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To describe 2 cases of corneal decompensation after iris-fixated phakic intraocular lens (pIOL) implantation requiring Descemet stripping automated endothelial keratoplasty (DSAEK).Case reports and literature review.Two cases of corneal decompensation after pIOL implantation are reported. The average age at presentation was 52 years (range: 37 to 67 years) in 2 women. The mean presentation time of corneal decompensation after pIOL implantation was 29 months (range: 22 to 36 months). Both the affected eyes required pIOL explantation and DSAEK to treat corneal decompensation. One patient (1 eye) had concurrent cataract surgery to maximize visual rehabilitation. The mean follow-up after DSAEK surgery was 14 months (range: 12 to 16 months). The best-corrected visual acuity was 20/50 (range: 20/40 to 20/60) at the last follow-up.Despite a good safety profile for iris-fixated pIOLs, some patients may still develop corneal decompensation after implantation. We report a pair of cases with corneal decompensation severe enough to warrant endothelial transplantation and pIOL explantation, with and without concomitant cataract surgery.