PurposeTo compare the outcomes of deep anterior lamellar keratoplasty (DALK) using dehydrated versus standard organ culture stored donor corneas for eyes with keratoconus. DesignProspective, randomized, single-center trial conducted in Italy ParticipantsAdult patients with keratoconus (≥ 18 years old) with keratoconus scheduled for an elective DALK MethodsCases with successful type 1 bubble pneumatic dissection using standard DALK technique were intraoperatively randomized to receive either dehydrated (n=30) or standard organ culture stored donor corneas (n=30). Main Outcome MeasuresThe primary study outcome was best spectacle-corrected visual acuity (BSCVA) 12 months after surgery. Secondary outcomes were refractive astigmatism (RA), endothelial cell density (ECD) and complication rates. ResultsPostoperative logMAR BSCVA did not significantly differ between groups at both time points (mean difference at 6 months = 0.030 [95%CI: -0.53-0.10] p = 0.471) and at 12 months = -0.013 [95%CI: -0.10-0.08] p = 0.764). No significant differences between groups were observed in terms of postoperative RA and ECD at all time points. In the first 3 days after DALK, an epithelial defect was present in 10 cases (33%) of the organ culture cornea group and in 29 cases (97%) of the dehydrated cornea group. Complete re-epithelialization was achieved by day 7 in all cases (100%) of both groups. ConclusionsThe study provides evidence that the use of dehydrated corneas is non-inferior to the use of standard organ culture donor corneas for DALK. Corneal tissue dehydration represents a viable solution that can allow long-term cornea preservation and avoid wastage of unused corneas.