The findings of our study indicate that both Trinova Pro C and Tecnis Eyhance IOLs provide satisfactory visual outcomes in distance and intermediate. However, Trinova Pro C performed better in near vision. All patients in the Trinova Pro C group achieved spectacle independence, while the majority of patients in the Tecnis Eyhance group required near glasses. The rate of photic phenomena was reported to be lower in the Tecnis Eyhance group, which minimally reduces incoming light to the eye. The high rates of patients satisfaction and recommendations for both IOLs suggest that they are well received by patients.
In a study conducted with Trinova, the first diffractive IOL that the manufacturer produced using a sinusoidal design, MUDVA results similar to those of Trinova Pro C were obtained at our postoperative 6th month [18]. In another study, Trinova and FineVision Micro F (PhysIOL SA, Belgium), a trifocal diffractive IOL, were compared and the DVA values were found to be similar [19]. In the study, when comparing the DVA values obtained with Trinova and those obtained with Trinova Pro C better results were found. According to data obtained from the producer, light transmission which was 92% in Trinova was increased to %93 in Trinova Pro C. This difference may partially explain the better DVA values observed. The DVA values obtained in our study were similar to the studies conducted with other trifocal IOLs available in the market [20–22]. Similarly, studies comparing Tecnis Eyhance with standard monofocal IOLs did not show a significant difference in terms of UDVA [14, 23].
The lack of standardization in tests evaluating near and intermediate visual performance makes the design of studies difficult and hinders comparison [24]. In the study by Amigo et al., no statistically significant difference was found in terms of intermediate visual acuity between Trinova and FineVision Micro F at 3 months postoperatively [19]. Trinova’s + 1,50 D intermediate vision addition was increased to + 1,8 D by Trinova Pro C, which we used in our study. Alió et al. reported higher intermediate visual levels with AcrySof IQ Panoptix at 6 months postoperatively compared to our study [20]. AcrySof IQ Panoptix provides + 2.17 D addition for intermediate. Ünsal and Sabur obtained similar results to the MUIVA values we obtained in our study with Tecnis Eyhance [23]. On the other hand, Mencucci et al. reported MUIVA and MDCIVA values lower than those we obtained in our study with Eyhance [14].
In our study, Trinova Pro C achieved better results in near visual acuity. Amigo et al found the MUNVA and BUNVA values to be statistically better with FineVision Micro F compared to Trinova [19]. The Trinova near additional strength is 3.0 D, which value was raised to 3,6 D in Trinova Pro that we used in our study. Alió et al. reported lower near vision MUNVA levels with Panoptix compared to those we obtained with Trinova Pro C [20].
Mencucci et al. found similar MUNVA values for Tecnis Eyhance at 6 months compared to our study [14]. In a study evaluating Mini Well as a monofocal EDOF lens, Bellucci et al. reported better MUNVA values than those obtained with Tecnis Eyhance [25]. In this study, the mean spherical equivalent measured by postoperative autorefraction was − 0.59 ± 0.58 D, which was more negative than the values obtained in our study.
When spherical equivalent values were examined at 6 months postoperatively, significantly more myopic values were obtained with Trinova Pro C. The depth of focus of trifocal IOLs is larger than that of standard monofocal IOLs. The absence of a single focal plane makes it challenging to determine the patients' objective or subjective refraction accurately [26]. In our study, the negative measurements in spherical equivalent obtained in the Trinova Pro C group could be attributed to variations in pupil size and differences in depth of focus depending on different lighting conditions. The lack of standardization of ambient lighting in autorefraction measurements and the absence of objective refraction measurements can be considered as limitations of our study. However, the fact that the MUDVA and MBCDVA values obtained at 6 months were quite similar and no change in visual acuity was observed during the examination with myopic corrections applied suggests that the values obtained by autorefraction may not reflect the true refractive error.
Both IOLs used in our study are hydrophobic and have sharp edge designs. Shah et al. compared the rates of Nd:YAG laser capsulotomy for multifocal and monofocal IOLs and reported a higher rate of posterior capsulotomy in the multifocal group [27]. Dönmez et al. implanted hydrophobic Panoptix IOLs in 138 eyes of 69 patients and reported a PCO rate of 10% at 6 months postoperatively [28]. Çınar et al. reported that no cases of PCO development were observed in any patient who underwent Tecnis Eyhance IOL implantation during a follow-up period of 3.02 ± 1.3 months [29]. The incidence of PCO development can vary over time. Further clinical studies with longer follow-up periods are needed to evaluate both lens groups used in our study.
In our study, subjective photic complaints were more frequently observed in Trinova Pro C cases. Hamid et al. compared the results of AT LISA tri839MP, FineVision, and Tecnis Symfony IOLs and reported a lower frequency of photic complaints in the EDOF Tecnis Symfony group compared to trifocal IOLs at 6 months postoperatively [30]. In their study, Ceran et al. reported, at postoperative 6 months, halo in 13.3% of the patients, and glare complaints at a level that would prevent vehicle use at night in 3.33% of the patients [18]. However, there are also studies reporting a higher incidence of photic complaints with multifocal IOLs. Kohnen et al. reported a 93% incidence of halo complaints at 3 months postoperatively with Panoptix [31]. Amigo et al. reported similar halo and glare complaints for Trinova and FineVision Micro F [19]
Contrast sensitivity function is another important aspect that has been investigated with numerous IOLs with different materials and optical designs. Cochener et al. mentioned that EDOF IOLs could theoretically be superior to trifocal IOLs in terms of contrast sensitivity due to compensation for chromatic and spherical aberrations [32]. Mencucci et al. compared the EDOF Tecnis Symfony with the AT LISA Tri839MP and Acrysof IQ PanOptix trifocal diffractive IOL designs and showed that Tecnis Symfony was associated with improved contrast sensitivity under both photopic and mesopic conditions [33].
Assessment of improvement in patients' daily activities after cataract surgery is becoming increasingly important. One of the questionnaires developed for this purpose is VF-14, reported by Steinberg et al., and it has been validated for use in populations with cataract [34]. Brydon et al. found higher VF-14 values measured without glasses in the multifocal group compared to the monofocal group in their study [35]. Dyrda et al. compared hybrid multifocal, refractive multifocal, diffractive multifocal, and monofocal IOLs and reported statistically significantly better VF-14 values with hybrid and diffractive optic-designed IOLs compared to monofocal IOLs [36].
In our study, all patients in the Trinova Pro C group achieved spectacle independence in their daily activities. In the Tecnis Eyhance group, 80% of patients reported using near glasses with varying frequency. Ceran et al. reported a spectacle independence rate of 96.6% at 6 months postoperatively with Trinova [18]. Amigo et al. reported that all patients implanted with Trinova were able to read unaided at near and intermediate distances without difficulty [19]. Ünsal and Sabur reported spectacle independence rates of 97% at distance, 84% at intermediate, and 6% at near with Tecnis Eyhance [23].
Our study has certain limitations. Firstly, it was designed retrospectively and limited to patients who completed the follow-up period. Another important limitation is the short follow-up duration and the limited number of patient groups. The absence of control groups involving IOL implantations with similar designs is another significant limitation of our study. Parameters such as reading speed, critical print size, and contrast sensitivity, which are important indicators of near vision, were not evaluated. Additionally, contrast sensitivity values were not detailed for different lighting conditions. Objective questionnaires or measurement methods to assess subjective photic complaints such as halo and glare were not used in our study. Nevertheless, we believe that if there is any bias in our study, it would affect the clinical outcomes of both IOLs, and parameters that would create different clinical outcomes are discussed in the relevant sections of our study, thus ensuring the reliability of the results.