A lamellar approach was employed to manage increased vitreous pressure during pediatric keratoplasty for Peters anomaly type 1. Using a 250 μm microkeratome head, a donor cornea was split into an anterior and posterior lamella, which were punched to 8.5 mm and 6 mm, respectively. The host cornea was partially trephined (250 μm in depth, 8.5 mm in diameter), and the anterior stroma was removed. A 6-mm partial trephination was performed and then completed full-thickness with the exception of few clock hours. The donor anterior lamella was fixated with four cardinal sutures, and the attachments of the underlying host button were severed, thus allowing its removal. The donor posterior lamella was then delivered into the anterior chamber using the pull-through technique and attached to the anterior lamella with air injection. Suturing of the anterior lamella was completed with 12 additional interrupted stitches. Fixation of a large anterior lamella over a smaller, partially excised host cornea allows selective exchange of the central diseased host cornea under ";semi-closed system" conditions, thus overcoming excessive vitreous pressure and minimizing endothelial trauma.