Reasons for dissatisfaction after implantation of extended depth-of-focus and trifocal intraocular lenses: a retrospective case series

Abstract

Background

To analyze the adverse visual symptoms, underlying causes of dissatisfaction, and the effectiveness of subsequent interventions after implantation of extended depth-of-focus (EDOF) and trifocal IOLs.

Methods

This retrospective case series included 307 patients (390 eyes) who underwent phacoemulsification with presbyopia-correcting IOL implantation between January 2023 and July 2025. Patients were divided into an EDOF group (AcrySof IQ Vivity; 203 patients, 256 eyes) and a trifocal group (PanOptix TFNT00; 104 patients, 134 eyes). Seventy-five patients (75 eyes) who reported postoperative dissatisfaction were included in the analysis. Visual acuity, refractive status, wavefront aberrations, ocular surface conditions, posterior capsule status, and fundus findings were evaluated. Causes of dissatisfaction and outcomes of interventions were assessed.

Results

Postoperative dissatisfaction occurred in 47 eyes (23.2%) in the EDOF group and 28 eyes (26.9%) in the trifocal group, with no significant difference between groups (χ² = 0.530, P = 0.467). Uncorrected distance visual acuity did not differ significantly between groups (P = 0.479), whereas uncorrected intermediate and near visual acuity were significantly better in the trifocal group (both P < 0.05). No significant intergroup differences were observed in postoperative visual quality index or total ocular aberrations, except for spherical aberration (P = 0.037). The primary causes of dissatisfaction were residual refractive errors, dry eye disease, posterior capsular opacification, and unmet visual expectations. Symptoms improved in 39 eyes after treatment, resulting in an overall intervention effectiveness rate of 95.1%.

Conclusions

Postoperative dissatisfaction after presbyopia-correcting IOL implantation is multifactorial and varies by IOL design. Individualized evaluation and tailored management strategies are essential to improve postoperative satisfaction.

Introduction

With the advancement of refractive cataract surgery, presbyopia-correcting intraocular lenses (IOLs) have become increasingly popular for restoring continuous vision across multiple distances. Currently available designs include multifocal (bifocal and trifocal), extended depth-of-focus (EDOF), enhanced monofocal, adjustable, and toric presbyopia-correcting IOLs [1, 2]. Trifocal IOLs improve near and intermediate vision by redistributing light energy across three focal points, whereas EDOF IOLs extend the focal range by elongating the depth of focus using wavefront-shaping or diffractive technologies [3, 4].

Although most patients achieve satisfactory visual outcomes, a proportion report postoperative dissatisfaction, manifested as blurred vision, visual disturbances, or ocular discomfort [5]. These symptoms may result from residual refractive errors, optical phenomena inherent to lens design, ocular surface disease, or postoperative complications, all of which can significantly affect vision-related quality of life [6].

Previous studies have primarily focused on visual performance and patient-reported outcomes after presbyopia-correcting IOL implantation [7, 8]; however, comprehensive analyses of dissatisfaction-specific causes and corresponding management strategies remain limited. Therefore, this study aimed to analyze the characteristics, etiologies, and treatment outcomes of postoperative dissatisfaction following implantation of EDOF and trifocal IOLs, providing clinical guidance for optimizing patient selection and postoperative management.

Methods

Study design and participants

This retrospective case series included patients who underwent phacoemulsification with presbyopia-correcting IOL implantation at Jinan Mingshui Eye Hospital between January 2023 and July 2025. The inclusion and exclusion criteria for surgical patients were in accordance with the Clinical Consensus on the Clinical Application of Multifocal Intraocular Lenses in China (2019) [9].The study adhered to the Declaration of Helsinki and was approved by the institutional ethics committee (Approval No. 2023-008).

Patients were divided according to implanted IOL type into the EDOF group (AcrySof IQ Vivity) and the trifocal group (PanOptix TFNT00). Eyes reporting postoperative dissatisfaction were included in the final analysis. To maintain statistical independence, only one eye per patient was included. In patients who underwent bilateral surgery, the first operated eye was selected according to a predefined objective rule.

