Corneal graft outcome was assessed within a large, prospectively collected database of 4499 records. Penetrating corneal graft survival was 91% at 1 year, 72% at 5 years and 69% at 7 years. The three most common indications for graft were keratoconus (30%), bullous keratopathy (25%) and failed previous graft (18%); the three most common causes of graft failure were rejection (34%), infection (18%) and glaucoma (9%). The vast majority of grafts were performed for improved visual acuity. About four-fifths of recipients achieved at least one line of better acuity on the Snellen chart post-operatively; of the remainder with unchanged or worse acuity, only 21% had failed grafts. Overall, 43% of recipients achieved a best corrected Snellen acuity of 6/12 or better, 52% achieved 6/18 or better, and 20% had acuitities of less than 6/60. Reasons for poor post-operative acuity (recorded as less than 6/60) included graft failure (41%) and comorbidities in the grafted eye (43%). A number of risk factors for graft failure were examined: in most instances, there was little room for decision-making or expert intervention.