Penetrating Keratoplasty Versus Deep Anterior Lamellar Keratoplasty for Advanced Stage of Keratoconus

center dot PURPOSE: To compare visual acuity, refractive error, and complications after penetrating keratoplasty (PK) vs deep anterior lamellar keratoplasty (DALK) in the man-agement of advanced stage of keratoconus.center dot DESIGN: Retrospective, comparative, interventional study. center dot METHODS: This study enrolled 411 consecutive ker-atoconus eyes with preoperative mean keratometry >= 60 diopters (D) that received either PK (218 eyes) or DALK (193 eyes). The outcome measures were postoperative vi-sual acuity, refraction, complications, and further surgical interventions.center dot RESULTS: The mean follow-up duration was 77.9 +/- 46.5 and 72.9 +/- 47.8 months in the PK and DALK groups, respectively ( P = .28). Compared with baseline values, postoperative visual acuity and refrac-tion significantly improved in both groups. Postoperative corrected distance visual acuity was 0.18 +/- 0.13 and 0.26 +/- 0.19 logMAR in the PK and DALK groups, re-spectively ( P < .001). Postoperative spherical equivalent refraction was -2.89 +/- 2.89 D after PK and -4.58 +/- 3.62 D after DALK ( P < .001). Final keratometric astigma-tism was comparable between the 2 groups ( P = .82). Suture-related complications were observed in 48.6% of the PK eyes and 72.0% of the DALK eyes ( P < .001). The incidence of graft rejection was 33.5% after PK and 19.7% after DALK ( P = .002). At the last visit, 98.2% of PK grafts and 94.8% of DALK grafts remained clear ( P = .06).center dot CONCLUSION: Both techniques of corneal transplanta-tion led to a significant improvement in the visual and re-fractive variables in eyes with advanced keratoconus. PK resulted in a better visual acuity and refraction with less suture-related complications compared to DALK. How-ever, PK was associated with a higher rate of graft rejec-tion. The 2 techniques were comparable in terms of graft survival. (Am J Ophthalmol 2023;248: 107-115.(c) 2022 Elsevier Inc. All rights reserved.)