Premium IOL Implantation - Multifocal Lens Surgery
Premium intraocular lenses replace the eye's natural lens during cataract or lens replacement surgery and focus at more than one distance. A Cochrane review of 20 trials found the same distance vision as standard lenses, far better near vision and less need for glasses, with more halos at night. We explain trifocal, EDOF and toric choices.
About This Department
Ophthalmology
A multifocal lens can free you from reading glasses. The price is some glare and halos at night, and the choice is yours to weigh.
Premium intraocular lenses replace the natural lens during cataract surgery, or during lens replacement for age-related near vision loss, with an artificial lens designed to focus at more than one distance. A Cochrane review of 20 randomized trials with 2,230 people found that multifocal lenses gave the same distance vision as standard monofocal lenses, much better near vision without glasses, and a 37 percent lower chance of needing glasses. It also found halos three and a half times as common. Most people adapt to them over months, some never do, and choosing well before surgery matters more than any brand.
37% less
Chance of needing glasses, multifocal against monofocal, Cochrane 2016
3.58 times
Risk of halos with multifocal lenses, Cochrane 2016
84 in 100
Unhappy eyes whose cause was found and treated, J Cataract Refract Surg 2011
Free
Surgeon review of your eye reports
Free consultation
Send your latest eye examination report, your glasses or contact lens prescription, any scans of the retina or cornea you have, and a note of what you want from surgery, whether it is reading without glasses, clear night driving, or both. An eye surgeon tells you whether a premium lens suits your eyes and your habits, which design fits best, and what to expect. The review is free and commits you to nothing.
Surgeons say premium IOL implantation and patients search for multifocal lens surgery, and this page, Premium IOL Implantation - Multifocal Lens Surgery, covers both. It explains the designs, what the trials show about their benefits and drawbacks, who they suit and who they do not, the tests that decide the choice, what recovery feels like, and how a patient from abroad plans the trip.
What a premium lens is
The lens inside your eye
Behind the colored iris sits a clear lens that focuses light on the retina. It ages. The lens stiffens from the mid-forties, so near vision fades and the arms grow too short for the newspaper, and later in life it clouds into a cataract that dims and yellows everything. Cataract surgery removes that lens through an opening of two to three millimeters, breaking it up with ultrasound, and places a folded artificial lens, an intraocular lens or IOL, in the same thin capsule that held the old one. The new lens unfolds there and stays for life. It does not wear out, cloud again or need replacing, so the choice of lens matters, since it sets how the eye will see for the rest of the patient's life. Patients without a cataract who want to be rid of reading glasses sometimes have the same operation, called refractive lens exchange, and the same lens choices then apply to them in full. Same operation, same lenses.
What premium adds
A standard monofocal lens focuses sharply at one distance, the far one as a rule. Reading glasses stay. A premium lens tries to do more, with multifocal and extended depth of focus designs spreading focus across distances and toric designs also correcting astigmatism. The surgery stays the same. The difference lies in the lens. And in the planning, and in the trade-offs the patient accepts.
How the designs share the light
Splitting light, or stretching it
Four kinds of lens
1
Monofocal
One sharp focus, usually for distance. The clearest image, the fewest night effects, and reading glasses afterward. Some patients choose one eye for distance and one for near, called monovision.
2
Multifocal, bifocal or trifocal
Diffractive rings split incoming light into two or three focal points, for distance, intermediate and near. Good reading without glasses, at the cost of some contrast and more halos around lights at night.
3
Extended depth of focus
Stretches one focus into a range covering distance and arm's length, such as a computer screen or a car dashboard. Fewer halos than trifocals in some designs, and fine print may still need weak readers.
4
Toric
Any of the above with added correction for astigmatism, an uneven curve of the cornea that blurs vision at every distance. The lens must be aligned to the right angle during surgery.
Who suits a multifocal lens
Eyes, habits and expectations
Good candidates
Healthy eyes apart from the cataract or the aging lens, a strong wish to read without glasses, and the patience to adapt for a few months. Screen workers gain most. So do cooks.
