Purpose: To describe the surgical technique and report the outcomes of patients treated with microkeratome-assisted anterior lamellar keratoplasty (MALK) for the correction of high-degree postkeratoplasty astigmatism. Methods: Four eyes of 2 patients with extremely high (>10 D) and irregular [surface asymmetry index >1.0 D] post-penetrating keratoplasty astigmatism occurring after complete suture removal underwent MALK and were followed for at least 3 years after the procedure. In all cases, 250-mm lamellar keratectomy was performed, followed by 2 full-thickness incisions through the penetrating keratoplasty scar and the placement of an appropriately sized donor graft, which was secured with a double-running 10-0 nylon suture. All sutures were removed in all eyes within 1 year from surgery. Corrected distance visual acuity, refraction, corneal topography, and endothelial cell density were noted at each examination. Results: At the last follow-up examination (3 years or longer after MALK), corrected distance visual acuity had improved to 20/20, refractive astigmatism had decreased to an average of 2.1 D (in all cases within 4.5 D), and the average surface asymmetry index had reduced from 2.27 to 0.56. Conclusions: MALK is an effective and safe technique for the correction of high-degree postkeratoplasty astigmatism.