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PURPOSE To identify preoperative corneal tomographic features that predict progression to Endothelial Keratoplasty (EK) following cataract surgery in Fuchs Endothelial Corneal Dystrophy (FECD) and establish a regression model to identify high-risk patients. DESIGN Prospective, observational cohort study. Methods SETTING: Hospital Universitario Ramón y Cajal, Madrid STUDY POPULATION: Sixty-eight patients (84 eyes) with FECD who underwent phacoemulsification. Intervention We assessed preoperative best-corrected visual acuity; ultrasound central corneal thickness (CCT); pachymetric, anterior chamber depth and corneal backscatter variables using Scheimpflug imaging; and endothelial cell density. MAIN OUTCOME MEASURES Progression to EK. RESULTS A total of 39.3 % (33 eyes) needed EK after phacoemulsification to rehabilitate vision. On multivariate analysis, Anterior-Layer (AL) corneal backscatter between 0 and 2 mm from the apex and relative increase in central corneal thickness from the "Relative Pachymetry Display" by the Pentacam were significant predictors of the risk of progression to EK. Using these two variables, a risk score (RISC score) was derived from the regression model (area under the curve (AUC) = 0.973; best cutoff point with a specificity of 95% representing a sensitivity of 96%). Excluding corneal backscatter data from the multivariate regression model, corneal thickness at the pupil center by the Pentacam, and relative increase in central corneal thickness were significant predictors and provided a modified risk score (RIPT score) with similar performance. CONCLUSION Both scores demonstrated accuracy in predicting progression to EK using easily accessible preoperative data. This approach, which can be readily implemented by surgeons, allows for individualized risk assessment.