Less suitable
Eyes with macular degeneration, advanced glaucoma, diabetic retinopathy, a damaged or irregular cornea, or severe dry eye. Split light leaves less contrast to spare in such eyes. People who drive a great deal at night for work, pilots and some surgeons choose monofocal or extended depth of focus lenses instead.
What to expect honestly
Near-total freedom from glasses for daily tasks is realistic.
Perfect vision at every distance with no night effects is not. A patient who would be upset by rings around headlights should say so before surgery, and the surgeon will steer toward another design.
What the trials found
Multifocal against monofocal lenses
Reading and glasses
Same distance vision, better near vision, fewer glasses
The Cochrane review pooled 20 randomized trials with 2,230 people. Distance vision was the same with both lens types. Near vision without glasses was far better with multifocal lenses, and the chance of needing glasses fell by 37 percent, although the size of the benefit varied between studies. de Silva and colleagues, Cochrane Database of Systematic Reviews, 2016.
Glare and halos
The price of the extra focus
In the same review, glare was 1.41 times and halos 3.58 times as common with multifocal lenses. In one trial against monovision, six multifocal patients had the lens exchanged within a year against none with monovision. The authors concluded that motivation to be free of glasses is likely to be the deciding factor.
Trifocal or extended depth of focus
Two modern choices
A randomized comparison
A Dutch trial randomized 30 patients to an extended depth of focus lens or a trifocal lens in both eyes. Intermediate vision at 66 centimeters came out slightly better with the extended depth of focus lens. Distance and near vision, reading, contrast and satisfaction did not differ significantly. Disabling halos were reported by 39 percent with the trifocal against 21 percent with the other lens, in a trial too small to prove the gap. Webers and colleagues, Journal of Cataract and Refractive Surgery, 2020.
This table scrolls sideways on a narrow screen. Swipe or drag to see every column.
Choosing between lens designs
Design
Best at
Main compromise
Monofocal
Sharp distance vision, least night glare
Reading glasses needed
Trifocal
Distance, computer and reading without glasses
Halos and glare at night, some loss of contrast
Extended depth of focus
Distance and computer range
Weak readers for fine print in some patients
Toric version of any
Corrects astigmatism as well
Needs exact alignment, rarely rotation afterward
Measurements before surgery
The tests that choose the lens
What is measured
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Tests before premium lens surgery
Test
What it measures
Why it matters
Optical biometry
Length of the eye and curve of the cornea
Calculates the lens power
Corneal topography
Shape and regularity of the cornea
Decides on a toric lens, rules out irregular corneas
Retinal OCT scan
The macula at the center of the retina
Hidden macular disease rules out a multifocal lens
Tear film and pupil tests
Dry eye and pupil size in dim light
Dry eye blurs results, large pupils raise halos
Astigmatism and toric lenses
Astigmatism left uncorrected spoils a multifocal result more than a monofocal one. A meta-analysis of 13 randomized trials found that toric lenses gave better distance vision without glasses and halved the need for distance glasses against standard lenses, with no rise in complications. Kessel and colleagues, Ophthalmology, 2016.
Surgery day and the months after
One eye at a time
In theater
Fifteen to twenty minutes an eye
Numbing drops, light sedation if wanted, a tiny incision, removal of the natural lens by ultrasound, and the folded lens slipped into place. No stitches in most cases. You go home the same day with a shield for the night, and the second eye follows one to seven days later.
Getting used to it
The brain has to learn the new optics
Vision is often clear within days, but halos and the knack of reading at the right distance improve over three to six months as the brain adapts. Surgeons judge the final result at three months, and most do not consider a lens exchange before then.
If you are not happy
Most causes can be found and fixed
What goes wrong
A Dutch clinic studied 76 eyes of 49 dissatisfied patients. Blurred vision led the complaints, in 94.7 percent, with light effects in 38.2 percent. Three causes stood out, a small leftover focusing error or astigmatism, clouding of the capsule behind the lens, and a large pupil. de Vries and colleagues, Journal of Cataract and Refractive Surgery, 2011.
