OBJECTIVE To evaluate the use of corneal donor tissue deemed unsuitable for full-thickness penetrating keratoplasty (PK) for use in deep lamellar endothelial keratoplasty (DLEK) and to compare postoperative results to those of DLEK surgery using donor tissue that is suitable for PK. METHODS Small-incision DLEK surgery was performed using 39 donor corneas unsuitable for PK. Thirty-five donors had anterior scars or opacities, 3 donors had pterygia within the 8-mm zone, and 1 had prior LASIK. All donor preparation was completed by manual stromal dissection. The DLEK surgical and postoperative courses were reviewed. Preoperative and 6-month postoperative results of this study group were compared with a control group consisting of the first 55 consecutive small-incision DLEK patients receiving donor corneas that had no criteria excluding them from use in PK. Four eyes in the study group and 1 eye in the control group had the confounding variables of the presence of an anterior-chamber lens or surgical vitrectomy with macular disease in the recipient eye. RESULTS There was no significant difference in preoperative measurements of best spectacle-corrected visual acuity (BSCVA; P = 0.372), donor endothelial cell density (ECD; P = 0.749), or corneal topography [surface regularity index (SRI), P = 0.485; or surface asymmetry index (SAI), P = 0.154] between the 2 groups. For the patients receiving corneas deemed unacceptable for PK, at 6 months after surgery, the vision (P = 0.002) and corneal topography measurements improved significantly from before surgery (SRI, P < 0.001; SAI, P < 0.001), and there was no significant change in refractive astigmatism (P = 0.240). There was a significant difference in the vision at 6 months postoperatively between the overall study group and the control group, with the mean vision of the study group at 20/56 and the control group at 20/43 (P = 0.015). If eyes with known cystoid macular edema (CME) and vitrectomy are removed from each group, there is no significant difference in vision at 6 months between the study group and the control group (P = 0.110), with the average BSCVA of those receiving donor corneas unsuitable for PK equal to 20/48 (range, 20/25-20/200) and the average vision for those receiving PK-acceptable donor tissue equal to 20/43 (range, 20/20-20/80). The 6-month average refractive astigmatism of the study group was 1.12 +/- 0.99 D (range, 0.00-4.00 D), and the average endothelial cell count was 2064 +/- 396 cells/mm(2) (range, 1208-2957 cells/mm(2)). There was no significant difference in 6-month postoperative endothelial cell count (P = 0.443), refractive astigmatism (P = 0.567), or corneal topography (SRI, P = 0.332; SAI, P = 0.110) in study patients who received corneas unsuitable for PK compared with control patients who received corneas suitable for PK. CONCLUSIONS Endothelial keratoplasty such as DLEK surgery with manual donor preparation broadens the donor pool by enabling corneas that cannot be used for PK to be used for selective endothelial transplantation without deleterious postoperative results.