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Introduction Late failure of penetrating keratoplasty (PK) due to combined stromal opacity and endothelial decompensation often requires either repeat PK or a staged lamellar approach. Repeat PK is associated with higher risks of rejection, suboptimal refractive outcomes, and open-sky complications. Simultaneous double lamellar keratoplasty (SDLK), combining deep anterior lamellar keratoplasty (DALK) with endothelial keratoplasty, offers a closed-globe, layer-selective alternative. This video demonstrates the surgical principles and clinical outcome of SDLK in a representative case.Methods A 54-year-old man with bilateral PK performed over 20 years previously for macular dystrophy presented with recurrent stromal disease and endothelial decompensation in the left eye, with visual acuity reduced to 0.76 logMAR. SDLK was performed using a 9.0 mm DALK-on-PK via stromal peeling to expose and retain the pre-Descemet layer (PDL), followed by insertion of an 8.5 mm DSAEK lenticule without descemetorhexis.Results Postoperatively, partial DSAEK detachment occurred and was successfully managed with rebubbling, achieving full attachment. Final best spectacle-corrected visual acuity was 0.30 logMAR following suture removal, with keratometric astigmatism of 0.69 D and refractive astigmatism of 0.75 D. No episodes of graft rejection or other significant complications were observed.Discussion This case demonstrates that SDLK can restore corneal clarity and functional vision in post-PK eyes with combined stromal and endothelial pathology while avoiding repeat open-sky surgery. Excellent visual and astigmatic outcomes reflect the refractive advantages of wide-diameter anterior lamellar replacement. By preserving globe integrity and enabling selective double lamellar replacement, SDLK represents a viable alternative to repeat penetrating keratoplasty in carefully selected patients.