How it is fixed
In 84.2 percent of those eyes a treatment helped, most often laser refractive surgery for leftover error, glasses for specific tasks, or a quick laser opening of a clouded capsule. Surgeons exchanged the lens in 4 percent. Exchange grows harder with time. Raise persistent complaints early.
Length of stay, flying, cost and follow-up
Length of stay and flying
How long to stay
Five to seven days covers both eyes. Day one brings the tests and consultation, then the first eye, a check the next morning, the second eye two to five days later, and a final check before you leave.
Flying
You can fly the day after each check. Use the drops on the flight schedule, avoid rubbing the eyes, and keep dust, tap water and swimming pools away from the eyes for a week, since the small incision is still sealing and a germ that gets in can cause a serious infection inside the eye.
Cost and follow-up
What decides the cost
The lens type makes the largest difference, with trifocal and toric lenses costing more than monofocal ones. Tests, surgery on one or both eyes and any sedation make up the rest. Published packages in Istanbul cover the tests, surgery, lenses, drops, the checks, an interpreter and transfers, and leave out the hotel and flights. The surgeon's review of your reports is free. The coordinator writes in English, Arabic, French, Russian, Serbian, Romanian or Spanish, or arranges an interpreter, sends an appointment confirmation and an invitation letter naming the hospital and the treating doctor ten days before travel, and books the hotel and transfers. Two family members may join consultations, halal, vegetarian and diabetic meals are available, a prayer room is on site, and you may request a female doctor at first contact.
Follow-up at home
Once you are back home, see an eye doctor there at one month and three months, with the surgical report in hand. The coordinator stays reachable on the same WhatsApp number, and questions go to the operating surgeon. Sudden loss of vision, increasing pain, a worsening red eye, or a curtain or shower of floaters needs an eye doctor the same day.
Premium IOL Implantation - Multifocal Lens Surgery FAQ
What is a premium IOL?
An artificial lens placed during cataract or lens replacement surgery that does more than a standard monofocal lens, focusing at several distances, extending the range of focus, or correcting astigmatism.
Will I need glasses after multifocal lens surgery?
Most people need them much less. The Cochrane review found a 37 percent lower chance of needing glasses than with monofocal lenses, although some still use them for fine print or in dim light.
Do multifocal lenses cause halos?
Yes, more than monofocal lenses. Halos were 3.58 times as common in the Cochrane review. They tend to fade over three to six months as the brain adapts, but some people keep noticing them at night.
Is a trifocal or an extended depth of focus lens better?
Neither suits everyone. In a randomized trial, intermediate vision was slightly better with the extended depth of focus lens, halos were reported less often, and reading and satisfaction were similar. Trifocals usually give better near vision without glasses.
Can a multifocal lens be removed if I cannot adapt?
Yes, although it is rarely needed. In a study of dissatisfied patients, 84.2 percent of eyes improved with simpler treatments and 4 percent had the lens exchanged. Exchange is easier in the first months.
How long do I need to stay in Istanbul?
Five to seven days for both eyes, with the second eye done a few days after the first and a check before you fly home.
References
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(12):CD003169.
Webers VSC, Bauer NJC, Saelens IEY, et al. Comparison of the intermediate distance of a trifocal IOL with an extended depth-of-focus IOL, results of a prospective randomized trial. J Cataract Refract Surg. 2020;46(2):193-203.
de Vries NE, Webers CA, Touwslager WR, et al. Dissatisfaction after implantation of multifocal intraocular lenses. J Cataract Refract Surg. 2011;37(5):859-65.
Kessel L, Andresen J, Tendal B, Erngaard D, Flesner P, Hjortdal J. Toric Intraocular Lenses in the Correction of Astigmatism During Cataract Surgery, A Systematic Review and Meta-analysis. Ophthalmology. 2016;123(2):275-286.
Editor's note
Written by the Biruni Hospital medical editorial team. Reviewed by Sepide Sadık, Ophthalmology.
