Advertisement

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
Objective:

The article presents Sheraz Daya’s case for deep anterior lamellar keratoplasty (DALK), describing its advantages over penetrating keratoplasty, barriers to its adoption in the United States, and techniques demonstrated at an AAO workshop.

Approach:
  • Procedure: DALK replaces diseased anterior corneal tissue while preserving a healthy endothelial layer; penetrating keratoplasty replaces the full corneal thickness.
  • Training: At an AAO 2026 skills transfer workshop, Daya and colleagues presented systematic techniques intended to make anterior lamellar surgery more accessible to surgeons.
Key Findings:
  • Daya cited UK registry data indicating a 7% chance of rejection and failure within three years after a full-thickness graft for keratoconus; he said survival after regrafting is about 50%.
  • He stated that full-thickness grafts last a mean of about 17–20 years, while lamellar grafts preserve the endothelium and may remain clear even if corneal shape changes.
  • DALK is a closed-system procedure. Daya contrasted it with open-sky surgery, which he said carries risks including expulsive hemorrhage, infection, and glaucoma; he cited a 19%–30% glaucoma risk in the literature for penetrating grafts.
  • Daya reported that DALK use is increasing globally but remains at about 900–1,000 cases annually in the United States, despite an estimated 40,000 eligible cases.
Interpretation:

Daya attributes low US uptake partly to the procedure’s perceived complexity, longer operating time, and steep learning curve. At the workshop, he and the faculty demonstrated systematic approaches and options for performing the surgery.

Limitations:
  • The material is an edited transcript of a presentation and primarily reflects Daya’s account.
  • The context does not provide study citations or methods for the registry figures, complication estimates, or US case estimates.
Conclusion:

Daya argues that DALK preserves a healthy endothelial layer and avoids the open-sky risks he associates with penetrating keratoplasty. He also notes that longer operating times, perceived complexity, and a steep learning curve may contribute to low US uptake.

Sources: