In-vitro Comparison of Trifocal Intraocular Lenses of Different Optical Zone Diameter and Design Across Pupil Sizes

Abstract

Background Trifocal intraocular lenses (IOLs) for the correction of cataracts allow patients to enjoy good uncorrected intermediate and near visual acuity, and allow them to be independent of spectacles. While clinical studies robustly support their advantages, laboratory evaluations of their objective performance are important. This study evaluated novel trifocal IOLs with 6.0 or 7.0 mm optical zone – Triva-aAY or Triva-aXAY – and compares them to a classic trifocal (Acrysof IQ PanOptix) and an extended-depth-of-focus trifocal (Triumf POD L GF).

Methods and Material The optical quality of two samples of each IOL model with a diopter power of 20 D was evaluated at 3-, 4.5-, and 6-mm apertures with OptiSpheric IOL PRO2 and measured per ISO 11 979 standard. The resulting modulation transfer functions (MTF), through focus area under the MTF curve (MTFa) and simulated visual acuity (VA) were assessed at near, intermediate, and far distances. Additionally, IOLʼs tolerance to misalignment was measured by inducing up to 0.7 mm of vertical decentration and 5° tilt. Measurements were repeated with the 1951 United States Air Force (USAF) resolution test chart.

Results The Triva-aXAY and Triva-aAY had equivalent optical performance at all apertures. For the 3- and 4.5-mm pupil, the Triva IOLs showed MTF levels close to that of the PanOptix but had a slightly extended focus range at a near distance. The MTF analysis did not reveal any difference in optical quality between the Triva IOLs at 6 mm. Although at far and intermediate focus, the Triumfʼs MTF was above the level of the other models, it was at the expense of the near focus. Triumf was the least tolerant of misalignment. All findings were supported by the USAF resolution test charts.

Conclusion Triva-aXAY and Triva-aAY IOLs have an equivalent optical performance at all apertures, with a slightly extended focus range compared to PanOptix at near focus, comparable MTF at intermediate focus, and lower optical quality than Triumf at far focus. The latter, however, may provide insufficient performance at reading distance. IOL misalignment affects the optical quality of the trifocal models and is design-dependent.

Zusammenfassung

Hintergrund Trifokale Intraokularlinsen (IOL) zur Behandlung des grauen Stars ermöglichen es den Patienten, eine gute unkorrigierte Sehschärfe im Fern-, Intermediär- und Nahbereich zu erreichen, was zu Brillenunabhängigkeit führt. Während klinische Studien ihre Vorteile eindeutig belegen, sind Laboruntersuchungen zur objektiven Beurteilung der Leistung wichtig. In dieser Studie wurden neuartige trifokale IOLs mit 6,0 und 7,0 mm optischer Zone – Triva-aAY und Triva-aXAY – untersucht und mit einer klassischen Trifokallinse (Acrysof IQ PanOptix) und einer Trifokallinse mit erweiterter Tiefenschärfe (Triumf POD L GF) verglichen.

Material und Methoden Die optische Qualität von 2 Linsen jedes IOL-Modells mit einer Dioptrienstärke von 20 dpt wurde bei 3-, 4,5- und 6-mm-Pupillen mit dem OptiSpheric IOL PRO2 bewertet und nach dem ISO-11979-Standard gemessen. Die resultierenden Modulationsübertragungsfunktionen (MTF), die Fläche unter der MTF-Kurve (MTFa) und die simulierte Sehschärfe (VA) wurden für Nah-, Intermediär- und Ferndistanzen dargestellt. Außerdem wurde die Toleranz der IOL gegenüber Fehlausrichtungen gemessen, indem eine vertikale Dezentrierung von bis zu 0,7 mm und eine Neigung von 5° induziert wurde. Die Messungen wurden mit der 1951 United States Air Force (USAF) Resolution Test Chart durchgeführt.

Ergebnisse Die Triva-aXAY und Triva-aAY zeigten bei allen Aperturen eine vergleichbare optische Leistung. Bei der 3- und 4,5-mm-Pupille wiesen die Triva-IOLs MTF-Werte auf, die denen der PanOptix nahekamen, hatten aber einen leicht verlängerten Fokus im Nahbereich. Die MTF-Analyse ergab keinen Unterschied in der optischen Qualität der Triva IOLs bei 6 mm. Obwohl die MTF der Triumf im Fern- und Intermediärfokus über dem Niveau der anderen Modelle lag, war sie im Nahfokus geringer. Die Triumf zeigte sich am wenigsten tolerant gegenüber Fehlausrichtungen. Alle Ergebnisse wurden durch den USAF-Test bestätigt.

