Keratoconus is a disease characterised by progressive thinning, bulging and distortion of the cornea. Corneal transplantation (keratoplasty), is the standard of care for severe disease, but is associated with risks such as rejection of the transplanted cornea. Collagen cross-linking (CXL) is a relatively new conservative approach to strengthen corneal tissue by reforming new covalent bonds. In an expert interview, Leopoldo Spadea of the University of Rome, Italy, discusses recent advances in keratoplasty and CXL.