Hybrid (multifocal-EDOF) IOL: e.g., TECNIS Synergy. Compared to trifocal IOLs, there was no significant difference in distance and intermediate corrected visual acuity; UIVA was slightly better with hybrid (MD=0.055, P<0.05), while UNVA was superior with trifocal. Halos occurred 32% more frequently with trifocal IOLs1).
Contralateral customized implantation (Gemetric/GPlus): A customized strategy using two types of IOLs with different light distribution in each eye has been reported to provide good near and intermediate visual acuity with comparable visual phenomena4).
Complementary IOL system: The concept of extending the overall depth of focus by combining the depth of focus of both eyes is being studied6).
Management of capsular contraction syndrome: The four-flange prolene fixation method (Mahmood method) for a decentered toric trifocal IOL has been reported7).
Optimization of low astigmatism management: Individualized approaches based on the high astigmatism tolerance of EDOF IOLs are being studied for optimization5).
Next-generation optical design: Advances in wavefront control technology and materials science are driving the development of next-generation IOLs that achieve a wide range of clear vision while minimizing photic phenomena.
8. References
Section titled “8. References”- European Society of Cataract and Refractive Surgeons (ESCRS). ESCRS recommendations for cataract surgery. ESCRS; 2024. Available from: https://www.escrs.org/escrs-recommendations-for-cataract-surgery
- Karam M, Alkhowaiter N, Alkhabbaz A, et al. Extended depth of focus versus trifocal for intraocular lens implantation: an updated systematic review and meta-analysis. Am J Ophthalmol. 2023;251:53-68.
- American Academy of Ophthalmology Cataract/Anterior Segment Preferred Practice Pattern Panel. Cataract in the Adult Eye Preferred Practice Pattern. Ophthalmology. 2022;129(4):P1-P126.
- Kaymak H, Potvin R, Neller K, et al. Customizing clinical outcomes with implantation of two diffractive trifocal IOLs of identical design but differing light distributions to the far, intermediate and near foci. Clin Ophthalmol. 2024;18:1009-1022.
- Rocha-de-Lossada C, Rodríguez-Vallejo M, Rodríguez-Calvo-de-Mora M, et al. Managing low corneal astigmatism in patients with presbyopia correcting intraocular lenses: a narrative review. BMC Ophthalmol. 2023;23:254. doi:10.1186/s12886-023-03046-0
- He Y, Zhu B, Li B, Zou H, Ma Y. Stereopsis following implantation of presbyopia-correcting intraocular lenses: a narrative review. Ophthalmol Ther. 2024;13:2331-2341.
- Mahmood AH, Aljodaie MK, Alsaati AF. Four-flanged prolene fixation for a toric trifocal intraocular lens of the double C-Loop design in an eye with severe capsular phimosis. Am J Ophthalmol Case Rep. 2021;21:101000.
- Khandelwal SS, Jun JJ, Mak S, Booth MS, Shekelle PG. Effectiveness of multifocal and monofocal intraocular lenses for cataract surgery and lens replacement: a systematic review and meta-analysis. Graefes Arch Clin Exp Ophthalmol. 2019;257(5):863-875. doi:10.1007/s00417-019-04247-6
- de Silva SR, Evans JR, Kirthi V, Ziaei M, Leyland M. Multifocal versus monofocal intraocular lenses after cataract extraction. Cochrane Database Syst Rev. 2016;12:CD003169. doi:10.1002/14651858.CD003169.pub4. PMID:27931035
- Bala C, Poyales F, Guarro M, et al. Multicountry clinical outcomes of a new nondiffractive presbyopia-correcting IOL. J Cataract Refract Surg. 2022;48:136-143. doi:10.1097/j.jcrs.0000000000000803