Deep Anterior Lamellar Keratoplasty (DALK)

Unlike a full-thickness transplant called penetrating keratoplasty (PK), which replaces all five layers of the cornea, DALK preserves your own endothelium. The endothelium is the innermost layer that keeps the cornea clear by pumping out excess fluid.

By keeping this critical layer in place, DALK offers better long-term stability and a much lower risk of rejection compared to procedures that replace the entire cornea.

DALK is most effective for corneal diseases that affect only the front layers while sparing the endothelium. Common conditions we treat with this procedure include:

• Keratoconus, where the cornea progressively thins and bulges
• Corneal scars from injury or infection
• Corneal dystrophies affecting the outer layers
• Pellucid marginal degeneration
• Other forms of progressive corneal ectasia

The ideal candidate has significant corneal disease affecting the front layers but a healthy endothelium beneath. Before recommending DALK, we use advanced diagnostic tools like corneal topography and pachymetry to map the cornea's shape and measure its thickness.

Patients with endothelial disease, corneal scarring that extends through all layers, or active eye infections typically require different treatment approaches.

With proper care and regular monitoring, DALK grafts commonly remain clear and functional for many years, often well over a decade. Because your own endothelium is preserved, the long-term graft survival rates are excellent, with studies showing over 95% success at 10 years for conditions like keratoconus.

Serious complications are rare, occurring in less than 1% of cases, but can include infection, bleeding inside the eye, or significant inflammation. During surgery, there is a small risk of accidentally perforating the inner layer, which may require converting to a full-thickness transplant.

While the rejection risk is much lower than with full-thickness procedures, it is not zero. Careful monitoring and early treatment of any rejection signs are important for long-term success.

Most patients can resume desk work and light activities within one to two weeks, though complete healing takes much longer. During the first four to six weeks, you should:

• Avoid rubbing your eye
• Avoid heavy lifting or strenuous exercise
• Avoid swimming and activities where water could enter your eye
• Wear protective eyewear during sports or outdoor activities

Your cornea specialist will let you know when it is safe to return to all normal activities.

Some degree of astigmatism, or irregular corneal curvature, is common after DALK due to the sutures holding the graft in place. Your cornea specialist can adjust or selectively remove sutures over time to help reshape the cornea and reduce astigmatism.

Once your eye stabilizes, prescription glasses or specialty contact lenses can further correct any remaining astigmatism for clearer vision.

The sutures used in DALK typically remain in place for several months to over a year, allowing the graft to heal securely. Using corneal topography mapping, your cornea specialist will determine the optimal timing and sequence for gradual suture removal to fine-tune your vision and minimize astigmatism.

Contact your cornea specialist immediately if you experience increasing redness, eye pain, sudden vision loss, or heightened sensitivity to light. These can be signs of infection, rejection, or other complications that require urgent treatment.

Early intervention is key to preserving your vision and protecting your graft.

Even after your eye has healed, regular eye exams remain important for monitoring corneal clarity, eye pressure, and overall graft health. These visits allow for early detection of any late complications and ensure your vision stays stable for years to come.