We first wish to thank Drs Chiang and Tsai for their interest in our article and appreciate their comments on transscleral fixation of foldable acrylic intraocular lenses (IOL) in combination with Descemet stripping automated endothelial keratoplasty (DSAEK). We agree that insertion of a foldable acrylic IOL prevents the need for wound enlargement in combined surgery and has the potential to help in anterior chamber maintenance; however, we would like to address certain points in relation to our specific technique of DSAEK and combined IOL exchange surgery which may explain the benefits of a slightly larger scleral tunnel wound and insertion of a polymethyl methacrylate (PMMA) lens.

First and foremost, all anterior chamber IOLs (ACIOL) removed during the IOL exchange portion of the procedure in our study were 1-piece, made of PMMA material, and often had a 6.0-mm size optic, which makes these types of lenses difficult to remove through a smaller incision. Also, cutting thick PMMA optics inside the eye requires larger IOL-cutting scissors and/or other instruments that have the potential to traumatize the iris and other anterior segment structures during the process of removal. Since this surgery is already complex in nature, we feel that a larger incision offers the benefit of safe and easy removal of PMMA ACIOLs from the eye with minimal risks, especially since, using our simplified DSAEK technique with scleral, beveled, and self-sealing incisions, the anterior chamber continues to remain stable throughout both portions of the procedure and specifically with insertion of the donor DSAEK tissue. We have also never experienced any significant induced astigmatism from the larger 7.0-mm scleral wound for any of our combined DSAEK procedures and therefore do not see the necessity of a smaller wound that would make IOL exchange more difficult.

Finally, the PMMA CZ70BD lens with its 7.0-mm optic (Alcon Laboratories, Fort Worth, Texas, USA) is specifically designed with eyelets on the haptics for suturing to the ciliary sulcus because prior to its design, late slippage of sutures tied to the polypropylene haptics of sulcus-placed 3-piece IOLs was reported. We acknowledge and commend Drs Chiang and Tsai for their success with their technique of transscleral fixation of foldable IOLs, but it is also important to mention that further long-term follow-up of their patients for IOL dislocation secondary to late suture slippage is equally necessary.

In conclusion, and based on our experiences with our specific DSAEK and IOL exchange technique, we feel that a larger scleral wound with placement of a PMMA lens with eyelets on the haptics makes for a safer and easier surgery without significantly increasing the rates of postoperative complications.