OBJECTIVE To compare the rejection rates, graft failure rates, mean visual, keratometric and refractive outcomes of combined penetrating keratoplasty and cataract extraction with penetrating keratoplasty alone. METHODS A retrospective study of all patients who had combined keratoplasty and cataract extraction/intraocular lens insertion (49 eyes; mean age 65.3 years; mean follow up 17 months) compared with all patients who had keratoplasty only (58 eyes; mean age 64.0 years; mean follow up 14 months). RESULTS One hundred and seven eyes in 99 patients had keratoplasty in the period and were included in the study. The most common indication for keratoplasty in patients who had triple procedures was Fuchs' endothelial dystrophy (24.5%). During the study seven (6.5%) grafts failed and four (3.7%) had allogenic rejection without failure during this period. There was no statistical difference between the graft survival rates of the two study groups. The mean postoperative logMAR visual acuity (VA) was 0.42 and postoperative VA of 6/12 or better was seen in 71% of patients. Mean postoperative corneal curvature was 44.6 dioptres (D), mean corneal astigmatism was -4.0 D and was >or=5 D in 38%. Mean double-angle Cartesian coordinates for corneal astigmatism were x-0.87 D and y-0.29 D. Mean best sphere of postoperative refractions was -0.61 D and mean absolute refractive error was 2.2 D. There was no statistically significant difference in VA, keratometric or refractive outcome measures between the two study groups. CONCLUSIONS Over a short follow up, keratoplasty combined with cataract extraction/intraocular lens insertion showed a similar risk of graft failure or allogenic graft rejection when compared with keratoplasty alone and we recommend the triple procedure for quicker visual recovery and less operative procedures.