Trifocal lens implantation replaces the eye's natural lens, during cataract surgery or refractive lens exchange, with an intraocular lens that focuses at near, intermediate and far distances. In a multicenter trial, 80.5 percent of patients never needed glasses at six months. Our ophthalmologists measure each eye, advise who suits a trifocal lens and who does not, treat both eyes within one week and follow you once you are back home.
About This Department
Ophthalmology
A trifocal lens replaces the natural lens with one that focuses at three distances. Most patients stop needing glasses for reading, screens and driving.
Trifocal lens implantation is eye surgery in which the eye's own lens, clouded by cataract or stiffened with age, is removed and replaced with a trifocal intraocular lens, an artificial lens with three focal points for near, intermediate and distance vision. Surgeons perform it during cataract surgery, or as refractive lens exchange for people over 45 who want to be free of reading glasses. In a multicenter trial, 80.5 percent of patients with a trifocal lens never needed glasses at six months, against 8.2 percent with a standard monofocal lens (Modi and colleagues, Ophthalmology, 2021). The trade-off comes as halos and glare around lights at night, which the majority notice at first and few find troubling after the brain adapts. Careful selection matters more than the lens itself. This page explains what trifocal lenses are, who suits them and who does not, results, halos and glare, how they compare with bifocal and extended depth of focus lenses, the tests, surgery and recovery, risks, and how patients from abroad arrange treatment at Biruni Hospital in Istanbul.
80.5
Percent of patients with a trifocal lens who never needed glasses at six months, against 8.2 percent with a monofocal lens
3.6
Times more likely to report halos with a multifocal lens than with a monofocal lens, across randomized trials
5
Percent ceiling of patients very bothered by halos, glare or starbursts at six months after a trifocal lens
Free
Review of your eye measurements and history by our ophthalmology team
Far, intermediate around 60 centimeters, near around 40 centimeters
Rarely
A trifocal lens has fine rings on its surface that split incoming light into three focal points. The eye receives three images at once, and the brain learns to attend to the one in focus. The lens sits inside the eye for life, in the capsule that held the natural lens, and cannot be felt or seen by others. A toric version also corrects astigmatism.
The lens splits light between three distances. That is how it gives sharp vision from near to far, and also why lights can show halos at night.
Cataract surgery or lens exchange
Either way, the operation is the same.
In cataract surgery the natural lens has clouded and must come out anyway. The only question is which lens goes in. Refractive lens exchange removes a clear lens, in people past their mid-forties who are tired of reading glasses or who have high long-sightedness, and replaces it with a trifocal lens so that glasses become the exception for reading, screens and driving over the decades that follow. The choice lasts a lifetime. A lens exchanged before a cataract forms also means no cataract can develop later. Under 45, laser eye surgery or an implantable contact lens suit most eyes better.
Who is a good candidate
1
The ideal candidate
A healthy eye apart from cataract or presbyopia, a strong wish to be free of glasses, and realistic expectations about halos at night.
Motivation matters most. The Cochrane review of multifocal lenses concluded that the desire for spectacle independence is the deciding factor, because the gain in near vision comes with some loss of contrast and more night-time halos.
Factors that favor or argue against a trifocal lens
Factor
Favors trifocal
Calls for caution
Eye health
Healthy retina, cornea and optic nerve
Macular disease, glaucoma, corneal irregularity
Daily life
Reading, screens, active lifestyle
Professional night driving, precision work in low light
Astigmatism
Low, or corrected by a toric trifocal
High irregular astigmatism
Expectations
Accepts some halos for fewer glasses
Wants perfectly crisp vision in all conditions
2
Lifestyle
Patients who spend long hours on screens and reading gain most from the intermediate and near focus.
Both eyes are usually treated with the same lens, a few days apart, because the brain adapts better to matched vision.
3
Astigmatism
Astigmatism above about one diopter blurs vision with any multifocal lens. A toric trifocal corrects it, and the lens is aligned precisely during surgery.
Who should consider another lens
1
Eye conditions
Age-related macular degeneration, diabetic retinopathy with macular changes, advanced glaucoma, keratoconus or previous corneal disease, and a weak or damaged lens capsule all reduce the sharpness a trifocal lens can deliver.
