Posterior keratoplasty, a corneal transplant technique wherein the posterior corneal stroma and endothelium are selectively transplanted, may provide a promising alternative to penetrating keratoplasty (PKP) in patients with Fuchs’ endothelial dystrophy and aphakic or pseudophakic bullous keratopathy. The visual outcome after PKP may be limited by postoperative irregular astigmatism and high ametropia. In addition, graft rejection may necessitate a repeat PKP. Despite innovative suturing techniques and nomograms, postoperative astigmatism after PKP remains an important limitation. The theoretical advantages of posterior keratoplasty over PKP may include preservation of host epithelium and reduced risk of epithelial surface irregularities, epithelial rejection, suture-related infections, graft melts, and poor vision due to irregular astigmatism. It may also be possible to use infantile corneal tissue in the posterior keratoplasty procedure without the added risk of corneal ectasia. At this stage, although posterior keratoplasty appears to be an attractive alternative to PKP, we feel that the limitations with this technique still outweigh the benefits over other forms of PKP. The use of the IntraLase laser may provide the added ease and reproducibility needed for widespread use of this surgical technique. Clinical trials with larger patient populations are needed to clarify whether posterior keratoplasty indeed reduces graft/host interface problems, improves visual outcomes, or is potentially a practical alternative for traditional PKP techniques; and if so, what additional parameters may potentially enhance the overall results. We are exercising caution in recommending using this surgical approach until more definitive improvements to this promising approach materialize.