Purpose To evaluate the outcome of primary adult optical penetrating keratoplasty (PKP) performed with internationally acquired donor tissue. Patients and methods A retrospective review was performed of the medical records of every patient 12 years of age or older who underwent PKP for keratoconus, corneal edema, stromal scarring, or stromal dystrophy at King Khaled Eye Specialist Hospital in the Kingdom of Saudi Arabia between January 1, 1997 and December 31, 2001, and for whom a minimum of 3 months’ follow-up was available. Results Of 885 eyes that met the inclusion criteria, there were 453 eyes with keratoconus, 180 eyes with corneal edema, 171 eyes with stromal scarring, and 81 eyes with stromal dystrophy. For the entire group, the probability of graft survival was 96.9% at 1 year, 86.0% at 3 years, and 80.3% at 5 years. The 5-year probability of graft survival was 96.2% for keratoconus, 39.4% for corneal edema, 71.1% for stromal scarring, and 85.2% for stromal dystrophy. Increasing donor age was significantly associated with an increased risk of graft failure on multivariate Cox proportional hazard regression analysis (P = 0.005). Endothelial cell density, death-to-preservation time, and preservation-to-surgery time were not significantly associated with an increased risk of graft failure. Conclusions In our patient population, excellent graft survival was achieved utilizing internationally acquired donor tissue for eyes with keratoconus, stromal dystrophy, and stromal scarring, but not for those with corneal edema.