Purpose: To compare vision-related quality of life (QoL) between surgical and nonsurgical interventions in Iraqi patients with unilateral keratoconus (KC) and to identify independent clinical predictors of QoL outcomes. Methods: This multicenter cross-sectional study enrolled 490 patients with unilateral KC. Participants were stratified into surgical (n = 240; intracorneal ring segments [ICRS], deep anterior lamellar keratoplasty [DALK], or penetrating keratoplasty [PKP]) and nonsurgical (n = 250; corneal collagen crosslinking [CXL], rigid gas-permeable, or scleral lenses) groups. Clinical assessments included best-corrected visual acuity (BCVA), maximum keratometry (Kmax), spherical equivalent, and disease stage. QoL was measured using the validated 25-item National Eye Institute Visual Function Questionnaire (NEI-VFQ-25). Subgroup analyses, pairwise comparisons, and multivariate regression were conducted to identify determinants of QoL. Results: Surgical patients demonstrated significantly higher NEI-VFQ-25 composite and subscale scores than nonsurgical patients (p < 0.001), with marked improvements in general vision, mental health, and daily activities. Subgroup analyses confirmed that ICRS provided superior outcomes in mild-to-moderate KC compared to CXL and contact lenses, while DALK and PKP yielded comparable benefits in advanced disease. Stratified analyses revealed sex-based and age-related differences, with females and older patients reporting better QoL. Multivariate regression analysis identified surgical treatment, BCVA ≤0.3 logMAR, patient satisfaction with surgery, and mild KC as independent positive predictors of QoL, whereas advanced stage, male sex, higher Kmax, and increasing age were identified as negative predictors. A treatment–age interaction indicated that younger patients benefited more from timely surgery. Conclusions Surgical interventions, particularly ICRS and PKP, are associated with superior QoL compared with nonsurgical options in Iraqi patients with KC. These findings underscore the importance of incorporating patient-reported outcomes into clinical decision-making and support individualized, stage-based surgical referral, especially in resource-limited settings.