How Likely Are You to be Satisfied with Your Visual Outcome After State of the Art Cataract Surgery: Dissatisfaction rates with multifocal implants

Understanding Patient Dissatisfaction with Presbyopia-Correcting IOLs After Cataract Surgery

Cataract surgery has evolved into a refractive procedure, offering patients the chance to reduce or eliminate their dependence on glasses through presbyopia-correcting intraocular lenses (IOLs). These advanced lenses—such as bifocal, trifocal, and extended depth-of-focus (EDOF) and Light Adjustable options—promise improved vision at multiple distances. 

However, not every patient walks away satisfied. 

This is the key question every surgeons asks herself or himself: How likely is this patient to be happy with the final visual outcome after cataract surgery?

Many factors affect final visual outcome: the brain's, optic nerve's, retina/macula's, cornea's tear film/meibomian glands'/lacrimal glands' potential to have good vision as well as the personality of the patient: will this patient help you help them get great vision and slow down the natural aging process that can decrease a person's vision?

Surgeons need to evaluate all of these factors often in a blink of an eye. Many offices only allocate 10-15minutes per patient, so the more a patient is educated about their options, the better they can help their surgeon help them make the best decision for their eye health, vision, and quality of vision.  

A recent study by Woosung Jeon and colleagues, published in BMC Ophthalmology, dives into the dissatisfaction rates and risk factors among patients receiving these IOLs, shedding light on why some outcomes fall short of expectations. The study looks at PanOptix which we still recommend in the right patient (not a night time driver and would not be bothered with halos or glare), but most of us no longer use Restor nor Symfony for the reasons clearly documeneted in the article summarized below. 

One often-overlooked factor? The quality of the tear film and underlying meibomian gland health, which play critical roles in optimizing vision and reducing dissatisfaction.

The Study at a Glance

The researchers conducted a retrospective case-control study, analyzing medical records from 340 eyes of 211 patients who underwent cataract surgery with presbyopia-correcting IOLs at Seoul National University Hospital. They examined three IOL types:

• Bifocal (ReSTOR®): Focuses on near and far vision.
• Trifocal (PanOptix®): Adds intermediate vision to the mix.
• EDOF (Symfony®): Provides a continuous range of vision with less emphasis on distinct focal points.

Patients self-reported dissatisfaction based on vision quality or photic disturbances (e.g., glare, halos). The study then explored factors like age, preoperative vision, and corneal characteristics to pinpoint what drives dissatisfaction.

Dissatisfaction Rates: How Common Is It?

Across all IOL types, the overall dissatisfaction rate was 18.5% (63 out of 340 eyes)—meaning nearly one in five patients wasn’t fully happy with their results. Here’s how it broke down by IOL type:

• Symfony® (EDOF): Highest near-vision dissatisfaction, likely due to its design prioritizing intermediate and distance vision over sharp near focus.
• PanOptix® (Trifocal): Showed balanced complaints, with similar rates of photic disturbances (e.g., halos) and near-vision issues.
• ReSTOR® (Bifocal): Specific rates weren’t highlighted individually, but it contributed to the overall 18.5% dissatisfaction pool.

Photic disturbances—like glare or halos—were a common grievance, especially with multifocal designs that split light into multiple focal points. Near-vision dissatisfaction was notable with EDOF lenses, aligning with their optical trade-offs.

Risk Factors for Dissatisfaction

The study identified several factors linked to higher dissatisfaction:

• Preoperative Myopia (< -0.5 D): Patients with mild nearsightedness before surgery were significantly more likely to be dissatisfied (P < 0.001). This may reflect unmet expectations for near vision or adaptation challenges.
• Younger Age (< 60 years): Younger patients reported higher dissatisfaction (P = 0.02), possibly due to higher visual demands or less tolerance for imperfections.
• Thinner Corneas and Higher Astigmatism: Specifically tied to photic disturbances (P = 0.007 and P = 0.01, respectively), these corneal traits may amplify glare or halos.

