In ancient times, cosmetical treatment of corneal scars had been performed by means of a tattoo-like coloration of the scar. Lampblack or soot was used in old Egypt (±1500 BC), and copper sulphate reduced with nutgall was applied to achieve reasonable cosmesis by Galenus (131–200 AD). In the eighteenth century, superficial removal of scars was widely performed by surgeons in France and Germany [1]. The idea of removing scars from the cornea using a trephine was first proposed by Erasmus Darwin (the grandfather of Charles Darwin) in 1796 [2]. In 1789 Pellier De Quengsy introduced his ideas on treating corneal opacification with what would now be called keratoprosthesis, i.e. the replacement of opaque corneal tissue by man-made material. His concept entailed an artificial cornea made from glass framed in silver [3]. Attempts in the second half of the nineteenth century to actually treat patients with artificial corneas, among others by von Hippel and by Nussbaum, were not successful [4, 5]. The artificial cornea concept was in fact not developed into a useful technique until 1963, when among others Strampelli published on successful clinical application of keratoprostheses. In Strampelli’s case, this was the osteo-odonto-keratoprosthesis, in which the optical element was embedded in a biocompatible carrier made out of the patient’s own tooth and jawbone [1, 6]. Recently the application of keratoprostheses made of artificial materials has increased, with variable results in patient groups with significant high-risk eyes [7].

The first widely known experiments with full-thickness tissue corneal transplantations in animals, conducted in 1818, either heterologous (between species a.k.a. xenografting) or homologous (within species), are attributed to Reisinger. He also introduced the term “keratoplasty” for corneal transplantation [8]. Wars at the end of the eighteenth and the beginning of the nineteenth centuries made corneal blindness from smallpox, venereal disease and “Egyptian ophthalmia” (trachoma) prevalent. With this background, Bigger performed the first successful corneal transplantation in animals. In 1837, during his captivity in Egypt by Sahara Bedouins, he performed a homograft on his captor’s pet gazelle which had been blinded by a corneal wound [9].

Heterologous transplantations of animal tissue into humans were then attempted. In 1838, the New York ophthalmologist and general practitioner Richard Sharp Kissam transplanted a pig’s cornea into a human patient. Kissam operated without any anaesthesia. Ether anaesthesia was not introduced until 1846, chloroform anaesthesia in 1847 and topical cocaine anaesthesia in 1858. His patient initially received more light in his eye, but the cornea opacified and absorbed over a 2-week period [10]. The experiments on corneal transplantation in humans and animals conducted by Power, described in 1872, suffered the same fate [11].

Success in heterografting remained elusive until the first successful lamellar heterograft in a human by Von Hippel. A leucoma corneae was excised from a young girl’s eye with Descemet’s membrane and endothelium remaining, and a rabbit cornea was transplanted into the wound bed. This procedure was performed in 1886 and was described in 1888 as the first in a series of 8 lamellar operations, of which 4 were successful [4]. Von Hippel performed anterior lamellar keratoplasty because he felt that corneal transparency depended on the integrity of the corneal endothelium and Descemet’s membrane. Therefore, he abandoned full-thickness corneal grafts.

It was not until 1905 that the first successful penetrating homologous corneal graft was performed in a human patient. The Moravian ophthalmologist Eduard Konrad Zirm transplanted a donor cornea obtained from an enucleated eye of a young boy into the eye of a 45-year-old labourer, suffering from corneal scars caused by a chemical lye injury. Zirm used general anaesthesia (chloroform) and strict asepsis [12].

Shortly thereafter, the concept of auto-keratoplasty or homograft was initiated. In this concept the donor cornea was harvested from the patient itself: from the fellow, blind eye, as described by Plange [1], or as a rotational graft in which a small corneal scar can be rotated out of the visual axis in the diseased eye, as described by Kraupa [5].

Allografting, in which the donor cornea is harvested from another individual of the same species, is currently the most commonly practised form of corneal transplantation. However, it took quite some time after Zirm, before reproducible results with penetrating corneal allografts were obtained. First the operative technique and donor tissue preservation and preparation had to be further developed and standardised. Much work in this respect was done and published in the 1920s and 1930s by Elschnig from Tsjechia, Filatov from Russia, Tudor Thomas in the UK and Castroviejo in the USA [13–18]. Improvements in lamellar transplant technique were achieved by the French ophthalmologists Paufique et al. [19] and Switzerland’s Franceschetti [20], from the 1930s through the 1950s, leading to a temporarily renewed popularity of this treatment modality.

The biggest hazard to a successful penetrating corneal graft is allograft rejection. Paufique described the concept of “maladie du greffon”, i.e. opacification of a previously clear cornea, which he attributed to sensitisation to the donor by the recipient [19]. This seminal concept of immunological rejection of the donor graft was proven by Maumenee in 1951 [21]. Much important work in the field of corneal allograft rejection was done by Khodadoust and Silverstein [22, 23]. The use of corticosteroids realised a breakthrough in the treatment and prevention of corneal transplant rejection and opacification. This concurred with the introduction of antibiotics, the introduction of the operation microscope, the development of microsurgical techniques and of newer suture materials that ensued. Other important developments included the better understanding of endothelial physiology and of donor cornea preservation. US-based ophthalmologists and scientists such as Paton, Troutman, Maurice, McCarey and Kaufman played important roles in these developments [24, 25]. All these developments led to a substantial improvement in the popularity of penetrating keratoplasty and hence in the number of cases operated with this technique.