Visual Performance Comparison Between Enhanced Monofocal and Extended Depth of Focus Intraocular Lenses: A Systematic Review and Meta-Analysis

The objective of this systematic review is to directly compare enhanced monofocal and extended depth of focus (EDOF) intraocular lenses (IOLs) with respect to visual outcomes after cataract surgery. MEDLINE, CENTRAL, clinicaltrials.gov and ICTRP were searched until April 1, 2025, to retrieve studies that compared postoperative outcomes between enhanced monofocal and EDOF IOLs. The search was based on prespecified criteria for patients, intervention, comparator, outcomes and study type. The outcomes in question were uncorrected and corrected distance, intermediate and near visual acuities, and subjective glare and halo perception. The Cochrane risk of bias tool (RoB 2) was used for risk of bias assessment for randomized studies, while the Joanna Briggs Institute (JBI) critical appraisal tool was used for risk of bias assessment for non-randomized studies. Random-effects meta-analysis was performed for uncorrected and corrected distance visual acuity. Five studies with a total of 672 eyes were included: one randomized study, one prospective comparative case control study, one retrospective comparative study and two prospective comparative case series. All studies directly compared enhanced monofocal with EDOF IOLs. Tecnis Eyhance was the enhanced monofocal IOL in all studies, while the EDOF lenses included Tecnis Symfony in three studies, Tecnis PureSee in one study and Acrysof IQ Vivity in one study. The meta-analysis that was performed for uncorrected and corrected distance visual acuity showed that there was no significant clinical difference between the two types of IOLs (mean difference: -0.01 (-0.03, -0.00), 95% CI and -0.01 (-0.02, -0.00), 95% CI, respectively). The results of individual studies pertaining to the rest of the outcomes (uncorrected and distance corrected intermediate visual acuity, uncorrected and distance corrected near visual acuity, subjective glare and halo perception) were also presented. Intermediate visual acuity improvement via cataract surgery is of particular interest contemporarily. A quantitative synthesis regarding this outcome was not feasible due to substantial heterogeneity (I2 > 50%), making meta-analysis inappropriate for this endpoint. Prevalence of non-randomized studies and different EDOF designs may have contributed to heterogeneity. Further research should be carried out.