Aims To determine the visual outcome, graft survival and complications after deep anterior lamellar keratoplasty (DALK) in patients with herpes simplex virus (HSV)-related corneal scarring.

Methods A retrospective analysis of the patients who had DALK for HSV-related corneal scarring between January 2004 and February 2007 was performed. Mean follow-up was 30 months (range 16–48 months). The statistical significance of host corneal vascularisation was determined using Fisher's exact test.

Results There were 18 eyes from 18 patients and the mean age was 57 years. Preoperative visual acuity ranged from hand movements (HM) to 6/12. Fifty per cent of the eyes achieved visual acuity of 6/12 or better postoperatively. Six eyes (33%) had recurrence of HSV-related inflammation, eight eyes (including four eyes with recurrence of HSV-related inflammation) developed graft rejection and four eyes (including two eyes with recurrence of HSV-related inflammation) had bacterial keratitis. The graft survival rate was 83%. Three eyes developed glaucoma and one eye required trabeculectomy. Immunohistochemistry revealed that HSV was focally positive or equivocal in four recipient corneal buttons, and transmission electron microscopy showed intracellular HSV virions in two of them.

Conclusions This is the largest series of DALK for herpetic corneal scarring that shows a comparable visual outcome and better graft survival rate than penetrating keratoplasty. There is significant risk of recurrence of HSV-related inflammation and graft rejection that requires timely recognition and adequate management.