Generally bilateral, most often asymmetrical, keratoconus is characterized by ongoing stromal thinning and anterior bulging of both corneal surfaces, with the apex of the cone-shaped change located paracentrally and inferiorly. The resulting conicoid geometry of the corneal surface gives rise to unstable, irregular myopic astigmatism and asymmetrical high order aberrations, which can be adequately corrected by spectacles and soft contact lenses only in early stages. In-mid advanced phases, quality of vision and quality of life improvements is usually considered as secondary aims, obtainable in the minority of cases, unless a corneal transplantation is performed, the last option to restore corneal architecture and improve eyesight. Purpose, methods and materials are discussed. Results are explained. Keratoconus is the most frequent reason for corneal transplantation surgery in the western world. Keratoconus appearance is sporadic in most situations, leaving no pharmacologic or genetic way to prevent its evolution to advanced stages. Evolution is unpredictable. Corneal collagen cross-linking with riboflavin may be associated to further enhance and stabilize the postoperative improvements of visual performances.