PurposeTo describe the use of high-resolution anterior segment optical coherence tomography (AS-OCT) during deep anterior lamellar keratoplasty (DALK). DesignProspective case series. MethodsAt the Singapore National Eye Centre we performed sequential intraoperative AS-OCT scans using iVue 100-2 (Optovue, Fremont, CA, USA) during various DALK techniques. ResultsIn case 1 (corneal scarring) the OCT images helped to guide manual dissection, showed the depth of the needle track before air injection, and identified the location of a small bubble when the big bubble failed. In cases 2 (macular dystrophy) and 3 (lattice), viscodissection was undertaken, but in case 2 the OCT showed the viscoelastic trapped intrastromally, compared to case 3, in which the viscobubble dissection was successful. In case 4 (irregular corneal thinning and scarring), AS-OCT enabled accurate decision on initial trephination and guided dissection. In case 5 (keratoconus), the OCT showed the achieved big-bubble and detached Descemet membrane. Case 6 was a repeat DALK; the OCT guided the manual dissection of the residual stroma underlying the failed graft. In case 7, the OCT showed an intrastromal retention of fluid that was not detectable by the operating microscope due to diffuse scarring following alkaline injury. The OCT helped to assess the location of the Descemet membrane and guided the manual dissection. ConclusionsIntraoperative high-definition AS-OCT obtained good-quality images of the cornea during DALK and proved useful in various cases of DALK to help the surgeon decide on a number of surgical steps.