In the past decade, novel lamellar keratoplasty techniques such as Deep Anterior Lamellar Keratoplasty (DALK) for anterior keratoplasty and Descemet stripping automated endothelial keratoplasty (DSAEK)/Descemet membrane endothelial keratoplasty (DMEK) for posterior keratoplasty have been developed. DALK eliminates the possibility of endothelial allograft rejection, which is the main reason for graft failure after penetrating keratoplasty (PK). Compared to PK, the risk of endothelial graft rejection is significantly reduced after DSAEK/DMEK. Thus, with modern lamellar techniques, the clinical problem of endothelial graft rejection seems to be nearly solved in the low-risk situation. However, even with lamellar grafts there are epithelial, subepithelial and stromal immune reactions in DALK and endothelial immune reactions in DSAEK/DMEK, and not all keratoplasties can be performed in a lamellar fashion. Therefore, endothelial graft rejection in PK is still highly relevant, especially in the “high-risk” setting, where the cornea's (lymph)angiogenic and immune privilege is lost due to severe inflammation and pathological neovascularization. For these eyes, currently available treatment options are still unsatisfactory. In this review, we will describe currently used keratoplasty techniques, namely PK, DALK, DSAEK, and DMEK. We will summarize their indications, provide surgical descriptions, and comment on their complications and outcomes. Furthermore, we will give an overview on corneal transplant immunology. A specific focus will be placed on endothelial graft rejection and we will report on its incidence, clinical presentation, and current/future treatment and prevention options. Finally, we will speculate how the field of keratoplasty and prevention of corneal allograft rejection will develop in the future.

在过去的十年中，已经开发了新颖的层状角膜成形术技术，例如用于前角膜成形术的深层前板层角膜成形术（DALK）和用于后部角膜成形术的Descemet剥离自动内皮角膜成形术（DSAEK）/ Descemet膜内皮角膜成形术（DMEK）。DALK消除了异体内皮移植排斥的可能性，这是穿透性角膜移植（PK）后移植失败的主要原因。与PK相比，DSAEK / DMEK后内皮移植排斥的风险显着降低。因此，利用现代的层状技术，在低风险情况下似乎几乎解决了内皮移植物排斥的临床问题。但是，即使使用层状移植物，DALK也会发生上皮，上皮下和基质免疫反应，DSAEK / DMEK也会发生内皮免疫反应，并非所有角膜移植术都可以层状进行。因此，PK的内皮移植排斥仍然非常重要，特别是在“高风险”情况下，由于严重的炎症和病理性新血管形成，导致角膜的（淋巴）血管生成和免疫特权降低。对于这些眼睛，当前可用的治疗方案仍然不能令人满意。在这篇综述中，我们将描述当前使用的角膜移植技术，即PK，DALK，DSAEK和DMEK。我们将总结他们的适应症，提供外科手术描述，并就他们的并发症和结果发表评论。此外，我们将概述角膜移植免疫学。我们将重点关注内皮移植排斥反应，并报告其发生率，临床表现，以及当前/未来的治疗和预防方案。最后，我们将推测将来角膜移植和角膜移植排斥反应的预防领域将如何发展。