An ectatic cornea presents unique challenges at the time of cataract surgery. Keratoconus is the most common corneal ectasia, affecting 2–54.5 per 100,000 people. Cataract surgery in keratoconus often yields suboptimal visual outcomes, with < 50% achieving within +/−0.5D of the desired refractive target in mild–moderate disease and worsening to 0%–18% in severe disease. Improving postsurgical visual outcomes requires a multifaceted approach, starting with modification of risk factors and patient education. Disease progression should be halted prior to any final surgical plan, often requiring the use of corneal crosslinking to create long-term stability in keratometry prior to cataract surgery. Inaccurate keratometry is a common and significant source of postoperative refractive error, and recent developments in keratoconus-specific intraocular lens (IOL) power calculations have attempted to address this. Despite the above strategies, correction of postsurgical refractive error may be done using corrective lenses or IOL-based techniques. Additionally, surgical strategies such as topography-guided photorefractive keratectomy, intrastromal ring segments, or corneal allogenic intrastromal ring segments can be performed pre- or postoperatively to enhance vision. This review seeks to provide an overview of the considerations and available strategies for cataract surgery in patients with keratoconus.