Preoperative examination

All patients underwent comprehensive ophthalmic examinations prior to surgery, including slit-lamp microscopy, visual acuity (VA), best-corrected visual acuity (BCVA), non-contact intraocular pressure (IOP) measurement (TX-20, Japan), corneal endothelium examination, and fundus examination. VA and BCVA were assessed using the Early Treatment of Diabetic Retinopathy Study (ETDRS) chart, with the total number of correctly read letters recorded and converted to the logMAR scale for statistical analysis. Corneal optical properties were measured using an anterior segment analyzer (Pentacam). Visual quality-related parameters were assessed with an iTrace visual function analyzer (Tracy, USA). Axial length, corneal curvature, anterior chamber depth, and lens thickness were measured with an IOL Master 700 biometer (Zeiss, Germany). IOL refractive power was calculated using the Barrett Universal II formula. For patients with a history of myopic PRK or LASIK, the Barrett True-K formula was used to calculate IOL power. The trifocal group was set with a target refractive power approaching 0, while the EDOF group was configured with a target refractive power of either 0 or -0.25 to -0.40D in the non-primary eye. The primary eye was identified and marked using the hole-in-the-card dominance test (Dolman’s test).

Surgical procedure

The surgeries were performed by the same experienced ophthalmologist, who conducted femtosecond laser-assisted phacoemulsification (Alcon LenSx) cataract extraction as per patient preference, with intraoperative IOL implantation. Patients undergoing bilateral surgery were scheduled 15–30 days apart. Postoperative treatment included: levofloxacin eye drops (4 times daily for 2 weeks); 1% prednisolone acetate eye drops (6 times daily, with 2 weekly reductions for 1 month); and tobramycin-dexamethasone ointment (once nightly for 1 week).

Postoperative follow-up

Standard postoperative checks were performed at 3 days, 1 month and 3 months. Routine procedures included collection of medical history, slit-lamp microscopy to assess corneal transparency, anterior chamber reaction, pupillary diameter, pupillary light reflex, IOL position, and posterior capsular opacification. Ocular pressure measurement, computerized refraction, 5 m unaided distance visual acuity (UDVA), 60 cm unaided visual acuity (UIVA), and 40 cm unaided near visual acuity (UNVA) were performed, with results converted to LogMAR visual acuity for statistical analysis. For patients with residual refractive errors, the IOL Master 700 was used to compare pre-and postoperative ocular biological parameters, observing IOL and posterior capsular adherence. Visual quality index (QVI), total ocular aberration, total low-order aberration, total high-order aberration, spherical aberration, comatic aberration, and trifoliate aberration were measured using the iTrace Visual Function Analyzer (Tracy, USA) based on subjective complaints. Patients with subjective dry eye symptoms underwent comprehensive ocular surface analysis (OCULUS, Germany), including tear film thickness, tear film breakage time, and meibomian gland analysis. Optical coherence tomography (OCT) was performed for patients with fundus lesions. Cases without any organic ocular lesions, where visual acuity and refractive errors met IOL specifications but patients still expressed dissatisfaction, were classified as “disappointment,” with cause classification based on objective examination results.

Statistical analysis

Statistical analyses were performed using SPSS version 26.0 (IBM Corp., Armonk, NY, USA). Continuous variables were assessed for normality using the Shapiro–Wilk test. Normally distributed data were presented as mean ± standard deviation, whereas non-normally distributed data were presented as median (interquartile range). Comparisons between groups were performed using independent-samples t tests for normally distributed variables or Mann–Whitney U tests for non-normally distributed variables. Categorical variables were compared using the chi-square test. Effect sizes (Cohen’s d) with 95% confidence intervals were calculated for continuous outcomes to quantify the magnitude and precision of between-group differences. A two-tailed P value < 0.05 was considered statistically significant.

Results

Baseline characteristics

This study enrolled a total of 75 patients (75 eyes) with postoperative dissatisfaction, including 37 females and 38 males, with an age range of 22–73 years (mean age: 52.5 ± 10.7 years). The time to postoperative dissatisfaction was 33 [12,60] days. Patients were divided into two groups based on the implanted lens: the EDOF group (47 cases, 47 eyes) and the trifocal group (28 cases, 28 eyes). In the EDOF group, 5 eyes received astigmatism-correcting EDOF IOLs, and 8 eyes underwent femtosecond laser-assisted arcuate keratotomy (FLAK) for corneal astigmatism correction. In the trifocal group, 7 eyes received astigmatism-correcting trifocal IOLs, and 3 eyes underwent FLAK for corneal astigmatism correction. No statistically significant differences were observed in preoperative baseline characteristics between the two groups (P > 0.05). The preoperative characteristics of the cataract surgery patients are summarized in Table 1.

Table 1.

Baseline demographic and preoperative ocular characteristics of dissatisfied patients implanted with EDOF or trifocal IOLs

Items	EDOF IOL group (47 eyes)	Trifocal IOL group (28 eyes)	t price	p price
Age, year	53.3 ± 9.3	51.1 ± 12.9	0.876	0.384
AL, mm	23.5 ± 1.2	24.0 ± 1.3	-1.738	0.086
ACD, mm	3.2 ± 0.4	3.3 ± 0.5	-0.889	0.377
LT, mm	4.2 ± 0.5	4.1 ± 0.6	0.670	0.505
Km, mm	44.4 ± 1.5	43.7 ± 1.6	1.799	0.076
pupil diameter, mm	4.3 ± 0.8	4.1 ± 0.9	1.148	0.255
IOL, power, D	20.8 ± 3.1	20.1 ± 3.4	0.986	0.327

Footnotes: Data are presented as mean ± standard deviation unless otherwise indicated. AL = axial length; ACD = anterior chamber depth; LT = lens thickness; Km = mean keratometry; IOL = intraocular lens; EDOF = extended depth-of-focus. Between-group comparisons were performed using independent-samples t tests. A P value < 0.05 was considered statistically significant

Main symptoms of dissatisfaction

Postoperative dissatisfaction was reported in 47 eyes (23.2%) in the EDOF group and 28 eyes (26.9%) in the trifocal group, with no statistically significant difference between the two groups (χ²=0.530, P = 0.467). The main complaints of dissatisfaction in the EDOF group were blurred vision in 28 eyes (59.6%), including 17 eyes complaining of near vision difficulty; optical interference in 10 eyes (21.3%), with 6 eyes also experiencing blurred vision; foreign body sensation, dry eye, and other discomfort symptoms in 8 eyes (17.0%); and visual distortion or visual fatigue in 6 eyes (22.2%). In the trifocal group, the main complaints of dissatisfaction were foreign body sensation and dry eye in 13 eyes (46.4%), with 1 eye additionally experiencing glare or halos; blurred vision in 10 eyes (35.7%); optical interference in 5 eyes (17.9%), with 2 eyes also having blurred vision; and floating shadows in 2 eyes (7.1%).

Visual acuity outcomes

The uncorrected distance, mid, and near visual acuity of patients in the EDOF group at presentation were 0.11 ± 0.12,0.01 ± 0.07, and 0.20 ± 0.08, respectively, while those in the trifocal group were 0.09 ± 0.15, -0.04 ± 0.04, and 0.05 ± 0.08, respectively. No statistically significant difference was observed in uncorrected distance visual acuity between the two groups (t = 0.711, P = 0.479), whereas statistically significant differences were noted in uncorrected mid and near visual acuity (t = 2.663,6.444; P < 0.05 for both) (Table 2).

Table 2.

Comparison of uncorrected distance, intermediate, and near visual acuity at the time of dissatisfaction between the EDOF and trifocal IOL groups

project	EDOF group (47 eyes)	Three focal groups (28 eyes)	t price	P price
UCDVA	0.11 ± 0.11	0.09 ± 0.15	0.711	0.479
UCIVA	0.00 ± 0.07	-0.04 ± 0.05	2.663	0.010
UCNVA	0.20 ± 0.08	0.05 ± 0.08	6.444	<0.001

Footnotes: Visual acuity values are expressed in logMAR units and presented as mean ± standard deviation. UCDVA = uncorrected distance visual acuity; UCIVA = uncorrected intermediate visual acuity; UCNVA = uncorrected near visual acuity; EDOF = extended depth-of-focus; IOL = intraocular lens. Between-group comparisons were performed using independent-samples t tests. A P value < 0.05 was considered statistically significant

Aberration analysis

Wavefront aberration examination was performed on 57 patients presenting with blurred vision and optical interference, including 34 eyes in the EDOF group and 23 eyes in the trifocal group. No statistically significant differences were observed in postoperative QVI, total aberration, total low-order aberration, total high-order aberration, coma, or trifocal aberration between the two groups (all P > 0.05). However, a statistically significant difference was noted in spherical aberration (U = 262.500, P = 0.037), as shown in Table 3.

Table 3.

Comparison of postoperative ocular wavefront aberrations between the EDOF and trifocal IOL groups

project	EDOF group (34 eyes)	Trifocal group (23 eyes)	U price	P price
QVI	7.30[5.50,8.65]	8.60[6.40,9.80]	272.500	0.075
total aberration	0.28[0.22,0.31]	0.22[0.17,0.32]	316.000	0.222
total low order aberration	0.24[0.18,0.28]	0.20[0.12,0.29]	308.000	0.177
total higher-order aberration	0.11[0.10,0.14]	0.12[0.08,0.14]	337.000	0.380
spherical aberration	0.01[-0.01,0.03]	-0.01[-0.02,-0.00]	262.500	0.037
coma	0.06[0.04,0.07]	0.06[0.03,0.07]	390.00	0.987
whitetip clover	0.06[0.04,0.09]	0.06[0.04,0.09]	368.000	0.708

Footnotes: Data are presented as median (interquartile range). QVI = visual quality index; HOA = higher-order aberration; LOA = low-order aberration; EDOF = extended depth-of-focus; IOL = intraocular lens. Between-group comparisons were performed using the Mann–Whitney U test. A P value < 0.05 was considered statistically significant

Causes of dissatisfaction

Residual refractive errors, coexisting ocular surface or fundus diseases, and mismatched expectations were the primary causes of patient dissatisfaction. In the EDOF group, 22 eyes exhibited residual refractive errors, with spherical lens power of-0.19 ± 0.57D, cylindrical lens power of-0.78 ± 0.29D, equivalent spherical lens power of-0.54 ± 0.47D, and refractive prediction error of-0.49 ± 0.44D. Significant differences were observed in axial length, anterior chamber depth before and after surgery (t = 6.136, -16.894, all P < 0.001), while no statistically significant difference was found in corneal curvature (t=-1.069, P = 0.303). Among the 22 eyes, 8 showed complete adhesion between the posterior capsular membrane and IOL, 6 exhibited partial adhesion, 1 had no adhesion, and 7 could not be accurately identified. In the trifocal group, 4 eyes retained residual refractive errors, including 1 case with dry eye syndrome and 1 case with IOL displacement.

The causes of blurred vision also included postoperative posterior capsular opacification, with 5 eyes in the EDOF group and 5 eyes in the trifocal group, each group having 1 eye with intraoperative posterior capsular opacification, defined as cases in which, posterior capsule calcification or visually significant opacification that could not be fully removed during capsule polishing. In the EDOF group, 4 eyes were diagnosed with dry eye syndrome, and 2 eyes were complicated by refractive errors; in the trifocal group, 10 eyes were diagnosed with dry eye syndrome. The EDOF group had 10 eyes with mismatched expectations, while the trifocal group had 4 eyes. Postoperatively, 2 eyes in the trifocal group developed high intraocular pressure. Among the EDOF group, 42 eyes had patient dissatisfaction due to a single factor, and 5 eyes were complicated by multiple factors; in the trifocal group, 25 eyes had patient dissatisfaction due to a single factor, and 3 eyes were complicated by multiple factors. Specific analysis is shown in Table 4.

Table 4.

Etiological distribution of postoperative dissatisfaction in eyes implanted with EDOF or trifocal IOLs

Cause of disease	EDOF group (47 eyes)	Three focal groups (28 eyes)
Residual refractive error	22	4
Expectations are not met	10	4
Posterior capsular opacity	5	5
Dry eye	4	10
Corneal conjunctival diseases	3	2
Fundus oculi disease	2	3
Irregular corneal morphology	3	-
Amblyopia	2	-
Anisometropia	1	-
Bulbi hypertonia	-	2
IOL decentration	-	1

Footnotes: Values are presented as number of eyes. EDOF = extended depth-of-focus; IOL = intraocular lens; PCO = posterior capsular opacification. Multiple causes could be present in a single eye

Intervention outcomes

In the EDOF group, 23 eyes (48.9%) received intervention treatments, primarily including artificial tear instillation, dry eye fumigation, and spectacles. Four eyes underwent Nd: YAG posterior capsulotomy, and 2 eyes underwent IOL replacement. One eye still experienced blurred vision after IOL replacement, and 1 eye showed no improvement in corrected visual acuity after Nd: YAG posterior capsulotomy. The remaining patients reported symptomatic improvement following treatment. In the trifocal group, 18 eyes (64.3%) received intervention treatments, mainly including meibomian gland massage, dry eye fumigation, and artificial tear instillation. Two eyes underwent Nd: YAG posterior capsulotomy, 1 eye underwent fundus laser surgery due to peripheral retinal hole, and 1 eye received intravitreal injection of anti-VEGF drugs 50 days postoperatively due to macular cystoid edema. All patients in this group reported symptomatic improvement after treatment. The overall effectiveness rate of intervention in both groups was 95.1%.

Discussion

With the development of refractive cataract surgery, presbyopia-correcting intraocular lenses (PC-IOL) have been increasingly adopted to meet patients’ demands for spectacle independence and high-quality vision. Extended depth-of-focus (EDOF) IOLs and trifocal IOLs represent two widely used optical strategies, each with distinct advantages and limitations. The Vivity IOL features a biconvex optical design with two transitional elements with a wavefront-modulating elevation of 1 μm in the central 2.2 mm area to modulate primary and secondary spherical aberrations and enhance intermediate vision [8, 10].The PanOptix trifocal IOL employs non-progressive diffractive optical technology, with its innovative design based on four-focus technology. It redistributes the 120 cm focal length, shifting the intermediate focus to 60 cm, thereby meeting the visual needs of patients at close (40 cm), intermediate (60 cm), and distant (infinite) distances [11]. Numerous previous studies [2, 12, 13] have reported the safety and efficacy of Vivity IOL and PanOptix trifocal IOL implantation. The PanOptix trifocal IOL demonstrates a higher rate of postoperative spectacle independence, while the Vivity IOL exhibits fewer occurrences of glare and halos in dim light conditions. This study focuses on patients with postoperative dissatisfaction, analyzing the causes of such dissatisfaction to reduce the occurrence of adverse visual phenomena and improve visual quality.

Postoperative refractive errors and residual astigmatism have negative impacts on visual acuity and patient satisfaction [14]. In this study, the primary complaint in the EDOF group was blurred vision, with 60.7% (17/28) reporting poor near vision. Among these, 22 eyes exhibited residual refractive errors, with an average spherical error of -0.19 ± 0.57 D, cylindrical error of -0.78 ± 0.29 D, and SE of -0.54 ± 0.47 D. Wanten et al. [15] analyzed 52 patients (83 eyes) with dissatisfaction after Vivity IOL implantation, finding that 28 cases (45 eyes) had refractive errors, with spherical error of -0.18 ± 0.66 D, cylindrical error of -0.12 ± 0.94 D, and SE of -0.60 ± 0.58 D. The results of this study are consistent with theirs, demonstrating that UDVA, UIVA, UNVA significantly deteriorates with increasing astigmatism [16]. In previous studies, the average uncorrected distance, intermediate, and near vision after Vivity IOL implantation were 0.00 ± 0.08, 0.07 ± 0.06, and 0.25 ± 0.11, respectively [10]. In this study, the UDVA was 0.11 ± 0.12, slightly lower than in previous studies, while the intermediate and near vision were similar to those in previous studies. This was because some patients in this study had postoperative complications or ocular diseases, which affected the UDVA due to fundus lesions or dry eye syndrome. Additionally, the residual mild astigmatism increased the depth of focus, thereby maintaining a certain level of intermediate and near vision [14]. In this study, the UDVA, UIVA, UNVA in the trifocal group were 0.09 ± 0.15, -0.04 ± 0.04, and 0.05 ± 0.08, respectively. Kohnen et al. [17]patients who received trifocal IOLs achieved uncorrected distance, mid-distance, and near visual acuity of 0.00 ± 0.094,0.00 ± 0.111, and 0.01 ± 0.087, respectively.Trifocal IOLs provide superior all-corrected visual acuity. In contrast, the mid-distance and near visual acuity in the EDOF group were inferior to those with bifocal IOLs, which explains the patients’ complaints of blurred near vision.

