Objective To examine factors affecting penetrating corneal graft survival and visual outcomes in patients aged less than 20 years. Design Large prospective, cohort study. Participants Records of 14 865 followed penetrating corneal grafts in 11 929 patients were searched to identify 765 grafts in 640 patients aged younger than 20 years of age at the time of graft. Methods Records submitted to the Australian Corneal Graft Registry by 381 ophthalmic surgeons and 253 follow-up practitioners from May 1985 to June 2009 were analyzed using KaplanMeier survival plots and Cox proportional hazards regression analysis. Main Outcomes Measures Probability of corneal graft survival and Snellen acuity at the time of most recent follow-up and at defined intervals post-graft. Results Infants (<5 years) exhibited poorer graft survival than children aged 5 to 12 years. Adolescents (1319 years) exhibited better corneal graft survival than other age groups; 86% of grafts in adolescents were for keratoconus. Factors significantly affecting corneal graft survival in pediatric patients included indication for graft, graft inflammation, history of intraocular surgery, vascularization, rejection episodes, post-graft operative procedures, and refractive surgery. Fourteen percent of pediatric grafts failed, of which 65% failed within 2 years post-graft. Forty-four percent of failures were due to unknown causes (18) or irreversible rejection (30). Conclusions Corneal grafts for keratoconus in adolescents show excellent survival. Infants exhibit poor graft survival and visual outcomes, especially those undergoing transplantation for Peters' anomaly. Corneal graft survival and visual outcomes vary more by indication for graft than recipient age. The major reason for graft failure is irreversible rejection. Corneal transplantation improves overall bilateral vision in pediatric patients. Financial Disclosure(s) The author(s) have no proprietary or commercial interest in any materials discussed in this article.