 Welcome to this surgical video on deep anterior lamellar keratoplasty performed by Dr. Mifflin at the Moran Eye Center. The geographic center of the cornea is marked. Then an appropriate sized vacuum tree fine is selected. Generally, cottery of the anterior surface is avoided in adult procedures. In this case, a Moria tree fine is used and set to about two-thirds of the corneal thickness. A stainless steel crescent blade is used to remove about half of the anterior stroma, making later removal of more posterior tissue easier. The anterior chamber is decompressed slightly. Small indicator air bubbles are then injected into the anterior chamber. Then create a big bubble to separate decimase membrane and endothelium from the anterior stroma. As decimase is pushed deeper, the air bubbles in the anterior chamber are often seen getting moved to the periphery. Then apply dispersive viscoelastic in advance of puncturing the lamella covering the big bubble. Puncture the remaining stroma while avoiding perforation of decimase. Following the puncture of the big bubble, decimase will once again move to its more natural anterior position, and this allows the air bubbles in the anterior chamber to return from the periphery to the center. Between decimase and remaining anterior lamella, apply dispersive OVD, or ophthalmic viscoe surgical device. We used viscote for this case. Cut the remaining stroma into four quadrants and manually cut away, often using curved corneal scissors. Calipers are used to verify bed diameter prior to preparing and punching donor tissue. Now let's shift our attention over to the donor cornea. Tripan blue is used to stain donor decimase, which is then removed. Remove decimase and endothelium from the donor tissue, then trefinate the donor cornea. Now let's go focus on the patient again. Place donor graft on the host. Donor tissue is typically cut to the same diameter or smaller if needed to decrease myopia in a keratoconus patient. Then suture the graft using standard techniques.