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A Cochrane review comparing deep anterior lamellar keratoplasty (DALK) with penetrating keratoplasty (PK) for keratoconus found no clear difference in final visual acuity, keratometric astigmatism, or spherical equivalent across the small randomized evidence base available. The review did, however, find evidence that graft rejection was more likely after PK. DALK preserves the patient's own endothelium and therefore reduces exposure to endothelial rejection and chronic endothelial cell loss, but it is technically demanding and can be complicated by conversion to PK if the deep stromal plane cannot be reached safely. For corneal surgeons, this evidence supports the concept of matching the depth and location of disease to the least invasive effective graft. In a keratoconus eye with relatively healthy endothelium, DALK may offer meaningful biological advantages even when final visual acuity is similar. At the same time, surgeons must account for interface quality, intraoperative perforation, suturing requirements, and their own experience with big-bubble or other lamellar dissection techniques. The evidence remains limited enough that individualized case selection is essential.
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A Cochrane review comparing deep anterior lamellar keratoplasty (DALK) with penetrating keratoplasty (PK) for keratoconus found no clear difference in final visual acuity, keratometric astigmatism, or spherical equivalent across the small randomized evidence base available. The review did, however, find evidence that graft rejection was more likely after PK. DALK preserves the patient's own endothelium and therefore reduces exposure to endothelial rejection and chronic endothelial cell loss, but it is technically demanding and can be complicated by conversion to PK if the deep stromal plane cannot be reached safely. For corneal surgeons, this evidence supports the concept of matching the depth and location of disease to the least invasive effective graft. In a keratoconus eye with relatively healthy endothelium, DALK may offer meaningful biological advantages even when final visual acuity is similar. At the same time, surgeons must account for interface quality, intraoperative perforation, suturing requirements, and their own experience with big-bubble or other lamellar dissection techniques. The evidence remains limited enough that individualized case selection is essential.
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