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A randomized clinical trial directly compared deep anterior lamellar keratoplasty (DALK) using the big-bubble technique with penetrating keratoplasty (PK) in patients with keratoconus. DALK removes diseased corneal stroma while retaining the recipient Descemet membrane and endothelium, whereas PK replaces the full thickness of the cornea. The study is important because it illustrates the central surgical trade-off in keratoconus transplantation: achieving good optical rehabilitation while preserving healthy host tissue. Randomized evidence has generally shown broadly comparable visual outcomes between DALK and PK, while DALK offers theoretical and practical advantages related to endothelial preservation and reduced endothelial rejection risk. The operation is technically more demanding and may require conversion when a satisfactory stromal plane cannot be achieved. For HCP education, the paper supports discussion of DALK as a structured alternative rather than a niche technique reserved for a few centers. Case selection remains critical, particularly the absence of deep scarring that would compromise the interface. Training should emphasize tissue-plane recognition, controlled dissection, prevention of perforation, and the decision points that determine whether to continue with DALK or convert to PK.
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A randomized clinical trial directly compared deep anterior lamellar keratoplasty (DALK) using the big-bubble technique with penetrating keratoplasty (PK) in patients with keratoconus. DALK removes diseased corneal stroma while retaining the recipient Descemet membrane and endothelium, whereas PK replaces the full thickness of the cornea. The study is important because it illustrates the central surgical trade-off in keratoconus transplantation: achieving good optical rehabilitation while preserving healthy host tissue. Randomized evidence has generally shown broadly comparable visual outcomes between DALK and PK, while DALK offers theoretical and practical advantages related to endothelial preservation and reduced endothelial rejection risk. The operation is technically more demanding and may require conversion when a satisfactory stromal plane cannot be achieved. For HCP education, the paper supports discussion of DALK as a structured alternative rather than a niche technique reserved for a few centers. Case selection remains critical, particularly the absence of deep scarring that would compromise the interface. Training should emphasize tissue-plane recognition, controlled dissection, prevention of perforation, and the decision points that determine whether to continue with DALK or convert to PK.
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