OBJECTIVE To assess the safety of cataract extraction following penetrating keratoplasty for corneal graft survival and to evaluate visual and refractive outcomes in corneal graft patients undergoing cataract extraction. METHODS Retrospective chart review of 29 eyes of 24 patients with corneal grafts who underwent cataract extraction from January 1, 1993 to December 31, 2002, followed on the Cornea Service at Wills Eye Hospital. RESULTS The mean time from penetrating keratoplasty to cataract extraction was 8.4 years (range 2 months to 36 years). Following cataract extraction, the corneal grafts remained clear in all but 1 eye (3%), during an average follow-up time of 44.5 months (range 3-118 months). All of the remaining patients benefited from improved visual acuity, with 15 of 28 patients having a postoperative best-corrected visual acuity of 20/30 or better. Patients also benefited from decreased absolute spherical refractive error, with a preoperative mean value of 6.6 +/- 3.4 D compared with 2.4 +/- 1.6 D postoperatively, while cylindrical refractive error remained relatively stable at 3.2 +/- 2.9 D preoperatively and 2.8 +/- 2.4 postoperatively. The patient who developed graft failure had 3 episodes of preoperative endothelial rejection and a clear corneal graft at the time of cataract surgery. CONCLUSIONS Cataract surgery following penetrating keratoplasty is a safe and effective procedure, with a low but definite risk of corneal graft failure. In patients with clear grafts and visually significant cataracts, cataract extraction alone is preferred over repeat penetrating keratoplasty and cataract extraction.