Multifocal intraocular lenses (multifocal IOLs) are designed to reduce spectacle dependence after cataract surgery by creating more than one focal point (typically distance and near, and sometimes intermediate). For many patients, this can meaningfully improve uncorrected near vision and reduce the need for reading glasses, but it also increases the likelihood of dysphotopsias (eg, halos/glare), and can reduce perceived visual quality in low-light conditions for some individuals (de Silva et al., 2016). (1)

This blog post discusses the framework for deciding who is a good candidate, as shown in CRSToday, and bases its main points on research reviewed by other experts. (5)

What the evidence consistently shows

Across comparative studies and systematic reviews, multifocal IOLs tend to:

• Compared to single-vision lenses, these lenses reduce the need for glasses (de Silva et al., 2016). (3)
• They are more likely to cause halos and glare than single-vision lenses (de Silva et al., 2016). (3)
• There are trade-offs in vision performance: better vision at different distances may lead to more light-related visual disturbances (Cho et al., 2022). (2)

A practical interpretation is that multifocal IOLs are most successful when the patient’s priority is spectacle independence and when the patient’s eyes are at low risk of factors that could degrade image quality (Miller, 2019; de Silva et al., 2016). (5)

The “ideal” candidate, simplified

An ideal candidate typically has three characteristics:

1. High motivation to reduce dependence on glasses
   Patients who strongly value near vision without readers (and accept that “perfect night vision” is not guaranteed) tend to be more satisfied (Miller, 2019; de Silva et al., 2016). (5)
2. Healthy ocular surface and stable measurements
   Dry eye disease can destabilize keratometry/biometry, raising the risk of refractive error—an issue that matters more with multifocal optics (Biela et al., 2023). (1)
3. Having a low “optical risk” means the cornea, macula, or optic nerve is healthy. Problems that degrade the image quality reaching the retina, such as uneven astigmatism, macular disease, or severe glaucoma, make it harder to accept the compromises of multifocal lenses and increase the risk of being unhappy with them. (Liang & Salim, 2019). (4)

Common “do not recommend” or “use caution” categories

1) Eye surface problems that are noticeable (especially dry eyes that haven’t been treated).

Untreated dry eye can make preoperative eye measurements less accurate and lead to vision problems after surgery. A review of studies showed that treating dry eye before taking final measurements helped correct vision errors (Biela et al., 2023). (1)

2) Uneven eye surface or uncorrected astigmatism.

Because multifocal lenses spread light to different focus points, any existing unevenness in the eye can make vision quality issues seem worse(Miller, 2019). (5)

3) Eye conditions affecting the retina or macula.

Even small issues with the macula can reduce your ability to see details and clarity; multifocal lenses might make these vision problems more noticeable (Miller, 2019). (5)

4) Moderate to severe glaucoma (generally caution)

Premium IOL selection in glaucoma is often approached cautiously due to disease effects on contrast sensitivity and overall visual function; careful selection is emphasized, especially as disease severity increases (Liang & Salim, 2019). (4)

5) Experiencing significant visual disturbances at night.

Research indicates that multifocal lenses are associated with a higher frequency of halos and glare compared to single-focus lenses. Individuals who frequently drive at night or are sensitive to visual problems may find alternative choices more suitable. (de Silva et al., 2016; Miller, 2019). (3)

Preoperative evaluation: a simple, evidence-aligned checklist

A practical candidacy workup should prioritize preventing the most common drivers of dissatisfaction:

1. First, make the eye’s surface healthy (especially if it’s dry), then measure the eye again. (Biela et al., 2023). (1)
2. Make sure your measurements are consistent; if they don’t change much over time, they’re likely correct. (Biela et al., 2023). (1)
3. Check the cornea for any irregularities or astigmatism, using specialized imaging if needed. (Miller, 2019). (5)
4. Examine the health of the central retina, often with an OCT scan if necessary. (Miller, 2019). (5)
5. Clearly explain what to expect, such as whether glasses will still be needed and whether there’s a risk of halos or glare. (de Silva et al., 2016; Miller, 2019). (3)

Other options exist for patients who aren’t a good fit for multifocal lenses.

When the risk profile is higher—or when a patient strongly prioritizes night vision quality—alternatives may offer a better balance:

• Single-vision (monofocal) IOLs: These usually give the clearest vision, but patients will likely need reading glasses for close-up tasks.
• Toric monofocal IOLs: These are best when the main problem to be corrected is astigmatism (blurred vision due to an unevenly shaped cornea).
• Extended depth-of-focus (EDOF) lenses or other types that help with presbyopia (age-related difficulty seeing up close): The choice depends on what the patient wants and how much risk they are willing to take. Research on how these different lens types compare is still changing (2)

Conclusion

Multifocal intraocular lenses can greatly reduce the need for glasses, but they can also increase the risk of halos and glare, so choosing them carefully is important (de Silva et al., 2016). (3)Simply put, the most suitable patients are those who really want to use glasses less, have healthy eye surfaces and consistent measurements, and don’t have other major health issues that would worsen their vision (Miller, 2019; Biela et al., 2023). (5)

References

1. Biela, K., Winiarczyk, M., Borowicz, D., & Mackiewicz, J. (2023). Dry eye disease as a cause of refractive errors after cataract surgery: A systematic review. Clinical Ophthalmology, 17, 1629–1638. https://pmc.ncbi.nlm.nih.gov/articles/PMC10257420/
2. Cho, J.-Y., Min, S., Kim, N., Chung, T.-Y., Lee, E.-K., Kwon, S.-H., & Lim, D. H. (2022). Visual outcomes and optical quality of accommodative, multifocal, extended depth-of-focus, and monofocal intraocular lenses in presbyopia-correcting cataract surgery: A systematic review and Bayesian network meta-analysis. JAMA Ophthalmology. https://pubmed.ncbi.nlm.nih.gov/36136323/
3. de Silva, S. R., Evans, J. R., Kirthi, V., Ziaei, M., & Leyland, M. (2016). Multifocal versus monofocal intraocular lenses after cataract extraction. Cochrane Database of Systematic Reviews. https://pmc.ncbi.nlm.nih.gov/articles/PMC6463930/
4. Liang, S., & Salim, S. (2019). IOL selection for glaucoma patients. Glaucoma Today. https://glaucomatoday.com/articles/2019-nov-dec/iol-selection-for-glaucoma-patients
5. Miller, K. M. (2019, May). The ideal multifocal candidate. CRSToday. https://crstoday.com/articles/2019-may/the-ideal-multifocal-candidate