[Update: Deep anterior lamellar keratoplasty (DALK) for keratoconus. When, how and why]

The treatment of keratoconus has been significantly expanded in recent years. In addition to the previous options for correction by fitting hard contact lenses and penetrating keratoplasty (PK), corneal cross-linking and lamellar transplantation techniques have been added.

The aim of this review article is to highlight currently available options for minimization of complications and standardization of deep anterior lamellar keratoplasty (DALK) for keratoconus.

This article summarizes our own data and gives a review of the literature in PubMed.

Performing DALK can provide keratoconus patients with corneal grafts with considerably longer graft survival and a reduced risk of complications.

The DALK procedure provides numerous advantages over PK, especially the reduced intraoperative opening of the eye, which thus reduces the risk of serious intraoperative complications. A further benefit is the complete absence of postoperative endothelial immune reactions as the recipient's endothelium remains untouched. The absence of endothelial immune reactions is especially advantageous for young patients with keratoconus and patients with an increased risk of graft rejection, e.g. in atopic dermatitis; however, there are also typical complications of DALK that do not occur during PK. The outlined strategies for standardization of DALK and avoidance of intraoperative and postoperative complications should make DALK safer and more reproducible and lead to possible establishment as a standard procedure in keratokonus.