Lamellar keratoplasty was the first form of corneal transplantation attempted, with a history over a century, and has been regarded mainly as a therapeutic technique.^1,2 Lamellar grafting offers several advantages over penetrating keratoplasty, including the elimination of allograft rejection and the avoidance of intraocular complications. In addition, more donor cornea can be used in lamellar keratoplasty since the procedure does not require donor endothelium. This is particularly important in countries where donor corneas are scarce. However, the use of lamellar keratoplasty has been limited by difficulties such as irregularity and scarring of tissue interfaces, leading to poor visual outcomes compared with penetrating keratoplasty,^1–3 as well as technical difficulties and prolonged operating time. Penetrating keratoplasty has thus been the most common corneal transplantation procedure for visual restoration for many years. Although penetrating keratoplasty has been shown to be effective and safe for most anterior segment pathologies, there are persistent long term risks such as endothelial failure and immunological graft rejection.⁴

Deep lamellar keratoplasty (DLK) is a logical step in the surgical management of corneal stromal opacification in the setting of functional endothelium.¹ …