Penetrating keratoplasty (PKP) is a highly successful procedure in which full thickness cornea is replaced. Recent advancements in surgical techniques and instrumentation have shifted away from conventional PKP to Deep Anterior Lamellar Keratoplasty (DALK) performed by several forms of manual, microkeratome/femtosecond laser-assisted lamellar procedures.

Deep anterior lamellar keratoplasty has been used as an alternative to PKP especially in keratoconus and corneal scarring1–,4 with some advantages compared with PKP including reduced risk of intraoperative complications, elimination the risk of endothelial graft rejection, and minimal endothelial cell loss.1 ,5 ,6 Therefore, it is the first choice for many surgeons that appreciate the advantages of an extraocular surgery, associated good visual outcome and the absence of endothelial rejection. However, technical difficulties, …