Purpose: To report alterations in the anterior segment following accelerated corneal collagen cross-linking and topo-guided customized ablation treatment with the Nidek vision excimer laser system (Nidek Co., Ltd., Gamagori, Japan) in a single procedure. Methods: We reviewed the medical records of patients who underwent cross-linking for progressive keratoconus. We divided patients into four groups based on the treatment protocol. Eyes were evaluated regarding uncorrected distance visual acuity, corrected distance visual acuity, keratometry (maximum [K-max], equivalent keratometry readings, K-steep, and K-flat parameters), corneal elevations (anterior and posterior), the anterior radius of curvature, the posterior radius of curvature, anterior chamber volume, anterior chamber depth, anterior chamber angle and the pachymeter of the thinnest locale of the cornea before the surgery and at 1, 3, 6, and 12 months after the procedure. Results: We included 259 eyes of 227 patients with progressive keratoconus who underwent treatment. The mean respective baseline uncorrected distance visual acuity and corrected distance visual acuity were: 0.68 +/- 0.45 and 0.34 +/- 0.40 in Group 1; 0.82 +/- 0.44 and 0.33 +/- 0.23 in Group 2; 0.61 +/- 0.36 and 0.21 +/- 0.17 in Group 3; and 0.65 +/- 0.38 and 0.23 +/- 0.18 in Group 4; logMAR did not show significant difference among the groups (p =0.14 and p=0.06, respectively). Visual improvements were better in the combined surgery groups. Mean K-max in Groups 1, 2, 3, and 4 were 57.24 +/- 7.51, 59.26 +/- 6.94, 53.73 +/- 4.60, and 54.31 +/- 4.25 diopter (D), respectively. Group 1 demonstrated increased K-max for 6 months. Maximum flattening by 3.38 +/- 2.35 D 1 year after surgery was observed in Group 4 (p <0.05). Decreased anterior chamber angle, anterior chamber depth, and anterior chamber volume were similar, indicating the stability of the anterior chamber. Conclusion: Visual and anatomical improvement is better, with improved stability of the anterior segment, in combined surgery groups compared with cross-linking alone.