In his recent skills transfer workshop, “Anterior Lamellar Keratoplasty: Principles and Practice,” at the American Academy of Ophthalmology (AAO) 2026 Meeting, Sheraz Daya, MD, chairman and medical director of Centre for Sight UK, outlined the benefits of deep anterior lamellar keratoplasty (DALK) for cornea surgeons. While the transplant procedure is increasing globally, Dr. Daya says, take-up in the US is still surprisingly low.
The following transcript has been edited for clarity.
Thank you for inviting me to speak about the course that we've done at the American Academy of Ophthalmology in New Orleans this year. This is a course that's now in its 24th or 25th year, and it's conducted by Sadeer Hannush, a good friend and colleague from Will's Eye Hospital in Philadelphia, and myself.
We've been advocates of deep anterior lamellar keratoplasty (DALK) for all this time. I started doing the procedure in the mid-90s and transformed completely to anterior lamellar keratoplasty, which is a partial thickness graft, and the reason for this is that we're preserving tissue that does not need to be replaced in the patient. So the endothelial cell layer, if it's normal, why would we want to change it? It can reject, it can fail over time, and so what's the alternative? Patients who have, for instance, keratoconus: If they have a full-thickness graft, it works really well. The vision recovery is within about a year or so if it's done well, and they get vision back. However, they are prone to rejection.
Looking at the United Kingdom registry data, there is a period of 3 years for keratoconus where there is a 7% chance of rejection and failure. So if that's the case, and if you have to regraft those patients, then the chance of a graft surviving is about 50%. And that's terrible for a young person who has to have a graft.
However, if you do a DALK, we preserve the back layer, and that graft will never fail. Generally speaking, full thickness grafts will only last a mean of about 17 to 20 years and then need to be replaced again because the cells eventually reduce in number and the cornea becomes thick again. Whereas with a lamellar graft, that does not happen—the shape might change, but the cornea stays clear. So it is a much better procedure.
The second reason why it's a better procedure is that it's closed system surgery: We're not opening the eye (an “open-sky” procedure). In a full-thickness graft, we penetrate all the way through, and during that period of time when the eye is open, there's a risk of an expulsive hemorrhage, which can occur in between 0.5-1% of individuals—and it is blinding.
My rate is lower, but I have had them. I've had 6 in my time as a corneal surgeon, and I've done over 1,200 grafts. But we've taken precautions, and because I've transformed completely to doing a DALK, the number of full-thickness grafts—penetrating keratoplastys—I do have reduced tremendously, and my patients are safer.
With this procedure, there's also an increased risk of infection because the eye is also open, and there's also an increased risk of glaucoma in these patients. It's listed between 19% to 30%, if one looks at the literature. But that doesn't happen with DALK.
So there are many reasons for the benefit of patients to do DALK. Now, the good news is, around the world DALK is increasing in numbers. However, in the United States, disappointingly, the number hasn't changed: It's between 900 and 1,000 cases per year, when actually around 40,000 cases are eligible for the procedure. So the take-up rate is currently not high enough.
And why is that? I think a lot of it is to do with how long it takes to do the procedure and the perceived complexity of it all. That's where we—Sadeer, myself, and the whole faculty who were involved in the course—try to transform that thinking and change that thinking, and show our colleagues how the surgery can be accomplished in a systematic and more facile manner, using a variety of options.
It can take longer and, like any new procedure, there's a steep learning curve, but it's really well worthwhile, and what a great benefit to patients if you can do a lamellar transplant.