Precise surgical techniques and corneal astigmatism are critical factors influencing postoperative refractive status. In this study, there was no statistically significant difference in preoperative ocular biometric measurements between the two groups (P > 0.05). Both groups utilized the Barrett Universal II or Barrett True K formula for IOL power calculation, which has been widely validated in previous studies [18]. The study employed a standardized surgical protocol. When the estimated postoperative corneal regular astigmatism was ≥ 0.75D, Toric IOL or FLAK surgery was selected, with no intraoperative complications reported. In this study, the refractive prediction error in the EDOF group was-0.49 ± 0.44D, and the number of patients with residual refractive errors was significantly higher than in the trifocal group. Repeat biometric measurements were performed for patients with residual refractive errors, revealing statistically significant differences in axial length, anterior chamber depth, and lens thickness before and after surgery (all P < 0.001), but no significant difference in corneal curvature (t=-1.069, P = 0.303). The IOL power was accurately implanted. This study suggests that the special optical section of the Vivity IOL, with a central diameter of 2.2 mm, may affect the accuracy of refraction. However, corneal curvature and anterior chamber depth may fluctuate for a certain period postoperatively, with anterior chamber depth gradually increasing 4–12 weeks after surgery, leading to hyperopic drift in refractive power [19]. This study also observed the adhesion status of IOLs to the posterior capsule in the EDOF group, which can also cause fluctuations in refractive status, thereby affecting retinal imaging quality. In this study, posterior capsular opacification was observed in 10 eyes, with Nd: YAG laser capsulotomy performed only in 6 eyes with significant opacification. Chen Lulu et al. [20] observed 175 cases (350 eyes) of patients who received trifocal IOL implantation, and 81.7% of the operated eyes underwent Nd: YAG laser capsulotomy due to posterior capsular opacification or thickening postoperatively. Compared with monofocal IOLs, even mild posterior capsular opacification or thickening after PC-IOL implantation can lead to vision loss and visual disturbances [6].

Visual interference is a significant factor affecting postoperative satisfaction with presbyopic correction IOL implantation. In this study, 10 eyes in the EDOF group and 5 eyes in the trifocal group reported optical interference, accounting for 21.3% and 17.9% of the total dissatisfaction cases, respectively, with an overall incidence rate of 4.9% and 4.8% in the cohort. In addition to positive optical disturbances such as glare, halos, and starburst, 2 eyes in the EDOF group exhibited negative optical disturbances, including temporal crescent shadows, all of which had some impact on daily life. Modi et al. [13]visual disturbances caused by glare and halos gradually decreased with postoperative time, with only 5% of patients still experiencing discomfort at 6 months postoperatively. The presence of neural adaptation effectively alleviates or resolves most visual discomfort symptoms following presbyopic correction IOL implantation. After ruling out ocular diseases and refractive errors as causes, patients should be patiently explained. For those who fail to adapt and for whom other treatments prove ineffective, IOL replacement may be considered.

Visual imaging and visual perception in the human eye are the result of the combined effects of multiple factors, including psychological and physical aspects. Only by integrating subjective and objective visual quality assessments can the true and reliable status of human visual quality be reflected [21]. In this study, aberration measurements were performed on patients who complained of blurred vision and optical interference phenomena. The results showed that there were no statistically significant differences in postoperative QVI, total aberration, total low-order aberration, total high-order aberration, coma, and trefoil aberration between the two groups (all P > 0.05), while spherical aberration showed a statistically significant difference (P = 0.037). Previous studies have demonstrated that the magnitude of wavefront aberration is closely related to visual quality. Among high-order aberrations, different types of aberrations have varying impacts on the visual system. Coma and spherical aberrations play crucial roles in focal depth and retinal image quality. Under the same best-corrected visual acuity, spherical aberration has a more pronounced effect on visual quality [22]. In this study, the spherical aberration in the trifocal group was -0.01 [-0.02, -0.00]. Generally, spherical aberration in the human eye is typically positive. Multiple previous studies have shown that trifocal IOL implantation does not introduce additional high-order aberrations [23]. The occurrence of negative spherical aberration may exacerbate nocturnal halos or glare [24]. Numerous factors influence human eye aberration, including pupil diameter, age, eye type, accommodation state, and tear film stability. In this study, there was no statistically significant age difference between the two groups (P > 0.05). Aberration values were measured at a pupil size of 3 mm both before and after surgery. Since this study included patients with dry eye, dynamic changes in the tear film may directly affect the stability of high-order aberrations, thereby leading to a decline in visual quality.

