This prospective randomised comparative study compared a simultaneous approach of combined scleral-fixated intraocular lens (SF IOL) and Descemet-stripping automated endothelial keratoplasty (DSAEK) compared to intrascleral haptic fixation technique, followed by DSAEK in a sequential fashion with an interval of at least three months. Patients with pseudophakic or aphakic bull’s keratopathy were randomised into two groups with 20 patients in each. The mean uncorrected and corrected distance visual acuity (0.62 ±0.17 vs. 0.87 ±0.19 logMAR; p=.002) at six months was significantly better in the sequential group than those in the simultaneous group. The simultaneous group had significantly higher mean endothelial cell loss than that of the sequential group at six months (33.65% vs. 30.8%; p=.006). The sequential approach group had a lower rate of rebubbling for a graft detachment (12/20 [60%] vs. 5/20 [25%], p=.025), a lesser mean central corneal thickness and no graft failure during the study period. Eight (40%) of 20 cases in the simultaneous group had graft failure (p=.002). This study demonstrates the superiority of a two-staged approach to SF-IOL followed by DSAEK grafts as compared to simultaneous surgery.