Purpose: To assess the accuracy of intraocular lens (IOL) power formulas modified specifically for patients with keratoconus (Holladay 2 with keratoconus adjustment and Kane keratoconus formula) compared with normal IOL power formulas (Barrett Universal 2, Haigis, Hoffer Q, Holladay 1, Holladay 2, Kane, and SRK/T). Design: Retrospective consecutive case series. Participants: A total of 147 eyes of 147 patients with keratoconus. Methods: Data from patients with keratoconus who had preoperative IOLMaster biometry were included. A single eye per qualifying patient was randomly selected. The predicted refraction was calculated for each of the formulas and compared with the actual refractive outcome to give the prediction error. Subgroup analysis based on the steepest corneal power measured by biometry (stage 1: 48 diopters [D], stage 2: >48 D and 53 D, and stage 3: >53 D) was performed. Main Outcome Measure: Prediction error. Results: On the basis of the mean absolute prediction error (MAE), the formulas were ranked as follows: Kane keratoconus formula (0.81 D), SRK/T (1.00 D), Barrett Universal 2 (1.03 D), unmodified Kane (1.05 D), Holladay 1 (1.18 D), unmodified Holladay 2 (1.19 D), Haigis (1.22 D), Hoffer Q (1.30 D), and Holladay 2 with keratoconus adjustment (1.32 D). The Kane keratoconus formula had a statistically significant lower MAE compared with all formulas (P < 0.01). In stage 3 keratoconus, all nonmodified formulas had a hyperopic mean prediction error ranging from 1.72 to 3.02 D. Conclusions: The Kane keratoconus formula was the most accurate formula in this series. The SRK/T was the most accurate of the traditional IOL formulas. All normal IOL formulas resulted in hyperopic refractive outcomes that worsened as the corneal power increased. Suggestions for target refractive aims in each stage of keratoconus are given. Ophthalmology 2020;127:1037-1042 ª 2020 by the American Academy of Ophthalmology Keratoconus is a progressive disorder characterized by central or paracentral corneal thinning and ectasia. Intraocular lens (IOL) power calculation in these eyes represents a significant challenge. Kamiya et al 1 reported on 71 patients with keratoconus comparing the Haigis, Hoffer Q, Holladay 1, Holladay 2, and SRK/T formulas and found that that the SRK/T formula was the most accurate with 36% of eyes within 0.50 diopters (D) of the final manifest refraction. Savini et al 2 also found that the SRK/T was the most accurate formula in 41 patients (compared with Barrett Universal 2, Haigis, Hoffer Q, and Holladay 1), with 43.9% of eyes within 0.50 D. Both studies found that all formulas resulted in a hyperopic refractive surprise that worsened with more advanced stages of the disease. Suggestions regarding an appropriate myopic refractive target to avoid unwanted postoperative hyperopic error have been proposed. 3 These refractive results in keratoconus studies are significantly worse than the 75% to 80% of eyes within 0.50 D usually seen in nonkeratoconic eyes, 4 for which there are many reasons. First, the calc...