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The femtosecond laser (FSL) is a focusable infrared laser that delivers ultrashort pulses in the femtosecond duration range. Contiguous pulses are placed at a definite depth within the cornea, thus resecting only targeted tissue. This surgical device allows cutting of corneal tissue in a number of reproducible, customised transplant designs, and allows the use of sagittal plane trephination profiles, such as zigzag, top-hat, Christmas tree and mushroom shapes to improve wound stability and, probably, postoperative astigmatism.1–5 The unique capability of the FS laser to photo-disrupt tissue with minimal collateral damage has made it a promising tool for increasing accuracy and predictability in corneal surgery.6 It has mainly been used in refractive surgery, for example, for flap preparation in Laser in Situ Keratomileusis (LASIK), for intrastromal corneal ring segments (ICRS) implantation in keratoconus patients7 or astigmatic keratotomy.
Penetrating keratoplasty (PKP) has been the treatment of choice for advanced cases of keratoconus for a long time. During the past decade, however, deep anterior lamellar keratoplasty (DALK) has regained more popularity in the treatment of keratoconus. The advantages of DALK over PKP surgery are: no corneal endothelial rejection; it is an extraocular procedure; early discontinuation of topical corticosteroids, minor loss of endothelial cells; possible superior resistance to rupture of the globe after blunt trauma; and the potential for early removal of sutures.8 With the advent of newer techniques and instrumentations, visual and refractive outcomes of DALK have been reported comparable with PKP.9 Therefore, in moderate keratoconus, cases with clear visual axis and intolerance to contact lenses who do not wish to try ICRS, DALK may be the surgical indication of choice. Overusage of PKP should be avoided. Especially in keratoconus, a very well done DALK may yield the same refractive and visual outcomes as PKP with a lower …