Refractive surgery for keratoconus

Traditionally, keratoconus has been managed with glasses when mild, contact lenses when moderate and keratoplasty when severe. When cornea-based refractive surgery was first developed it appeared to be a useful option for keratoconus until reports of post-operative progressive ectasia emerged and thus keratoconus was considered a contraindication to refractive surgery. However, improvements in older techniques and the development of new techniques mean that there are now several viable options to avoid keratoplasty in contact lens-intolerant patients. This review discusses the risks and benefits of excimer laser refractive procedures, both with and without corneal collagen cross linking, as well as intra-corneal ring segments, phakic intraocular lenses and refractive lens exchange with toric intraocular lens implantation.