Adult keratoplasty outcomes have significantly improved in the past quarter century as a result of new pharmaceuticals, advanced surgical devices, better understanding of what causes graft failure, and targeted techniques for selective replacement of only diseased corneal layers. Prevention and treatment of graft rejection, which has long been a leading cause of graft failure, has improved with the development of innovative topical and systemic immuno-suppressants. New methods for preventing and treating ocular surface complications have been devised, and limbal stem cell grafts have significantly improved management of severe ocular surface disease. Improved intraocular lens designs cause less corneal damage and have increased corneal graft survival. Non-steroidal anti-inflammatory (NSAID) eyedrops and more complete vitrectomies have reduced the incidence of chronic cystoid macular edema, which could prevent eyes with clear grafts from regaining useful vision. Patients with keratoconus or corneal scars can now benefit from advanced anterior lamellar keratoplasty techniques, which reduce the risk of immunologic rejection and endothelial failure, while matching the visual outcomes achieved with penetrating keratoplasty. Patients with endothelial dysfunction can now benefit from advanced endothelial keratoplasty techniques, which provide more rapid visual recovery, minimize induced astigmatism and ocular surface problems, and virtually eliminate the risk of wound rupture from minor trauma. Finally, femtosecond lasers now provide transplant surgeons with a precise tool for creating complex, interlocking corneal incisions that may facilitate wound healing.