To compare the therapeutic outcomes after deep anterior lamellar keratoplasty (DALK) and penetrating keratoplasty (PKP) in patients with keratoconus.

We retrospectively reviewed the clinical records of 57 patients diagnosed with keratoconus who had undergone DALK (19 eyes of 19 patients) and PKP (38 eyes of 38 patients) in Samsung medical center between January 1995 and January 2006.

The 19 and 38 patients with keratoconus who underwent DALK and PKP had mean ages of 25.3 (range: 17-46) and 26.2 (range: 12-51) years, respectively. These groups were followed up for mean times of 16.7 (range: 6-34) and 45.7 (range: 6-115) months after surgery, respectively. The DALK group showed significantly higher values of refractive power, central corneal thickness, and endothelial cell density, while two eyes (10.5%) in the DALK group developed stromal rejection, which resolved after steroid therapy. In the PKP group, eight eyes (21%) developed endothelial rejection, among whom one eye (2.6%) resulted in a graft failure of a patient who underwent re-PKP, and two eyes (5.3%) in the PKP group developed secondary glaucoma.

DALK should be considered as the primary surgical technique in keratoconus, because the visual outcome is comparable with PKP and it reduces severe complications such as secondary glaucoma and the risk of graft failure by preserving the corneal endothelium compared to PKP.