OBJECTIVES The purpose of this study was to assess the cost-utility of posterior lamellar keratoplasty techniques, including deep lamellar endothelial keratoplasty (DLEK), Descemet stripping endothelial keratoplasty (DSEK) and Descemet stripping automated endothelial keratoplasty (DSAEK), in the treatment of corneal endothelial diseases. METHODS This cost-utility analysis was performed from a Canadian health system perspective over a lifetime period. A Markov model was constructed to compare the cost per quality adjusted life year (QALY) associated to penetrating keratoplasty (PK) and lamellar keratoplasty techniques (DLEK, DSEK and DSAEK). The Markov model included all major health states relevant to patients scheduled for corneal transplantation: waiting for transplantation, surviving graft with or without complications, irreversible failure, non-eligibility and death. Transition probabilities between health states were obtained from results of published clinical trials. Costs included in the model comprised those associated with surgery, patients' follow up and post-surgical complications. Specifically, costs related to visits to physician, medications as well as those incurred at the hospital were included in the model. Number of QALYs was estimated pre and post-surgery using the EQ-5D questionnaire from patients undergoing PK or lamellar surgery at Maisonneuve Rosemont Hospital (Montreal, Qc). RESULTS The lamellar keratoplasty techniques were proved to be more effective, providing more QALYs (+43 QALYs / 100 patients), and were less costly (-50,437 CD$ / 100 patients) compared to PK. The gain of QALYs associated with lamellar keratoplasty resulted from a reduction of the waiting time for transplantation and from lower postoperative complication rates, both related to poor utility values. Deterministic and probabilistic sensitivity analyses confirmed the robustness of the base-case results. CONCLUSIONS From a clinical and an economic standpoint, lamellar keratoplasty represents a preferred strategy for the treatment of corneal endothelial diseases.