November 2019


EyeWorld Journal Club
Review of two studies examining trifocal lens use

by Rachel Patel, MD, Christopher Bair, MD, Bradley Jacobsen, MD, Theresa Long, MD, and William Barlow, MD

Jeff Pettey, MD
Director of education
John Moran Eye Center
Salt Lake City

“Consideration of which presbyopia-correcting IOL will
depend on lens availability, cost, and the patient’s unique needs.”
—EyeWorld Journal Club

From left: Jeff Pettey, MD, Rebekah Gensure, MD, PhD, Rachel Patel, MD, Marshall Huang, MD, Kathrine Hu, MD, Bradley Jacobsen, MD, Ariana Levin, MD, Sravanthi Vegunta, MD, Theresa Long, MD, Abigail Jebaraj, MD,
Christopher Bair, MD, Michael Burrow, MD, Christina Mamalis, MD, Michael Murri, MD
Source: John Moran Eye Center


The choice of intraocular lens (IOL) is an increasingly complex and important component of cataract surgery. The single focal length of a traditional monofocal lens gives excellent focal clarity at a single distance. Early generation multifocal IOLs with bifocal design give a discrete focal point at near and at far, while intermediate vision often required spectacles. Nowadays patients increasingly desire a surgical outcome allowing functional uncorrected vision at a variety of working distances, generating a market interest in presbyopia-correcting IOLs. Moreover, the availability of presbyopia-correcting IOLs may provide an attractive option for presbyopic patients who have not developed visually significant cataracts but seek to minimize their reliance on near correction.
Today we have a variety of potential presbyopia-correcting IOLs at our disposal for patients seeking increased spectacle independence. The AcrySof PanOptix trifocal IOL (Alcon) received FDA approval in August 2019 and is available for use in the United States. Fortuitously, U.S.-based ophthalmologists can learn from the experience of our international colleagues who have already had access to the PanOptix IOL. Thus, we herein take a look at the outcomes of the PanOptix as used in two papers published in this month’s JCRS.

Study #1

In “Visual and refractive outcomes, spectacle independence, and visual distrubances after cataract or refractive lens exchange surgery: Comparison of 2 trifocal intraocular lenses,” Dr. Bilgehan Sezgin Asena compared the PanOptix to the trifocal AT LISA tri839MP IOL (Carl Zeiss Meditec).
The study enrolled patients who underwent bilateral cataract surgery or refractive lens exchange; complicated cataracts and those with more than 1 D of corneal astigmatism were excluded. Uncorrected and corrected visual acuity at distance and near were similar between both groups. Intermediate vision at 80 cm was superior in the AT LISA group, while intermediate vision at 60 cm was better in the PanOptix group. This outcome matches the designated intermediate target for each IOL; the diffractive PanOptix IOL contains a +2.17 D add optimized for 60 cm viewing, and the diffractive AT LISA IOL has a +1.66 D add optimized for 80 cm viewing.
This study further evaluated the outcomes of the two IOLs by generating defocus curves, which measure visual acuity with various positive and negative powered lenses in front of the eye to simulate distances from far to near. By this method, the PanOptix IOL was superior to the AT LISA IOL at +1 D as well as –1 D through –2.5 D, while both had excellent distance (0.5 through –0.5 D) visual acuity.
In a post-implant survey, the vast majority of patients with either IOL reported never using spectacles for far or near vision. Yet for intermediate vision, there was a significant difference in spectacle independence between those with PanOptix and AT LISA IOLs (100% vs. 89.7%).
One of the most common drawbacks to presbyopia-correcting IOLs is the potential for dysphotopsias.1 The study also evaluated postoperative visual disturbances and found that the frequency of experiencing glare or halo is similar in eyes with PanOptix and AT LISA IOLs, but the severity and “bother” of these disturbances was less in the PanOptix group. However, given that more of the patients undergoing clear lens extraction were in the AT LISA group it is possible that patients who received the PanOptix IOL may be relatively less bothered by postoperative glare and halos compared to their preoperative baseline.

