Surgical Planning in Keratoconus

Surgical procedures play a fundamental role in the treatment of keratoconus; the final result in visual rehabilitation depends on their adequate indication and performance. Eye rubbing has proven to be a triggering factor for the disease, and warning the patient to stop eye rubbing is a nonsurgical measure that should always be present as a mainstay of treatment. However, in cases of progression despite suspension of eye rubbing, or in patients who are not adherent to changes in lifestyle, corneal collagen cross-linking has proven to be the only procedure that stops the progression of ectasia. The patient with keratoconus is a daily challenge in clinical practice because of high ametropia and anisometropia, which makes its correction difficult with conventional optical aids. Despite progress in contact lens technology, the use of contact lenses requires a learning curve and daily placement and removal routines that often lead the patient to request a “more definitive” visual improvement option. Surface ablation for higher order aberrations and refractive component, intracorneal ring segments (ICRSs), phakic intraocular lenses, and keratoplasty in advanced stages are the procedures that improve visual acuity and visual quality in keratoconus patients for which the most scientific evidence exists. This chapter will deal with the planning and the decision-making necessary when considering surgical treatment in keratoconus. After presenting the surgical solutions that are currently available, we will offer a recommended flowchart that can assist the reader further.