Causes Of Dissatisfaction After Presbyopia Correcting Intraocular Lenses: A Structured Clinical Framework For Evaluation And Management

Presbyopia correcting intraocular lenses (IOLs), including trifocal and extended depth-of-focus (EDOF) designs, are widely used to improve functional vision at multiple distances. Although visual acuity outcomes are generally favorable, a subset of patients report postoperative dissatisfaction that is often disproportionate to objective findings. The underlying causes are frequently multifactorial and inconsistently addressed in routine practice, sometimes leading to unnecessary or premature interventions. This study aims to synthesize current evidence on the determinants of dissatisfaction following presbyopia-correcting IOL implantation and to develop a structured, clinically applicable diagnostic and management framework.

Literature-based study focused on contemporary refractive cataract surgery practice.

A structured literature review was conducted using PubMed and Google Scholar to identify studies published between 2008 and 2024. Search terms included “presbyopia-correcting IOL,” “trifocal,” “EDOF,” “patient satisfaction,” “dysphotopsia,” “residual refractive error,” and “IOL exchange.” Titles and abstracts were screened using Rayyan AI. Prospective and retrospective clinical studies and relevant reviews were included; case reports were excluded. Findings were narratively synthesized into actionable domains, forming a stepwise diagnostic and management algorithm.

Six principal domains contribute to dissatisfaction after presbyopia-correcting IOLs: ocular surface disease, residual refractive error (including low astigmatism), posterior capsular opacification, IOL-related factors (decentration, tilt, effective lens position variability, pupil interaction, optical design), undetected macular or optic nerve pathology, and neuroadaptation failure. Ocular surface dysfunction and minor refractive error are common and reversible causes. Evaluation should follow a structured pathway prioritizing reversible factors before invasive intervention.

Dissatisfaction after presbyopia-correcting IOL implantation is multifactorial and frequently attributable to modifiable factors when assessed systematically. A structured diagnostic framework facilitates differentiation between optical, ocular surface, anatomical, and neuroadaptive causes, helping to avoid unnecessary surgical procedures and improving patient counselling. Adoption of a standardized evaluation pathway may enhance postoperative satisfaction and optimize outcomes in modern refractive cataract surgery.