Fifty children, 2 months to 14 years of age underwent 66 penetrating keratoplasties. Included were 18 eyes with congenital corneal opacification, 16 with corneal decompensation (either from congenital glaucoma, trauma, or multiple surgeries), 10 with corneal hydrops secondary to keratoconus, and 10 with failed grafts. There were 32 clear grafts with a 1- to 10-year follow-up, 30 failed grafts, and 4 lost eyes. Acquired corneal scars, corneal decompensation, older children, and phakic eyes had the best prognosis. Corneal perforations, active inflammation or infection, and infants with multiple ocular anomalies had the poorest prognosis. Children undergoing combined procedures did less well than those undergoing a single- or two-staged procedure.