Aim To compare visual outcomes between deep anterior lamellar keratoplasty (DALK) and penetrating keratoplasty (PK). Secondarily to compare refractive outcomes, complications and graft survival between the three cohorts.

Methods Retrospective case-control study evaluating visual acuity outcomes (VA) following DALK with complete Descemet's baring (DALKa) (modified Anwar big bubble technique—51 eyes), pre-descemetic anterior lamellar keratoplasty (DALKm) (manual technique—52 eyes) and PK (103 eyes) with mean follow-up of 13.6, 19.3 and 18.6 months, respectively.

Results The common indications for surgery were corneal scars (36.4%), keratoconus (28.6%) and corneal dystrophies (13.6%). A best-corrected VA of 6/7.5 or better was achieved in 19.4% (PK), 21.6% (DALKm) and 38.5% (DALKa) of cases (p=0.02), and eyes that underwent DALKa had significantly better visual outcomes than PK (p=0.03). Complications following PK were glaucoma (15%), endothelial rejection (12%) and epithelial problems (11%); in the lamellar group, glaucoma (9%), epithelial problems (5%) and Descemet's detachment (3%) were more common. The 2-year estimated probability of graft survival was 90% for PK, 98% for DALKm and 100.0% for DALKa (p=0.35).

Conclusions Lamellar keratoplasty with complete baring of the Descemet's membrane (DALKa) gave significantly better visual outcomes compared to PK or pre-descemetic ALK and should be the preferred from of corneal replacement in corneal disorders with healthy endothelium.