Long-Term Graft Survival and Visual Outcomes in Deep Anterior Lamellar Keratoplasty (DALK): A Narrative Review

Deep anterior lamellar keratoplasty (DALK) selectively replaces the scarred or diseased corneal stroma, while preserving healthy endothelium, thus providing an alternative to penetrating keratoplasty (PK) for patients with stromal disorders. Despite its recognized advantages, DALK has not become as widely adopted as anticipated over the past decades. The satisfactory visual outcomes of PK, the lack of standardized DALK techniques, as well as the limited long-term data on visual and refractive outcomes for both DALK and PK are commonly cited as barriers to its broader implementation. Evidence from long-term studies indicates that DALK offers superior graft survival and provides a safer intraoperative profile with fewer complications and lower endothelial cell loss, making it the preferred option for stromal diseases with healthy endothelium.