Dry eye has become the second most common cause of dissatisfaction after presbyopic correction IOL implantation, following visual disturbances. Gibbons et al. [25]35% of patients reported dry eye complaints post-cataract surgery, while Wanten et al. [15] found that 26.5% of dissatisfied patients after EDOF IOL implantation experienced dry eye. In our study, 10.7% of patients in the EDOF group complained of discomfort such as dryness and foreign body sensation, compared to 46.4% in the trifocal group, with 35.7% of patients diagnosed with dry eye. Dry eye is a common ocular surface disorder with a rising global incidence [26]. Abnormal tear film can affect corneal refractive status, astigmatism, higher-order aberrations, and other ocular measurements. Moreover, dry eye is closely associated with refractive errors after cataract surgery [27]. Patients who receive presbyopic correction IOLs often have higher expectations for postoperative refractive status and visual quality, making them more susceptible to visual disturbances caused by dry eye. Fluctuating vision between blurred and clear can lead to visual fatigue, and postoperative tear film stability is crucial for improving visual quality [28]. When postoperative visual outcomes are unsatisfactory, ocular surface issues should be first identified and addressed through interventions such as artificial tears, lacrimal secretion-promoting medications, or eyelid cleaning, warm compresses, and massage. Only after adequate dry eye treatment should the possibility of IOL-related issues be considered.

Due to the persistent difference between visual acuity after presbyopic correction IOL implantation and natural vision, even when there are no organic ocular pathologies and visual acuity and refractive status align with IOL characteristics, some patients remain dissatisfied. In this study, two eyes in the EDOF group were replaced with monofocal IOLs due to unmet expectations and persistent waxy vision. Takabatake et al. [29] reported 25 cases (29 eyes) where diffractive bifocal IOLs were replaced with EDOF IOLs due to waxy vision. The difference in corrected distance vision before and after replacement was not statistically significant (P = 0.273), but the area under the contrast sensitivity function showed a significant increase, with marked improvement in waxy vision symptoms. In this study, both replaced eyes exhibited corneal optical characteristics incompatible with presbyopic correction IOLs. Although Pentacam indicated total higher-order aberrations < 0.3 μm in the 4 mm central corneal diameter region, preoperative corneal morphology and asphericity typically do not cause visual problems, but may serve as potential triggers for decreased contrast sensitivity and visual disturbances.

In this study, 54.7% (41/75) of the patients received treatment, including interventions such as optical correction, artificial tear instillation, meibomian gland massage, dry eye fumigation, Nd: YAG laser posterior capsulotomy, IOL replacement, fundus laser therapy, and intravitreal injection of anti-VEGF agents. One eye still experienced blurred vision after IOL replacement, and one eye showed no improvement in corrected visual acuity following Nd: YAG laser posterior capsulotomy, ruling out the diagnosis of congenital amblyopia. The majority of the remaining patients reported symptomatic improvement after treatment.

Some limitations of this study should be acknowledged. First, loss to follow-up in a subset of patients may have introduced selection bias or misclassification. Second, binocular visual function was not assessed as an outcome measure for postoperative patient satisfaction. Third, the follow-up period was relatively short, and further long-term studies are needed to evaluate postoperative satisfaction over time. Nevertheless, our findings indicate that blurred vision, optical interference, and dry eye disease are the primary causes of dissatisfaction after presbyopia-correcting IOL implantation, with distinct patterns depending on IOL design. Optimizing perioperative management, minimizing residual refractive error, maintaining ocular surface health, and providing thorough patient counseling are essential for improving visual outcomes and patient satisfaction.

Conclusions

Postoperative dissatisfaction following presbyopia-correcting IOL implantation is multifactorial and IOL-design dependent. Careful patient selection, accurate refractive targeting, ocular surface optimization, and timely postoperative interventions are critical for improving visual outcomes and patient satisfaction.

Abbreviations

IOL

Intraocular lens

EDOF

Extended depth-of-focus

UDVA

Uncorrected distance visual acuity

UIVA

Uncorrected intermediate visual acuity

UNVA

Uncorrected near visual acuity

QVI

Visual quality index

Author contributions

KFW and XMW conceived and designed the study. KFW, CJG, SSQ, and XLW collected the data. KFW performed the statistical analysis. KFW drafted the manuscript. XMW critically revised the manuscript. All authors read and approved the final manuscript.

Funding

This study was supported by the Science and Technology Development Program of Jinan Municipal Health Commission (Grant No. 2025305022) and the Young Elite Sponsorship Program of Shandong Provincial Medical Association.

The funding bodies had no role in the design of the study, data collection, analysis, interpretation of data, or writing of the manuscript.

Data availability

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

This study was approved by the Medical Ethics Committee of Jinan Mingshui Eye Hospital (Approval No. 2023-008) and adhered to the Declaration of Helsinki. Written informed consent to participate in the study was obtained from all participants prior to enrollment.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.