Since the introduction of the triple procedure (simultaneous penetrating keratoplasty [PK], extracapsular cataract extraction [CE] and implantation of a posterior chamber intraocular lens [PCIOL]) in the mid-seventies, there is an ongoing discussion among corneal surgeons concerning the best approach for combined corneal disease and cataract.Besides the classical triple procedure (1), two alternative microsurgical approaches are feasible: (2) CE + PCIOL prior to PK and (3) CE + PCIOL after PK. For the refractive results after TRIPLE some intraoperative details are crucial: Trephination of recipient and donor from the epithelial side without major oversize (Guided Trephine System or Nonmechanical Excimer Laser Trephination) should preserve the preoperative corneal curvature. Graft and the PCIOL placed in the bag after continuous curvilinear capsulorhexis should be centered along the optical axis. If possible, performing the capsulorhexis under controlled intraocular pressure conditions prior to trephination may help to minimise the risk of capsular ruptures.The major advantage of the TRIPLE is the faster visual rehabilitation and less efforts for the mostly elderly patients. However, two intraocular interventions with approach (2) and (3) bear an increased risk of infection and suprachoroidal haemorrhage. Approach (2) requires a cornea that is still transparent enough to perform cataract surgery, and the risk of intraocular pressure rise after PK seems to be increased. Approach (3) has the potential of a simultaneous reduction of astigmatism during CE (appropriate location of the incision, simultaneous refractive keratotomies or implantation of a toric PCIOL). Disadvantages may include the loss of graft endothelial cells and the theoretically increased risk of immunological allograft reactions. After TRIPLE, major deviations from target refraction have been reported. However, individual multiple regression analysis may help to minimise this problem with appropriate methods of trephination. Since suture removal after PK may result in major individual changes of the corneal curvature, IOL power calculation for approach (3) requires all sutures to be removed at the time of CE. However, even after complete suture removal the abnormal proportions between anterior and posterior curvatures and/or the irregular topographies after PK may be responsible for marked IOL power miscalculations in the individual case.The postulated better refractive outcome and better uncorrected visual acuity after the sequential approach is opposed by a markedly delayed visual rehabilitation. For this reason, we consider the TRIPLE procedure including CE via open sky in general anesthesia as the method of choice for combined lens and corneal opacities. Because of the often rapidly progressive nuclear cataracts after PK, we recommend the simultaneous approach in elderly patients with Fuchs' dystrophy even with incipient lens opacities.