Eye conditions
Splitting light between three distances leaves less light for each. An eye with a healthy retina copes easily, but a retina already damaged loses contrast it cannot spare. For these patients a monofocal or extended depth of focus lens gives better quality of vision.
Can I have a trifocal lens if I drive at night for work?
Professional drivers and pilots who work at night are usually advised against multifocal lenses, since halos around headlights and runway lights, even when mild, affect safety-critical work. An extended depth of focus lens or monovision with monofocal lenses are the common alternatives.
Personality
People who notice every small visual imperfection and who dislike any compromise are less satisfied with multifocal lenses, even when the measured result is excellent.
Results
Trifocal against monofocal lens at six months, 243 patients
Measure
Trifocal lens
Monofocal lens
Never needing glasses
80.5 percent
8.2 percent
Distance vision
Equivalent
Equivalent
Near and intermediate vision
Much better
Reading glasses needed
Both eyes together reached 20/25 or better across the full range from distance to near. Distance vision with a trifocal lens matches that of a standard lens, so choosing it does not mean giving up sharp distance sight.
Starbursts, halos and glare were the most frequently rated severe symptoms with the trifocal lens. However, less than 5 percent of patients were very bothered at month 6 (Modi and colleagues, 2021).
Halos and glare
1
What patients see
Rings or haze around car headlights and street lamps at night, and sometimes starbursts. In daylight they are rarely noticed.
Halos are strongest in the first weeks and fade as the brain learns to ignore them.
Dry eye makes them worse, and treating it helps.
A second eye with the same lens improves adaptation.
Adverse visual phenomena were more prevalent with multifocal than monofocal lenses, with a risk ratio of 3.58 for halos and 1.41 for glare (de Silva and colleagues, Cochrane Database of Systematic Reviews, 2016).
2
Neuroadaptation
The brain needs three to six months to adapt to a multifocal lens. Patients who are troubled early are encouraged to wait before judging the result, and most settle.
A small number never adapt. For them the lens can be exchanged for a monofocal lens, ideally within the first months.
Trifocal, bifocal or EDOF
Compared with bifocal lenses, trifocal lenses may improve uncorrected intermediate visual acuity at one year, with no difference in distance or near vision (Zamora-de La Cruz and colleagues, Cochrane Database of Systematic Reviews, 2020).
Choosing between advanced lenses
Lens
Strength
Limitation
Trifocal
Near, intermediate and far without glasses in most patients
Halos and glare at night, slight loss of contrast
Bifocal
Near and far
Gap at computer distance, largely replaced by trifocals
EDOF
Fewer halos, good far and intermediate
Reading glasses for small print
Monofocal with monovision
One eye far, one eye near, few halos
Reduced depth perception, glasses for some tasks
Setting expectations
No lens restores the eyes of a twenty-year-old.
A trifocal lens frees the majority from glasses for most of the day. Very small print in dim light may still need a lamp. Night driving takes some weeks to feel normal again. Patients who go into surgery knowing all this, and who accept that a small compromise at night buys freedom from glasses by day, report the highest satisfaction afterwards.
Tests before surgery
1
The measurement visit
Around two hours of painless tests. The pupils are dilated at the end, so bring sunglasses and do not drive afterwards.
Tests and their purpose
Test
Measures
Why it matters
Optical biometry
Length of the eye, corneal power
Calculates the lens power
Corneal topography and tomography
Shape of the cornea, astigmatism
Decides on a toric lens, excludes irregular corneas
Macular OCT scan
Layers of the retina
Detects hidden macular disease
Pupil size and tear film
Night pupil, dryness
Predicts halos, treats dry eye first
Accurate measurements are essential, since a trifocal lens tolerates less error than a monofocal one. The surgeon repeats any reading that looks inconsistent.
Before the measurement visit
If you wear
Stop wearing them
Reason
Soft contact lenses
One week before
They change the shape of the cornea
Rigid or toric contact lenses
Two to four weeks before
Longer recovery of corneal shape
2
Previous laser eye surgery
Patients who had LASIK or PRK years ago can still receive a trifocal lens in many cases, with special formulas for the lens power. The surgeon reviews the old records if available.
Surgery day
1
The operation
Anesthetic drops numb the eye and a light sedative relaxes you. Through a cut of about two millimeters, the surgeon breaks up the natural lens with ultrasound and removes it, then places the folded trifocal lens in the empty capsule, where it unfolds. No stitches are needed. The operation takes 15 to 20 minutes per eye.
