Purpose: The aim of this study was to report three cases of stromal rejection after deep anterior lamellar keratoplasty using big bubble technique in keratoconus.

Methods: Deep anterior lamellar keratoplasty was performed in 3 cases of keratoconus (11-19 years of age) using the "big bubble" technique. All of them presented 4 to 19 months after uneventful surgeries with variable decrease of vision (1/200-20/200) along with foreign body sensation, mild pain, and corneal edema. Suture infiltrates were present in all eyes. Ultrasound pachymetry showed variable increase in central corneal thickness (711-894 μm). These patients with stromal rejection were administered pulse intravenous methylprednisolone, 500 mg in 150 mL of 5% dextrose and were started on 1% prednisolone acetate eye drops 1 hourly, moxifloxacin hydrochloride 0.5% 4 times a day along with homatropine 2% eye drops 4 times a day.

Results: Complete recovery of the stromal rejections was attained with clear graft and recovery of visual acuity (≥20/40) in all eyes. Central corneal thickness returned to prerejection values in all the eyes after 7 days. There was no significant change in specular count.

Conclusions: Deep anterior lamellar keratoplasty does not eliminate the risk of stromal rejection. Suture-related factors in the form of suture infiltrates and loose suture are an important risk factor for graft rejection. Graft rejection if treated promptly is reversible.