Visual Outcomes Following Bilateral lmplantation of Two Diffractive Trifocal Intraocular Lenses in 10 084 Eyes RAFAEL BILBAO-CALABUIG, ANDREA LLOVET-RAUSELL, JULIO ORTEGA-USOBIAGA, MERCEDES MARTI ´ NEZ-DEL-POZO, FERNANDO MAYORDOMO-CERDA ´ , CELIA SEGURA-ALBENTOSA, JULIO BAVIERA, AND FERNANDO LLOVET-OSUNA  PURPOSE: To investigate refractive and visual acuity outcomes, patient satisfaction, and spectacle indepen- dence at 3 months of 2 diffractive (non-toric) trifocal intraocular lenses (IOLs) in a large series of patients.  DESIGN: Multicenter, retrospective, nonrandomized clinical study.  METHODS: Patients underwent lens phacoemulsifica- tion and were implanted bilaterally with a diffractive trifocal IOL: FineVision Micro F (PhysIOL SA, Lie `ge, Belgium) or AT Lisa tri 839MP (Carl Zeiss AG, Jena, Germany). Surgeries were performed between 2011 and 2015 with at least 3 months of follow-up. Visual and refractive performance, patient satisfaction, and spectacle independence were evaluated.  RESULTS: A total of 10 084 trifocal IOLs were bilater- ally implanted (5802 FineVision in 2901 patients and 4282 AT Lisa in 2141 patients). Three-month mean (± standard deviation) acuity: AT Lisa, binocular uncorrected distance visual acuity (UDVA), L0.01 logMAR ± 0.06; monocular distance corrected visual acuity (CDVA), 0.02 logMAR ± 0.06; binocular uncorrected near visual acuity (UNVA) at 40 cm, 0.05 logMAR ± 0.08; binocular uncorrected intermediate visual acuity (UIVA) at 80 cm, L0.05 logMAR ± 0.14; postoperative spherical equivalent, 0.26 D ± 0.47; cylinder L0.34 D ± 0.38; Fine- Vision Micro F, binocular UDVA, 0.01 logMAR ± 0.05; monocular CDVA, 0.03 logMAR ± 0.06; binocular UNVA, 0.05 logMAR ± 0.08; binocular UIVA, L0.05 logMAR ± 0.12; spherical equivalent, 0.34 D ± 0.50; cylinder L0.39 D ± 0.40. The IOLs were equivalent in achieving spectacle independence; 98% were ‘‘satisfied’’ to ‘‘very satisfied’’ with their IOL performance.  CONCLUSIONS: In this retrospective study with over 5000 patients, implantation of both trifocal IOL models provided good functional distance, intermediate, and near visual acuity, resulting in high levels of both spec- tacle independence and patient satisfaction. (Am J Ophthalmol 2017;179:55–66. Ó 2017 Elsevier Inc. All rights reserved.) D IFFERENT MULTIFOCAL INTRAOCULAR LENS (MIOL) designs have been used for more than 25 years. 1 Unlike conventional monofocal intra- ocular lenses (IOLs), which bend light to a single focus point on the retina, MIOLs are designed to help patients to see at varying distances using different points of focus. MIOLs used in clinical practice were either refractive initially, or later diffractive in their optical design. Refrac- tive MIOLs incorporate a lens optic with different optical powers in different parts of the lens, whereas diffractive MIOLs use diffractive steps on the lens to distribute light rays into 2 or more principal foci. Irrespective of the design type, however, all MIOLs involve some form of optical compromise and a process of neuroadaptation for the patient. 2 Most first-generation multifocal implants incorpo- rated þ4.0 diopters (D) addition at the lens plane to mini- mize the risk of diplopia resulting from the superimposition of simultaneous sharp and defocused images, while still enabling useful near vision. More recently, the introduc- tion of lower near additions in the range of þ2.5 D to þ3.0 D, and mix-and-match strategies with different near additions, attempted to increase visual acuity at an in- termediate distance. 3,4 This improvement in optic lens design, however, has not been sufficient to provide satisfactory intermediate vision for all patients implanted with these bifocal IOLs, 5 prompting manufacturers to develop a new concept—trifocal MIOLs—in an effort to improve quality of vision at all distances. The 3 foci gener- ated by these lenses are obtained by combining 2 bifocal diffractive profiles in 1 surface of the IOL 6 or by using a trifocal diffractive profile combined with a bifocal diffrac- tive optic. 7 Initial studies of trifocal lenses have validated the ability of the eye to use the intermediate focus regard- less of lighting conditions and deliver good visual and refractive outcomes. 8–15 For instance, Jonker and associates reported an improvement in intermediate vision obtained with a trifocal lens compared to a reference bifocal implant. 16 Another study correlating op- tical bench performance with clinical defocus curves in Accepted for publication Apr 19, 2017. From the Clinica Baviera Madrid, Instituto Oftalmolo ´gico Europeo, Madrid, Spain. Inquiries to Rafael Bilbao-Calabuig, Clinica Baviera Madrid, Instituto Oftalmolo ´gico Europeo, Paseo Castellana 20, 28046 Madrid, Spain; e-mail: rbilbao@clinicabaviera.com 0002-9394/$36.00 http://dx.doi.org/10.1016/j.ajo.2017.04.013 55 © 2017 ELSEVIER INC.ALL RIGHTS RESERVED.