We read with great interest the recently published article “Complications and clinical outcomes of Descemet stripping automated endothelial keratoplasty with intraocular lens exchange” by Shah and associates. We agree that Descemet stripping automated endothelial keratoplasty (DSAEK) and sutured intraocular lens (IOL) can be performed simultaneously even via a 7.0-mm wound. Under such a large incision, however, the anterior chamber is less stable than under a small incision. Hence, in patients with 3-piece acrylic lenses in the anterior chamber or aphakia, suturing an acrylic foldable IOL may be better than polymethyl methacrylate lens because the sclera tunnel or clear cornea wound doesn’t have to be enlarged. In those cases, we used the Lewis method to suture the foldable acrylic IOL (AcrySof MA60AC; Alcon, Fort Worth, Texas, USA) in the sulcus. Because there were no eyelets in the haptics of the foldable IOL, the 2 fixation sites at the haptics should be as symmetrical as possible to keep the IOL not tilted in the posterior chamber. After the haptics are sutured, we pull the prolene in both sides together before implantation to test whether the IOL will be tilted or not.

The DSAEK was performed after suturing the IOL and the anterior chamber was then filled with air for 10 minutes. The transscleral fixation foldable IOL can stand the pressure of air tamponade and there is no suture slippage or IOL displacement in our cases. From our experience, transscleral fixation of a foldable IOL and DSAEK can be performed successfully in a small-incision procedure.