OBJECTIVE To determine the graft survival, visual outcome, complications, and frequency of subsequent cataract extraction after penetrating keratoplasty for Fuchs' dystrophy. METHODS The medical records of 236 patients with the diagnosis of Fuchs' dystrophy who were examined on the Cornea Service at Wills Eye Hospital, Philadelphia, Pa, between January 1, 1988, were reviewed retrospectively. METHODS Penetrating keratoplasties had been or were subsequently performed on 130 phakic eyes of the 236 patients with Fuchs' dystrophy. Results were analyzed in 126 eyes with at least 1 year of follow-up. Statistical analysis was done to determine the risk factors for subsequent cataract surgery in the first eye of patients who had penetrating keratoplasty as their initial surgical procedure. RESULTS Mean +/- SD follow-up after transplantation was 8.4 +/- 4.8 years. The graft remained clear in 112 eyes (89%). A best corrected acuity of 20/40 or better was achieved in 81 eyes (64%). Graft rejection occurred in 37 eyes (29%). Subsequent cataract surgery was performed in 55 eyes (44%), and the mean time from transplantation was 3.5 +/- 3.4 years. Advanced age at the time of transplantation was a significant risk factor for having cataract extraction (P = .003, Mantel-Haenszel chi 2 test) and a shorter time to cataract surgery after penetrating keratoplasty (P = .04, Mantel-Haenszel chi 2 test). Pregraft lens status approached significance as a risk factor for subsequent cataract surgery (P = .07, Mantel-Haenszel chi 2 test). CONCLUSIONS Long-term results are favorable after penetrating keratoplasty for Fuchs' dystrophy. In older patients with Fuchs' dystrophy and mild-to-moderate lens changes, combines penetrating keratoplasty, cataract extraction, and intraocular lens implantation procedure should be considered.