Comparison of trifocal or hybrid multifocal‑extended depth of focus intraocular lenses: a systematic review and meta‑analysis

Authors: Zhong Y, Wang K, Yu X, Liu X, Yao K.

Geographical coverage: Europe, Asia, and South America

Sector: Cataract and refractive surgery

Sub-sector: Intraocular lens

Equity focus: Not reported

Study population: Individuals who underwent bilateral cataract or refractive lens exchange surgeries

Review type: Effectiveness review

Quantitative synthesis method: Meta-analysis

Qualitative synthesis method: Not applicable

Background: The increasing demand for spectacle independence and full-range vision has led to innovations in intraocular lens (IOL) design. Trifocal IOLs split light into three focal points and offer clear vision at all distances, but they may cause photic effects and reduce contrast sensitivity. TECNIS Symfony, one of the commonly used multifocal IOLs, is often labelled as an extended depth of focus (EDOF) lens due to its echelette design and multifocality, which enhances image quality. While trifocal IOLs have demonstrated superior near and intermediate vision compared to monofocal lenses, the hybrid design may offer advantages in certain aspects of visual performance, such as intermediate acuity and refractive tolerance. Comparative clinical outcomes remain inconsistent. Therefore, a comprehensive evaluation is necessary to guide optimal lens selection in practice.

Objective: To compare the visual performance, spectacle independence and photic disturbance of trifocal IOLs and the hybrid multifocal-EDOF IOL after cataract or refractive lens exchange (RLE) surgeries.

Main findings: The review examined 13 comparative studies with bilateral implantation of trifocal (898 eyes) or hybrid multifocal-EDOF (624 eyes) IOLs published between August 2016 and March 2020. Of these, nine were non-randomised controlled studies and four were randomised controlled trials (randomised controlled trial (RCT)s). Ten of the included studies were performed in Europe, two in Asia and one in South America. The average Jaded scale for the four randomised controlled trial (RCT)s was 3.8 points (Studies with more than three points were considered as high quality), and the average Newcastle–Ottawa Scale (NOS) for the non-randomised studies was 7.6 Points (Studies with more than six points indicate high quality).

The findings revealed that trifocal IOLs provided significantly better uncorrected and corrected near visual acuity (VA) (mean difference, MD: − 0.143, 95% confidence interval [CI]: − 0.192 to − 0.010, P < 0.001 and MD: − 0.149, 95% CI: − 0.217 to − 0.082, P < 0.001, respectively), while the hybrid multifocal-EDOF group presented better uncorrected intermediate VA (MD: 0.055, 95% CI: 0.016 to 0.093, P = 0.005). Trifocal IOLs were more likely to achieve spectacle independence at near distance (risk ratio, RR: 1.103, 95% CI: 1.036 to 1.152, P = 0.002). The halo photic effect was generated more frequently by the trifocal IOLs (RR: 1.318, 95% CI: 1.025 to 1.696, P = 0.031). Contrast sensitivity and subjective visual quality yielded comparable results between the two groups.

Methodology:

The authors searched PubMed, Embase, and Web of Science to identify randomised controlled trial (RCT)s and prospective cohorts comparing clinical outcomes between trifocal, AT LISA tri 839MP IOL, AcrySof IQ PanOptix IOL, and TECNIS Symfony ZXR00 IOLs in patients who underwent bilateral cataract or RLE surgeries. The studies published from the inception of databases to 1 March 2020 were included in this review. Reference lists of the included studies and relevant review articles were also scanned to identify additional relevant publications.

Two reviewers independently screened the articles. Discrepancies between the reviewers were resolved through discussion. Relevant data were extracted in a standardised data collection form. The methodological quality of the included studies was assessed using the Jaded scale for randomised controlled trial (RCT)s and the NOS for cohort studies. The findings were synthesised using fixed or random-effects model meta-analysis depending upon heterogeneity. Heterogeneity was assessed using I2 statistics, and publication bias was assessed using a funnel plot and Egger’s test. Sensitivity analyses were performed to evaluate the influence of a single study on the pooled estimate. Subgroup analyses and meta-regression analyses were conducted to investigate the source of the heterogeneity.

Applicability/external validity:

The review did not discuss the external validity of its findings, but noted substantial heterogeneity in follow-up durations, patient demographics, and measurement techniques. They pointed out the low quality of some randomised controlled trial (RCT)s and non-randomised studies, emphasizing the need for more evidence-based publications and randomised controlled trial (RCT)s to guide IOL selection for optimal visual benefits and personalised needs.

Geographic focus:

The review did not apply any geographical limits. The included studies were performed in Europe, Asia, and South America.

Summary quality assessment:

There is low confidence in this study’s conclusions. The review did not mention language restrictions during the search, did not report findings by risk of bias, nor specify the number of reviewers for data extraction.