Phakic Presbyopic Intraocular Lenses: A Systematic Review

To provide the first comprehensive systematic review evaluating visual acuity, refractive predictability, patient-reported outcomes, and safety of presbyopia-correcting phakic intraocular lenses (PIOLs), including multifocal refractive, diffractive, and extended depth-of-focus (EDOF) designs. Outcomes across anterior and posterior chamber platforms were critically analyzed to determine their clinical performance and limitations.

Systematic review of clinical studies conducted in tertiary refractive surgery centers worldwide. Electronic searches were performed in MEDLINE, EMBASE, and the Cochrane Library through July 2025 according to PRISMA guidelines. The protocol was prospectively registered in PROSPERO (CRD420251138158).

Randomized and non-randomized clinical studies reporting outcomes of presbyopia-correcting PIOL implantation with ≥6 months follow-up were included. Primary outcomes were UDVA, CDVA, UIVA, and UNVA. Secondary outcomes included refractive predictability (percentage within ±0.50 D and ±1.00 D), defocus curves, photic phenomena, contrast sensitivity, endothelial safety, and adverse events. Risk of bias was assessed using the Cochrane RoB tool and ROBINS-I. Due to heterogeneity of optical designs and outcome reporting, a narrative synthesis was performed.

Six studies (354 eyes; mean age 38–62 years; follow-up 6–24 months) met inclusion criteria. Contemporary platforms (EVO Viva ICL, trifocal IPCL, ArtiPlus) achieved ≥75% of eyes within ±0.50 D and ≥95% within ±1.00 D of target refraction. Mean binocular UDVA was ≤0.1 logMAR in most series, with functional near and intermediate vision across designs. Spectacle independence ranged from 80–90%. Glare and halos were frequently reported; 96% reported starbursts with ArtiPlus, although only 2% described them as very bothersome. No sight-threatening complications were reported during short-term follow-up. Evidence certainty was low-to-moderate due to small, predominantly non-randomized, industry-sponsored studies.

Presbyopia-correcting PIOLs demonstrate promising short-term refractive accuracy, broad-range visual performance, and acceptable safety while preserving the crystalline lens. However, current evidence is limited by heterogeneity, short follow-up, and potential sponsorship bias. Long-term independent prospective trials are required to determine endothelial stability, cataract risk, optical durability, and their definitive role within the presbyopia surgical algorithm.