The Role of Tear Film and Meibomian Gland Health in Reducing Dissatisfaction

A healthy tear film—the thin layer of moisture coating the eye’s surface—is essential for clear, undistorted vision, especially with presbyopia-correcting IOLs that rely on precise light distribution. A poor tear film, often caused by meibomian gland dysfunction (MGD) and dry eye disease (DED), can scatter light, worsen photic disturbances like glare or halos, and blur vision, driving up dissatisfaction rates. DED is common after cataract surgery, yet many patients don’t realize they have it until post-op vision disappoints. Treating dry eye pre- and post-surgery (e.g., with artificial tears or anti-inflammatory drops) can significantly improve satisfaction, potentially lowering that 18.5% figure.

I usually recommend performing meibography whenever possible before cataract surgery. This non-invasive imaging technique evaluates the meibomian glands, which produce the oily layer of the tear film. By identifying MGD—such as gland dropout or atrophy—meibography helps patients understand why they might be dissatisfied with their vision quality post-surgery, even with a premium IOL. For example, blocked or dysfunctional glands can destabilize the tear film, undermining the IOL’s optical performance. Addressing MGD early (e.g., with warm compresses, lid hygiene, or advanced therapies) can optimize outcomes and set realistic expectations.

Where Does the Light Adjustable Lens Fit In?

The study didn’t specifically evaluate the Light Adjustable Lens (LAL), a unique IOL that allows postoperative adjustments using UV light to fine-tune refraction. Unlike the fixed-power IOLs in this study (ReSTOR®, PanOptix®, Symfony®), the LAL offers a solution to residual refractive errors—one of the top causes of dissatisfaction. If preoperative myopia or astigmatism increases dissatisfaction risk, the LAL’s adjustability could lower rates by correcting these issues post-surgery. While specific dissatisfaction data for the LAL isn’t provided here, other research suggests it achieves high satisfaction—often exceeding 90%—thanks to its precision. However, even with the LAL, a poor tear film from untreated MGD could undermine results, as photic disturbances persist if the ocular surface isn’t optimized.

Why Dissatisfaction Matters

An 18.5% dissatisfaction rate might sound modest, but as cataract surgery becomes more common and patients opt for premium IOLs, even this minority represents a significant number of people. Dissatisfaction often stems from mismatched expectations—patients dreaming of perfect, glasses-free vision may overlook the compromises (e.g., halos at night or softer near focus). The study, combined with the tear film and meibomian gland factors, underscores the need for thorough preoperative assessments and tailored lens selection.

Tips to Minimize Disappointment

• Screen Carefully: Assess corneal thickness, astigmatism, and refractive history to match the IOL to the patient’s eye.
• Check Meibomian Glands: Follow Dr. Cremers’ advice—use meibography to detect MGD and educate patients about how it might affect vision quality, then treat it proactively.
• Optimize Tear Film: Test for dry eye before surgery and treat it aggressively with lubricants or medications to enhance IOL performance and reduce photic issues.
• Set Expectations: Explain potential side effects like glare or the need for reading glasses with EDOF lenses.
• Consider Adjustability: For high-risk patients (e.g., myopic or young), the Light Adjustable Lens might offer a safety net by allowing post-op tweaks.

The Takeaway

Presbyopia-correcting IOLs are a game-changer for many, but they’re not one-size-fits-all. The 18.5% dissatisfaction rate from this study highlights the importance of personalized care—factoring in age, myopia, corneal health, and especially tear film and meibomian gland status. Whether it’s the trifocal PanOptix®, the EDOF Symfony®, or the adjustable LAL, success hinges on aligning the lens with the patient’s lifestyle and biology. If you’re considering cataract surgery, talk to your doctor about your vision goals, ask about meibography to assess your glands, and explore all your options. A clear lens, healthy glands, and a stable tear film together are your best defense against disappointment.