Penetrating keratoplasty (PK) is important for visual rehabilitation of an otherwise blind eye in infants or children with corneal opacities that preclude the development of normal visual function. Pediatric PK poses unique challenges and is technically more difficult than adult PK, owing to decreased scleral rigidity and anterior movement of the lens\|iris diaphragm in a young eyeball. The inability of children to cooperate with examination and postoperative management increases the risk of graft failure. Awareness of the factors associated not only with graft survival but also with visual outcome may be instrumental in improving vision after this type of surgery. Reasons cited for graft failure include rejection, glaucoma, infection and graft melting. Graft failure, graft\|induced optical distortion and amblyopia are thought to limit visual rehabilitation. We reviewed the prognostic aspects of pediatric PK and concluded that the surgical success and visual outcome are concerned with indications, concurrent ocular anomalies, onset ages, graft sizing, combined surgical procedures, postoperative complications, timely optical correction and amblyopia therapy. In summary, promising outcomes can be achieved by careful patient selection, efficient and meticulous surgery, and compulsive postoperative follow-up.