Aims To investigate possible predictive topographic characteristics for the development of Descemet's membrane (DM) folds after the uneventful deep anterior lamellar keratoplasty (DALK). Methods A retrospective study included 56 eyes of 56 consecutive patients who underwent uneventful DALK using the big-bubble technique to treat advanced keratoconus. At baseline and each visit, best-corrected logMAR visual acuity (BCVA), slit-lamp findings, endothelial cell density, topographic parameters were recorded. DM area is calculated using morphogeometric modelling. Results Twelve (21.4%) of them exhibited DM folds, whereas the remaining 44 (78.6%) did not exhibit any DM folds after the surgery. The mean follow-up time was 36.3 +/- 16.7 (range, 12-71) months. The mean posterior corneal power was - 13.8 +/- 0.6 D in patients with DM folds, whereas - 13.0 +/- 0.8 D in those without DM folds (p = 0.016). The mean DM area was 53.6 +/- 2.3 (50.9-57.9) mm(2) in patients with DM folds, whereas 51.6 +/- 1.7 (47.1-53.9) mm(2) in those without DM folds (p = 0.001). The ROC curve showed that two best cut-off value for the posterior corneal power and DM area were 13.75 D and 53.8 mm(2), respectively, to predict the occurrence of DM folds. Conclusion DALK surgery seems to cause DM folds in patients with large DM area and high posterior corneal power.