To investigate the clinical outcomes of primary pediatric keratoplasty.

Records of patients who underwent penetrating keratoplasty at the age of 5 years or younger were retrospectively reviewed. The survival rates of corneal grafts, postoperative complications, and causes of graft failure were evaluated.

A total of 31 penetrating keratoplasties were performed in 29 patients, two of which were bilateral. The mean follow-up period was 78.72 ± 8.94 months. The overall graft survival rate was 51.61%. The graft survival rate was 77.4% at 6 months, 61.3% at 12 months, 57.5% at 2 years, and 49.5% at 5 years after the surgery (the median survival time, 39.2 months). The main surgical indications included sclerocornea (35.5%), followed by Peter's anomaly (25.8%) and congenital glaucoma (9.7%). There were significant differences in graft survival time among the surgical indications, of which sclerocornea was the worst ( p = 0.003). The main cause of graft failure was rejection (46.7%), followed by infection (26.7%) and primary endothelial decompensation (20%). When patients were sub-grouped according to age (under 12 months, between 12 to 48 months, and over 48 months), there was significant difference in graft survival time ( p = 0.037) but not in overall graft survival rate ( p = 0.154). Graft rejection occurred more frequently in patients between 12 to 48 months of age compared to other age groups ( p = 0.016). Three out of 13 graft infections occurred in patients under 12 months of age.

The type of disease causing corneal opacity was a significant factor affecting the clinical outcomes of penetrating keratoplasty in children.