Sir,

We thank Park et al for their interest in our correspondence regarding the calcification of Rayner hydrophilic acrylic intraocular lens (IOL) implants following Descemet’s stripping endothelial keratoplasty (DSAEK).1

We agree that this phenomenon can occur after uncomplicated DSAEK without the need for a rebubble as described in their recent article2 as well as that of Werner et al.3 We have not seen this in any of our patients but have also heard anecdotal reports (unpublished) of such occurrences.

Ample clinicopathological evidence now exists of post-endothelial keratoplasty calcification being confined to the central IOL optic not covered by the iris. A change in ionic concentrations of the aqueous due to blood aqueous barrier (BAB) breakdown is likely to have a role in these cases, and so too is the use of intracameral air. The localization of the IOL opacification suggests air contact with the IOL is germane possibly through dessication or physical disruption of the IOL surface. Although both BAB breakdown and IOL surface change can occur with a single injection of air during standard DSAEK surgery, repeat injections post-operatively (rebubbling) will only intensify these processes and thereby increase the likelihood of calcification.

We also agree that this phenomenon is in no way unique to Rayner IOLs. It has been documented with hydrophilic IOLs from various manufacturers and we fully support Park et al2 in spreading the important message that patients who may require endothelial keratoplasty at some stage should receive hydrophobic lens implants.