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To report the indications, visual outcome, and development of ectasia in clear corneal transplants at least 20 years or more after penetrating keratoplasty (PK).A computer search of all post-PK patients in the electronic medical records of the Cornea Service was done. Only patients with clear primary grafts aged 20 years or more were included. Main outcome measures noted were indications for surgery, final visual outcome, and postoperative complications. A subset of patients who developed ectasia clinically was also analyzed.One hundred forty-nine eyes of 109 patients were identified. The most common indication was keratoconus (76.5%). After average follow-up of 27 years, the mean postoperative best-corrected visual acuity was 0.29 ± 0.38 logarithm of the minimum angle of resolution (Snellen equivalent 20/39). Postoperative complications included rejection (29.5%), cataract formation (26.2%), and steroid-induced elevated intraocular pressure (15.4%). Peripheral thinning and ectasia diagnosed by slit lamp were noted in 59 eyes (39.6%), most of which were mild (54.2%), inferiorly located (66.1%), and involved the graft–host junction (81.4%). Most of the grafts that developed ectasia had a preoperative diagnosis of keratoconus (91.5%). Mean postoperative visual acuity of ectatic grafts with rigid gas permeable contact lens and/or glasses was 0.24 ± 0.25 logarithm of the minimum angle of resolution (Snellen equivalent 20/34).PK grafts can remain clear for 20 years or more and have excellent visual outcome. Most of the 20-year-old grafts in our study were in patients with keratoconus. Rejection and graft–host ectasia are problems to be encountered in long-surviving grafts. Ectatic grafts can still attain good vision with properly fitted contact lenses and glasses.