To investigate indications and surgical procedures of keratoplasty in a tertiary comprehensive hospital in northern part of China over a 20-year period.All patients undergoing keratoplasty between January 1, 2002 to December 31, 2021 in a tertiary comprehensive hospital in northern part of China were retrospectively reviewed. The annual proportion of keratoplasty indications and surgical procedures was recorded and analyzed.A total of 8266 keratoplasty procedures were included. Leading indications were keratoleukoma (n = 2108, 25.50%), followed by regraft (n = 1453 ,17.58%), corneal endothelial dysfunction (n = 1085, 13.13%), and keratoconus (n = 922,11.15%). A decreasing trend was observed for keratoleukoma (P < 0.01) and an increasing trend for corneal endothelial dysfunction (P < 0.01), regraft (P = 0.012), corneal limbal dermoids (P < 0.01) and congenital corneal opacity (P < 0.01). From 2002 to 2021, the proportion of penetrating keratoplasty (PK) had decreased from 73.95% (2002 to 2006) to 53.49% (2017 to 2021). On contrary, anterior lamellar keratoplasty (ALK) (459-705, 26.05-31.96%, P = 0.034) and endothelial keratoplasty (EK) (0-321, 0.00-14.55%, P < 0.01) became more prevalent from 2002 to 2021. For cases with corneal endothelial dysfunction, EK became the preferred technique (74.72%) in the recent 5 years.Over the past 20 years, keratoleukoma and regraft have been the leading indications for keratoplasty. A noticeable shift in surgical preference from PK to DSAEK and ALK is evident, with key indications for keratoplasty including keratoleukoma, regraft, limbal dermoids, endothelial dysfunction, and keratoconus, respectively.© 2024. The Author(s).