Visual Outcomes After Mix-and-Match Implantation of Trifocal and Extended Depth-of-Focus Intraocular Lenses: A Systematic Review and Meta-Analysis

Background and Objectives: The use of presbyopia-correcting intraocular lenses (IOLs) has become an integral part of modern cataract surgery. Trifocal IOLs are designed to provide functional vision at multiple distances but may be associated with dysphotopsia and reduced contrast sensitivity. In contrast, extended depth-of-focus (EDOF) IOLs offer a smoother defocus profile and fewer photic phenomena; however, they often provide insufficient uncorrected near visual acuity. To overcome the limitations of each design, a mix-and-match implantation strategy, involving implantation of a trifocal IOL in one eye and an EDOF IOL in the fellow eye, has been proposed. The objective of this systematic review was to evaluate whether mix-and-match implantation can maintain high visual acuity at near, intermediate, and distance ranges in the early postoperative period. Materials and Methods: A systematic literature search was conducted in five electronic databases, including PubMed, Scopus, Web of Science, Google Scholar, and ScienceDirect, following PRISMA guidelines. Studies reporting outcomes of mix-and-match implantation with a trifocal IOL in one eye and an EDOF IOL in the fellow eye were included. Only studies presenting binocular uncorrected visual acuity (UCVA) at a distance, intermediate, and near ranges, expressed in logMAR units, were considered. Visual outcomes assessed at approximately 3 months postoperatively were extracted. Results: Five studies involving 225 patients were included. The pooled mean logMAR UDVA at 3 months was 0.05 (95% CI: 0.03–0.07), with substantial heterogeneity (I2 = 80.1%). The pooled mean logMAR UNVA was 0.09 (95% CI: 0.05–0.14), with high heterogeneity (I2 = 87.9%). For intermediate vision, the pooled mean logMAR UIVA was 0.03 (95% CI: −0.00 to 0.06), with moderate heterogeneity (I2 = 72.5%). Meta-regression analyses did not show statistically significant associations between publication year and visual outcomes for UDVA (p = 0.695), UNVA (p = 0.469), or UIVA (p = 0.099). Sensitivity analyses confirmed the robustness of the pooled estimates. Conclusions: Mix-and-match implantation of a trifocal IOL in one eye and an EDOF IOL in the fellow eye provides favorable early binocular visual acuity across distance, intermediate, and near ranges. However, substantial heterogeneity across studies and very low certainty of evidence warrant cautious interpretation of these findings.