When trifocal IOLs disappoint: diagnostic and management pathway

Trifocal presbyopia-correcting intraocular lenses (IOLs) are widely used in cataract surgery and refractive lens exchange to expand functional vision across distance, intermediate, and near ranges and to reduce spectacle dependence. Despite generally favorable visual outcomes, some patients experience postoperative dissatisfaction related to dysphotopsia, reduced visual quality, or unmet functional expectations. Evidence suggests that, at 1 year, trifocal IOLs show no clear differences versus bifocal IOLs in uncorrected distance or near visual acuity, while uncorrected intermediate acuity may be improved, although certainty is low and reporting of adverse visual phenomena and quality-of-life outcomes is limited. Comparative studies with bifocal and extended depth-of-focus lenses suggest that trifocal IOLs may provide stronger near performance and greater spectacle independence, although photic phenomena such as halos may occur more frequently in some patients. Contemporary evidence indicates that dissatisfaction is multifactorial and may involve residual refractive error, dysphotopsia, ocular surface disease, neuroadaptation failure, and IOL-capsule complex abnormalities such as tilt, decentration, capsular contraction, or posterior capsule opacification. This narrative review synthesizes current evidence on the epidemiology and contributors to trifocal IOL dissatisfaction and proposes a pragmatic diagnostic and management framework. The approach emphasizes symptom characterization, rigorous refraction and binocular testing, early ocular surface optimization, targeted evaluation of the IOL-capsule complex, and stepwise intervention sequencing, including deferring Nd:YAG capsulotomy until IOL exchange is unlikely. Standardized outcome sets and prospective trials of staged care pathways are needed to improve comparability and guide individualized treatment decisions.