Schlussfolgerung Die Triva-aXAY und Triva-aAY IOLs zeigen eine vergleichbare optische Leistung bei allen Pupillenweiten, mit einem leicht erweiterten Fokusbereich im Vergleich zur PanOptix im Nahfokus, vergleichbarer MTF im Intermediärfokus und geringerer optischer Qualität im Vergleich zur Triumf im Fernfokus. Letztere bietet jedoch möglicherweise eine unzureichende Leistung im Leseabstand. Die IOL-Fehlausrichtung beeinflusst die optische Qualität der trifokalen Modelle und ist designabhängig.

Conclusion Box

Already known:

• Trifocal IOLs provide improved range of vision for patients undergoing cataract surgery, with clinical studies consistently supporting their use.

• With introduction of new trifocal IOLs and lack of clinical data on them, laboratory studies can provide valuable information for assessing and comparing various IOLs.

• To date, there are no laboratory studies in the literature that compare Triva-aAY and Triva-aXAY trifocal IOLs.

Newly described:

• Triva-aXAY and Triva-aAY, despite the optic-diameter difference, had an equivalent optical performance at all apertures, with slightly extended focus range compared to PanOptix at near focus, comparable MTF at intermediate focus, and lower performance to Triumf at far focus.

• Our data agreed with the available clinical literature, yielding consistent predictions of PanOptix and Triva, but not for the Triumf most likely due to the controlled conditions achieved in the laboratory and limited comparative clinical data on the Triumf lens.

• The Triumf was the least tolerant to misalignment while the PanOptix and the Triva IOLs were more robust against misalignment. The latter showed a small improvement in far distance MTF beyond the 0.5 mm decentration, potentially at the expense of contrast at near and intermediate focus.

Keywords

cataract surgery - optical quality - modulation transfer function - trifocal intraocular lenses

Schlüsselwörter

Kataraktchirurgie - optische Qualität - Modulationsübertragungsfunktion - trifokale Intraokularlinsen

