Aim: This article reports the case of a patient with severe symptoms related to bad quality of vision after toric multifocal intraocular lens (IOL) that was diagnosed with mild keratoconus. Materials and methods: To present a case report and prospectively review of the literature, considering the relevance of screening ectaticconreal disease prior to refractive cataract (or lens) surgery. Results: The patient was dissatisfied, seeking a second opinion after the implantation of a toric multifocal IOL in the left eye. The IOL was properly centered and surgery had no complications. The preoperative refraction was −4.00 − 1.50 × 160, giving 20/40. Patient denied any history of keratoconus or transplant in his family. After cataract surgery, uncorrected distance vision acuity (UDVA) was 20/60, and J4 for near. Manifest refraction was + 2.00 − 0.50 × 130, giving 20/30. Corneal topography, tomography, and biomechanical assessments indicated the diagnosis of mild keratoconus. The patient was advised for IOL exchange, which was successfully done for a monofocal aspheric IOL. The patient was satisfied with the final result, presenting a final UDVA of 20/25, J3, and manifest refraction of +0.75 − 0.50 × 105, giving 20/20. Conclusion: Screening for corneal abnormalities including ectatic corneal disease is fundamental prior to the indication of a premium lens. Advanced corneal imaging plays a fundamental role to help select candidates for multifocal IOLs, as for individualized planning of refractive cataract surgery.