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The management of keratoconus has been changed significantly due to the advancement of technology in the field of contact lens materials and designs and introduction of new surgical approaches that aim to avoid or postpone corneal transplantation until the advanced stage of the disease. Deep anterior lamellar keratoplasty (DALK) has the advantage of preserving the patient’s own endothelium and eliminating endothelial graft rejection. Since the recent trend is to perform corneal transplantation mainly for severe keratoconus that are not amenable to other less invasive approaches, this review aims to provide an update on the outcomes of DALK in eyes with the advanced stage of keratoconus. A comprehensive literature review of studies in English was conducted using the following keywords: ‘deep anterior lamellar keratoplasty’ or ‘anterior lamellar keratoplasty’ or ‘DALK’ and ‘keratoconus’ and ‘severe’ or ‘advanced.’ DALK significantly improves vision and refraction in advanced keratoconus and provides favorable graft survival. Femtosecond laser seems to improve the technique of the DALK procedure, and future developments could improve the reproducibility of DALK even further. However, current data is inconclusive for the benefit of femtosecond laser-assisted DALK for advanced keratoconus.

Deep anterior lamellar keratoplasty for advanced keratoconus: an updated review of indications, techniques and outcomes