Publication History

Received: 26 November 2024

Accepted: 30 June 2025

Article published online:
21 August 2025

• References

• 1 Breyer DRH, Kaymak H, Ax T. et al. Multifocal Intraocular Lenses and Extended Depth of Focus Intraocular Lenses. Asia Pac J Ophthalmol (Phila) 2017; 6: 339-349
• 2 Cochener B, Lafuma A, Khoshnood B. et al. Comparison of outcomes with multifocal intraocular lenses: a meta-analysis. Clin Ophthalmol 2011; 5: 45-56
• 3 Kawamura J, Tanabe H, Shojo T. et al. Comparison of visual performance between diffractive bifocal and diffractive trifocal intraocular lenses. Sci Rep 2024; 14: 5292
• 4 Son HS, Labuz G, Khoramnia R. et al. Ray propagation imaging and optical quality evaluation of different intraocular lens models. PLoS One 2020; 15: e0228342
• 5 Yang YP, Tan Y, Liao Q. Analysis of visual quality improvement after implantation of PanOptix trifocal intraocular lens in cataract patients with different axial lengths. Am J Transl Res 2024; 16: 2995-3004
• 6 Hayashi K, Sato T, Igarashi C. et al. Comparison of visual outcomes between bilateral trifocal intraocular lenses and combined bifocal intraocular lenses with different near addition. Jpn J Ophthalmol 2019; 63: 429-436
• 7 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: e275
• 8 Gatinel D, Pagnoulle C, Houbrechts Y. et al. Design and qualification of a diffractive trifocal optical profile for intraocular lenses. J Cataract Refract Surg 2011; 37: 2060-2067
• 9 Łabuz G, Yan W, Baur ID. et al. Chromatic aberration and spectral dependency of extended-range-of-vision intraocular lens technology. Sci Rep 2023; 13: 14781
• 10 Wang L, Dai E, Koch DD. et al. Optical aberrations of the human anterior cornea. J Cataract Refract Surg 2003; 29: 1514-1521
• 11 Alarcon A, Canovas C, Rosen R. et al. Preclinical metrics to predict through-focus visual acuity for pseudophakic patients. Biomed Opt Express 2016; 7: 1877-1888
• 12 Thibos LN, Hong X, Bradley A. et al. Accuracy and precision of objective refraction from wavefront aberrations. J Vis 2004; 4: 329-351
• 13 Swedish Institute for Standards. Ophthalmic implants – Intraocular lenses – Part 2: Optical properties and test methods (ISO 11979-2: 2014). https://www.sis.se/en/produkter/health-care-technology/medical-equipment/ophthalmic-equipment/sseniso1197922014/ Stand: 10.10.2024
• 14 Pastor-Pascual F, Orts-Vila P, Tañá-Sanz P. et al. Clinical Performance of a New Trifocal IOL with a 7.0 mm Optical Zone. Clin Ophthalmol 2023; 17: 3397-3407
• 15 HumanOptics. TRIVA: Die neue Trifokalität – Trifokale Presbyopiekorrektur. http://ttps://www.humanoptics.com/arzte/intraokularlinsen/trifokal-triva/ Stand: 05.05.2025
• 16 Yan W, Auffarth GU, Khoramnia R. et al. Spectral Effects and Range of Focus in a Multizonal-Refractive Intraocular Lens Compared with a Standard Trifocal Diffractive Design. Ophthalmol Ther 2023; 12: 1621-1634
• 17 BVImedical. FINEVISION TRIUMF Trifocal EDOF Hydrophobic IOL. https://www.bvimedical.com.br/wp-content/uploads/2022/03/TRIUMF-technology-brochure-1581269-01.pdf Stand: 05.05.2025
• 18 Carson D, Xu Z, Alexander E. et al. Optical bench performance of 3 trifocal intraocular lenses. J Cataract Refract Surg 2016; 42: 1361-1367
• 19 Son HS, Tandogan T, Liebing S. et al. In vitro optical quality measurements of three intraocular lens models having identical platform. BMC Ophthalmol 2017; 17: 108
• 20 Ruiz-Alcocer J, Madrid-Costa D, García-Lázaro S. et al. Optical performance of two new trifocal intraocular lenses: through-focus modulation transfer function and influence of pupil size. Clin Exp Ophthalmol 2014; 42: 271-276
• 21 Lee Y, Łabuz G, Son HS. et al. Assessment of the image quality of extended depth-of-focus intraocular lens models in polychromatic light. J Cataract Refract Surg 2020; 46: 108-115
• 22 Łabuz G, Yan W, Khoramnia R. et al. Through-focus performance and off-axis effects in aspheric monofocal intraocular lenses. Biomed Opt Express 2024; 15: 6073-6082
• 23 Yan W, Auffarth GU, Khoramnia R. et al. Blue-Light Filtering Monofocal Intraocular Lenses: A Study on Optical Function and Tolerance to Misalignment. J Refract Surg 2024; 40: e79-e88
• 24 Winn B, Whitaker D, Elliott DB. et al. Factors affecting light-adapted pupil size in normal human subjects. Invest Ophthalmol Vis Sci 1994; 35: 1132-1137
• 25 Linke SJ, Baviera J, Munzer G. et al. Mesopic pupil size in a refractive surgery population (13,959 eyes). Optom Vis Sci 2012; 89: 1156-1164
• 26 Wolffe M, Landry RJ, Alpar JJ. Identification of the source of permanent glare from a three-piece IOL. Eye (Lond) 2007; 21: 1078-1082
• 27 Coroneo MT, Pham T, Kwok LS. Off-axis edge glare in pseudophakic dysphotopsia. J Cataract Refract Surg 2003; 29: 1969-1973
• 28 van Gaalen KW, Koopmans SA, Hooymans JMM. et al. Straylight measurements in pseudophakic eyes with natural and dilated pupils: one-year follow-up. J Cataract Refract Surg 2010; 36: 923-928
• 29 Martínez de Carneros-Llorente A, Martínez de Carneros A, Martínez de Carneros-Llorente P. et al. Comparison of visual quality and subjective outcomes among 3 trifocal intraocular lenses and 1 bifocal intraocular lens. J Cataract Refract Surg 2019; 45: 587-594
• 30 Lapid-Gortzak R, Bhatt U, Sanchez JG. et al. Multicenter visual outcomes comparison of 2 trifocal presbyopia-correcting IOLs: 6-month postoperative results. J Cataract Refract Surg 2020; 46: 1534-1542
• 31 Kim JW, Eom Y, Park W. et al. Comparison of visual outcomes after two types of mix-and-match implanted trifocal extended-depth-of-focus and trifocal intraocular lenses. Graefes Arch Clin Exp Ophthalmol 2022; 260: 3275-3283
• 32 Danzinger V, Schartmüller D, Lisy M. et al. Fellow-Eye Comparison of Monocular Visual Outcomes Following Monofocal Extended Depth-of-Focus (EDOF) and Trifocal EDOF Intraocular Lens Implantation. Am J Ophthalmol 2024; 267: 76-83
• 33 Taketani F, Matuura T, Yukawa E. et al. Influence of intraocular lens tilt and decentration on wavefront aberrations. J Cataract Refract Surg 2004; 30: 2158-2162
• 34 Crnej A, Hirnschall N, Nishi Y. et al. mpact of intraocular lens haptic design and orientation on decentration and tilt. J Cataract Refract Surg 2011; 37
• 35 Łabuz G, Auffarth GU, Knorz MC. et al. Trifocality Achieved Through Polypseudophakia: Optical Quality and Light Loss Compared With a Single Trifocal Intraocular Lens. J Refract Surg 2020; 36: 570-577