Historically, penetrating keratoplasty (PK) has been the gold standard surgical approach for the treatment of advanced keratoconus. In contemporary practice, however, deep anterior lamellar keratoplasty (DALK) is increasingly becoming the preferred primary surgical option. PK, nonetheless, has a significant role in the surgical management of keratoconus, especially where there is deep stromal scarring, a history of corneal hydrops, or, less commonly, coexisting endothelial dysfunction.