We reviewed the preoperative clinical indications and associated surgical procedures for 2,299 penetrating keratoplasties performed at our institution from 1983 through 1988. Pseudophakic bullous keratopathy was the most common indication overall, accounting for 526 cases (23%). A marked increase was noted in the incidence of pseudophakic bullous keratopathy as an indication for penetrating keratoplasty beginning in 1985. The association of anterior chamber intraocular lenses in eyes with pseudophakic bullous keratopathy undergoing penetrating keratoplasty increased from 19 of 43 cases (44%) in 1983 to 79 of 108 cases (73%) in 1988. The incidence of intraocular lens exchange at the time of penetrating keratoplasty in cases of pseudophakic bullous keratopathy increased from six of 43 (14%) in 1983 to 63 of 108 (58%) in 1988. Other major indications for penetrating keratoplasty included Fuchs' dystrophy (375 cases, 16%), keratoconus (348 cases, 15%), aphakic bullous keratopathy (331 cases, 14%), and regraft (233 cases, 10%). Cataract extraction, with or without intraocular lens implantation, was combined with penetrating keratoplasty in 397 of 1,532 phakic eyes (26%). The incidence of triple procedure (penetrating keratoplasty, cataract extraction, and intraocular lens implantation) increased from 27 of 248 phakic eyes (11%) in 1983 to 68 of 258 phakic eyes (26%) in 1988.