Purpose <p>To compare clinical outcomes, complications, and long-term graft survival following penetrating keratoplasty (PK) versus deep anterior lamellar keratoplasty (DALK) in keratoconus, with 10 years of follow-up.</p> Methods <p>This retrospective, comparative cohort study included 224 consecutive primary grafts performed for keratoconus, each with a minimum follow-up of 10 years. Of these, 116 eyes underwent PK and 108 eyes underwent DALK. Outcome measures included postoperative visual acuity, refractive error, and postoperative complications. Graft survival at 10 and 15 years was also evaluated.</p> Results <p>The mean follow-up was 11.7 ± 1.4 years in the PK group and 11.4 ± 1.6 years in the DALK group (<i>P</i> = 0.10). Final visual acuity and refractive error were similar between groups; however, PK resulted in faster visual recovery and a higher proportion of eyes achieving corrected distance visual acuity (CDVA) ≥ 20/25. Episodes of graft rejection were more frequent after PK, with 10-year rejection-free survival rates of 66.4% for PK versus 77.8% for DALK. Rates of ocular hypertension, cataract formation, traumatic wound dehiscence, and keratoconus recurrence were comparable between groups. Graft survival was excellent in both groups: 100% (10 years) and 99.0% (15 years) for PK, compared with 97.2% (10 and 15 years) for DALK (<i>P</i> = 0.26).</p> Conclusion <p>PK and DALK provide comparable long-term visual, refractive, and graft survival outcomes in keratoconus. PK offers faster visual rehabilitation and a greater likelihood of achieving CDVA ≥ 20/25, but carries a higher risk of graft rejection.</p>