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To compare outcomes and complications of Descemet stripping automated endothelial keratoplasty (DSAEK) in complicated cases with intraocular lens (IOL) exchange, aphakia, or anterior chamber intraocular lens (ACIOL) implants with a group of noncomplicated DSAEK cases.Of the 30 complicated DSAEK cases, 14 eyes underwent concurrent IOL exchange, 5 ACIOLs were not removed, 5 eyes remained aphakic, and 5 eyes had IOL exchange done before or after DSAEK. One eye had an iris-supported phakic IOL removed, followed by cataract extraction with IOL implantation at the time of DSAEK. The comparison group included 109 consecutive DSAEK cases with a history of Fuchs dystrophy or pseudophakic bullous keratopathy.In the complicated group with significant ocular comorbidities, 27.6% achieved best-corrected visual acuity (BCVA) ≥20/40 and 60% had a final BCVA ≥20/70. In the comparison group of patients without visually significant comorbidities, 94.4% of eyes achieved BCVA ≥20/40 with no complication of graft detachments. Of the 30 complicated eyes, 5 (16.7%) had graft detachments and 5 (16.7%) developed IOL dislocations. All grafts remained clear at the last follow-up visit, except 3 cases (10%) in the complicated group, 2 of which were because of primary graft failure and required penetrating keratoplasty.In comparison with uncomplicated DSAEK cases, higher graft and IOL dislocations were observed in cases involving IOL exchanges, ACIOLs, or aphakia.