Study #2

In “Comparative analysis of defocus curves of four presbyopia-correcting intraocular lenses with four designs: diffractive panfocal, diffractive trifocal, segmental refractive, and extended depth of focus,” Dr. Myriam Böhm and colleagues compared not only the diffractive panfocal (PanOptix) and diffractive trifocal (AT LISA tri839MP), but also the segmental refractive (LENTIS Mplus X LS-323 MF30, Oculentis) and the extended depth of focus (TECNIS Symfony ZXR00, Johnson & Johnson Vision) lenses.
The study included patients who underwent bilateral cataract or refractive lens exchange surgery. Of note, those who underwent refractive lens exchange only chose the PanOptix or AT LISA IOLs, with higher proportion receiving the AT LISA. Patients with significant ocular pathology or prior ocular surgeries were excluded.
The uncorrected or distance-corrected visual acuity at 80 cm of the Symfony and AT LISA IOLs was found to be significantly better than that of the PanOptix or Mplus IOLs. At 60 cm, the PanOptix and Symfony groups both had excellent uncorrected and distance-corrected visual acuity. At a near target of 40 cm, the Symfony demonstrated worse uncorrected visual acuity than the other three IOLs. Notably, the PanOptix had the best visual acuity at 50 cm compared to all other IOLs, and was equivalent to the AT LISA and Mplus at 40 cm.
The defocus curves of the four IOLs were tested, revealing that the PanOptix IOL performed better than all other IOLs at –2 D, and better than the AT LISA IOL at –1.5 D. Meanwhile, the Symfony IOL had greater vision at –1 D compared to all others. All IOLs tested had excellent, similar visual acuity at a defocus level of 0 D and –0.5 D.
Böhm and colleagues report that over 90% of patients who received the AT LISA, PanOptix, or Mplus IOLs reported spectacle independence, compared to only 70.8% of patients with Symfony IOLs.


As expected, both studies found that the optimal intermediate performance of the PanOptix and AT LISA IOLs were at their target focal distance at 50–60 and 80 cm respectively.2 A difference in target distance of 20 cm may make a significant change in comfort level for certain tasks, and thus the choice of IOL may depend on the patient’s working distance. Moreover, the study by Böhm echoes previous investigations that have demonstrated that the PanOptix and the Symfony IOLs perform similarly at distance and intermediate distances but that the PanOptix offers superior near visual acuity,3 a particularly relevant finding for U.S.-based ophthalmologists where both IOLs are now available.
Both investigations were prospective in design, but neither was randomized. In the Asena study, patients self-selected the IOL, while the Böhm study did not specify the method of IOL selection. While the lack of randomization may confound the ultimate findings, self-selection of IOL does mimic real world practice in which the IOL is chosen based on the patient’s individual needs and preferences.
All IOLs employed were non-toric, with the Asena study excluding patients with corneal astigmatism above 1 D, while Böhm and colleagues performed clear cornea keratotomy incisions in line with the steepest astigmatic meridian for patients with 0.5 to 1.5 D of astigmatism. The studies do not allow for a comparison of outcomes in patients with more than minimal astigmatism, which can be managed through limbal relaxing incisions, arcuate keratotomy, or toric IOL designs.
Consideration of which presbyopia-correcting IOL will depend on lens availability, cost, and the patient’s unique needs. As U.S. surgeons now consider the PanOptix and Symfony lenses for their patients, special consideration should be paid to the patient’s need and desire for uncorrected near visual acuity. Compared to the Symfony, the PanOptix performs better at closer viewing (all distances 50 cm and below) but is inferior to the Symfony at 1 m viewing. The PanOptix IOL may be better suited for patients preferring a closer intermediate working distance of around 60 cm, such as for some handheld devices and computer work. Notably, the PanOptix is only available in powers +13 D and above, which limits its utility in highly myopic patients when compared to the Symfony. The choice of IOL should continue to be contingent upon individual patient preferences and needs.


1. Monaco G, Gari M, Di Censo F, et al. Visual performance after bilateral implantation of 2 new presbyopia-correcting intraocular lenses: Trifocal versus extended range of vision. J Cataract Refract Surg. 2017;43(6):737–747.
2. Kohnen T, Herzog M, Hemkeppler E, et al. Visual performance of a quadrifocal (trifocal) intraocular lens following removal of the crystalline lens. Am J Ophthalmol. 2017;184:52–62.
3. Ruiz-Mesa R, Abengózar-Vela A, Ruiz-Santos M. A comparative study of the visual outcomes between a new trifocal and an extended depth of focus intraocular lens. Eur J Ophthalmol. 2018;28(2):182–187.

Contact information


Review of two studies examining trifocal lens use Review of two studies examining trifocal lens use
Ophthalmology News - EyeWorld Magazine
283 110
220 96
True, 11