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Article | 2026 AAO

Making the Case for DALK

An look into the advantages of deep anterior lamellar keratoplasty and practical techniques to help cornea surgeons overcome barriers to adoption.

Ophthalmology Management October 1, 2026

Clinical Scorecard: Making the Case for DALK

At a Glance

CategoryDetail
ConditionCorneal conditions eligible for deep anterior lamellar keratoplasty (DALK), including keratoconus
Key MechanismsDALK replaces diseased anterior corneal tissue while preserving the endothelium and posterior corneal layer; it is performed as closed-system surgery.
Target PopulationPatients eligible for anterior lamellar keratoplasty, including patients with keratoconus and a normal endothelial cell layer
Care SettingCorneal surgery practice and surgical skills-transfer training

Key Highlights

  • DALK preserves the endothelial cell layer when it is normal, rather than replacing it with a full-thickness graft.
  • The speaker reports that preserved posterior tissue avoids endothelial graft failure; corneal shape may change, but the cornea can remain clear.
  • Unlike penetrating keratoplasty, DALK is closed-system surgery and does not require opening the eye.
  • The article cites expulsive hemorrhage risk of 0.5%–1% during open-sky full-thickness graft surgery and glaucoma rates of 19%–30% in the literature; it states these risks do not occur with DALK.
  • The speaker reports that DALK use is increasing globally, while US volume remains about 900–1,000 cases annually despite an estimated 40,000 eligible cases.

Guideline-Based Recommendations

Diagnosis

    Management

    • For eligible patients with a normal endothelial cell layer, the speaker advocates DALK to preserve the posterior cornea rather than performing a full-thickness graft.
    • The article describes DALK as an alternative to penetrating keratoplasty for patients with keratoconus.

    Monitoring & Follow-up

      Risks

      • The speaker cites a 7% chance of rejection and failure within 3 years after full-thickness grafting for keratoconus, based on UK registry data.
      • The article reports that repeat graft survival is about 50% when regrafting is required.
      • The speaker states that full-thickness grafts last a mean of about 17–20 years before endothelial cell loss may lead to corneal thickening and replacement.
      • Open-sky full-thickness graft surgery carries a cited 0.5%–1% risk of expulsive hemorrhage; the article also cites increased infection risk and glaucoma rates of 19%–30%.
      • DALK can take longer to perform and has a steep learning curve.

      Patient & Prescribing Data

      Patients eligible for DALK, including those with keratoconus; the article emphasizes preserving a normal endothelial cell layer.

      DALK is a partial-thickness corneal graft that preserves the posterior layer. The speaker describes it as avoiding the endothelial failure associated with full-thickness grafts and as closed-system surgery.

      Clinical Best Practices

      • Assess whether the endothelial cell layer is normal when considering a partial-thickness graft.
      • Use systematic surgical techniques and skills-transfer training to address DALK's perceived complexity and learning curve.
      • Discuss the article's reported differences between DALK and full-thickness grafting, including tissue preservation and open-sky surgical risks.

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