AIM: To study the survival and visual outcome of penetrating keratoplasty in an African setting. METHODS: A retrospective analysis of 216 corneal grafts, performed on 203 eyes of 186 patients, at Kikuyu Hospital, Kenya over a 5 year period. RESULTS: Half of the transplants were carried out for keratoconus with only 5% of the grafts being undertaken for corneal scarring caused by trachoma or measles. The average follow up was 27.3 months. The probability of graft survival at 2 years was 87.4% (95% CI 80.6%-94.3%) for keratoconus and 64.7% (95% CI 54.8%-74.6%) for other corneal pathologies. Forty seven grafts (21.8%) in 36 patients (17.7%) are known to have become opaque. The commonest causes of graft opacification were bacterial keratitis (6.0%), endothelial failure (6.0%), and graft rejection (5.1%). Preoperatively 55% of keratoconus eyes and 75.7% of non-keratoconus eyes were blind. Postoperatively, 5% of keratoconus eyes and 41.7% of the non-keratoconus eyes were blind. Normal vision was achieved in 53.7% of operated eyes. Grafts carried out for keratoconus had a better visual outcome than grafts performed for other corneal pathologies. Preoperatively, 12.4% of keratoconus and 48.5% of non-keratoconus patients were blind in their better eye. Postoperatively, 1.1% of keratoconus patients and 25.7% of non-keratoconus patients were blind. The number of patients with normal vision in the better eye increased from 32 (17.2%) to 106 (57.0%). Sight was restored to 34 blind patients, but two patients with severe visual impairment preoperatively were blind at their last follow up. There was therefore a net reduction of 32 in the number of blind patients after 216 keratoplasties. CONCLUSIONS: Penetrating keratoplasty can be successful in Africa, particularly for keratoconus and other corneal dystrophies. However, penetrating keratoplasty has a limited role in the treatment of blindness from corneal scarring due to trachoma, measles, and vitamin A deficiency for which community based preventive measures must remain the priority.