This chapter depicts the evolution of laser keratoplastyKeratoplasty, which started two decades before the clinical introduction of the femtosecond lasersFemtosecond laser (FSL) and compares the intraoperative feasibility and postoperative outcome of the excimer and femtosecond laserFemtosecond laser approaches. Hypothesizing that the properties of the wound bed are of utmost importance for the final optical performance of the graft, Naumann GOH et al. have developed and optimized the techniqueTechnique of non-mechanical corneal trephinationTrephination using a 193 nm excimer laserExcimer laser along metal masks for penetrating keratoplastyKeratoplasty (PKP) since 1986. Starting out with an elliptical trephinationTrephination the major improvement resulted from the introduction of eight “orientation teeth/notches” at round mask edges minimizing “horizontal torsion”. For non-contact donor trephinationTrephination from the epithelial side, an artificial anterior chamber was used. Prospective clinical studies have shown that the techniqueTechnique of non-contact excimer laserExcimer laser PKP may improve donor and recipient centration, reduce “vertical tilt” and “horizontal torsion” of the graft in the recipient bed, thus resulting in significantly less “all-sutures-out” astigmatismAstigmatism, higher regularity of the topography and better visual acuity. Besides less blood-aqueous barrier breakdown during the early postoperative course after PKP, excimer laserExcimer laser trephinationTrephination does not induce cataract formation and does not impair the graft endothelium. Likewise, the rate of immunologic graft rejectionsGraft rejection is not adversely affected by the excimer laserExcimer laser. In addition, trephinationTrephination of an instable corneaCornea, such as in (pre-) perforated corneal ulcersCorneal ulcer or after RK or LASIKLASIK is facilitated. Clinical results of FSL lamellar or penetrating keratoplastiesKeratoplasty—requiring variable amounts of applanation thus causing distortion of corneal tissue, especially in keratoconusKeratoconus—are still limited and not yet finally convincing. The evolution of non-mechanical laser keratoplastyKeratoplasty started in Erlangen in 1986. Because of undisputed clinical advantages, especially in eyesEye with keratoconusKeratoconus and instable thin corneasCornea after PKP, noncontact excimer laserExcimer laser trephinationTrephination with orientation teeth/notches is still favored in Homburg/Saar in daily practice. The FSL-assisted keratoplastyKeratoplasty techniqueTechnique has been very exciting but due to major lack of all-suture-out data after introduction of the techniqueTechnique 20 years ago—the superiority of this high price and difficult to maintain option has not been proven, yet! FSL-assisted PKP without liquid interface seems to have major disadvantages in comparison to excimer laserExcimer laser PKP especially in keratoconusKeratoconus.