You are awake, feel no pain, and see only bright lights during the operation.
You go home the same day with a clear shield over the eye and a schedule of antibiotic and anti-inflammatory drops for about four weeks. The second eye is operated a few days later.
A companion takes you home. You cannot drive on the day of surgery.
Recovery
The first weeks
Distance vision is often clear the next day. Near and intermediate vision sharpen over the following weeks as both eyes are done and the brain adapts.
Avoid rubbing the eye, swimming and dusty places for two weeks, and wear the shield at night for the first week. Reading, screens and walking are fine from the next day.
When is the second eye done?
Usually two to seven days after the first, once the first eye is checked and healing well. Having both eyes done within the same week suits patients traveling from abroad.
Recovery timeline
Time
What to expect
Activities
Day 1
Check-up, distance vision clearing
Reading and screens allowed
Week 1
Both eyes done, near vision improving
Most office work, flying
Weeks 2 to 4
Drops finished, halos fading
Swimming, sport, makeup
Months 3 to 6
Adaptation complete
Final result assessed
Risks
Risks of lens replacement surgery
Risk
How common
Treatment
Posterior capsule clouding
Develops in a share of patients over months to years
A painless laser treatment in the clinic, YAG capsulotomy
Residual refractive error
A few percent
Glasses, laser touch-up or lens adjustment
Macular swelling
One to two percent
Anti-inflammatory drops
Retinal detachment
Uncommon, higher in very short-sighted eyes
Retinal surgery the same week
Serious infection
Fewer than 1 in 1,000
Same-day treatment with antibiotics
Multifocal lens wearers notice even mild capsule clouding sooner, since the lens needs a clear optical path. The laser treatment takes minutes and restores vision.
For patients from abroad
Before traveling, send any recent eye examination reports and your glasses prescription, and stop contact lenses as described above. The final lens choice is made after the measurement visit here, and patients are told before any fee is due if a trifocal lens is not advisable for their eyes.
One coordinator from the international patients office handles arrangements from the first message through discharge and answers the same WhatsApp number once you are back home. The office works in English, Arabic, French, Russian, Serbian, Romanian and Spanish and books interpreters for other languages, and it arranges the visa invitation letter, airport transfers, daily transport and accommodation near the hospital. Halal, vegetarian and diabetic meals, a prayer room on site, and a female physician on request wherever the rota allows.
Length of stay
1
Length of stay and fitness to fly
A stay of seven to ten days covers the measurement visit, surgery on both eyes a few days apart and the check-ups after each. Patients are fit to fly from the day after surgery, and the one-month check can be done by a local ophthalmologist once you are back home, with results sent to us.
Cost
1
What changes the price
The lens model, whether a toric version is needed for astigmatism, and whether one or both eyes are treated. Trifocal lenses cost more than monofocal lenses, and the price is quoted per eye.
What a quote for trifocal lens implantation covers
Item
Included
Priced separately
Preoperative tests
Biometry, topography, OCT, consultation
Treatment of dry eye or other conditions found
Surgery
Lens, operation, anesthesia, day-case stay
Laser touch-up if needed later
Aftercare
Drops, check-ups during the stay
YAG laser for capsule clouding in later years
Compare quotes for the same lens type, toric or not, and both eyes, and ask whether the measurement tests are included.
References
Modi S, Lehmann R, Maxwell A, et al. Visual and patient-reported outcomes of a diffractive trifocal intraocular lens compared with those of a monofocal intraocular lens. Ophthalmology. 2021;128(2):197-207.
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.
Zamora-de La Cruz D, Zúñiga-Posselt K, Bartlett J, Gutierrez M, Abariga SA. Trifocal intraocular lenses versus bifocal intraocular lenses after cataract extraction among participants with presbyopia. Cochrane Database Syst Rev. 2020;6(6):CD012648.
Yoon CH, Shin IS, Kim MK. Trifocal versus bifocal diffractive intraocular lens implantation after cataract surgery or refractive lens exchange. A meta-analysis. J Korean Med Sci. 2018;33(44):e275.
Editor's note
Written by the Biruni Hospital medical editorial team. Reviewed by Assistant Professor Selin ŞİMŞEK ALKAN, Ophthalmology.
