Multifocal intraocular lenses in refractive lens exchange: Guidelines to optimize their use and indications

Refractive lens exchange (RLE) with presbyopia-correcting intraocular lenses (IOLs) can provide high levels of spectacle independence, but the procedure is unforgiving. Small residual refractive errors, ocular surface instability, undiagnosed corneal or macular disease, capsule-related IOL malposition, and mismatched expectations are common pathways to postoperative dissatisfaction. The literature on multifocal and extended-range optics is now complemented by consensus documents and functional classification frameworks that help standardize terminology and reduce "marketing-driven" decision making.

This narrative review aims to define practical indications for multifocal IOL use in RLE, clarify borderline cases, summarize the level of evidence supporting current recommendations, and present a staged algorithm for management of dissatisfaction. Priority was given to international consensus statements, systematic reviews/meta-analyses, randomized or comparative studies, large contemporary cohorts, and focused case series dealing with dissatisfaction, neuroadaptation failure, and IOL exchange. The literature was organized around the terms refractive lens exchange, refractive lensectomy, multifocal intraocular lens, trifocal, extended depth of focus, enhanced monofocal, dysphotopsia, neuroadaptation failure, and lens exchange, with emphasis on contemporary evidence available up to January 2026.

The evidence can be translated into two clinic-ready workflows. The first is a preoperative selection pathway that starts with patient goals, prioritizes optical quality, treats astigmatism aggressively, and reserves range-first optics for eyes and expectations that can tolerate their trade-offs. The second is a symptom-first rescue pathway built on a strict reversible-first and YAG-last sequence. Borderline eyes are best handled with conservative category selection or deferred surgery. Contemporary exchange series show that persistent neuroadaptation failure may be successfully managed either by exchange to monofocal optics or by exchange to another multifocal platform with a different optical profile, provided that refraction, ocular surface disease, posterior-segment pathology, and IOL position have already been addressed.

Multifocal IOLs remain valuable in RLE, but success depends more on indication discipline and rescue sequencing than on lens marketing labels. A structured algorithm, clear counseling, and explicit documentation of rescue options improve safety, readability, and everyday clinical usefulness.