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An increasing number of people are seeking elective cosmetic change of eye color. We review the surgical techniques, outcomes and complications arising from the various existing surgical alternatives, including cosmetic iris implants—which based on the available evidence should be considered malpractice—as well as laser iris depigmentation and cosmetic keratopigmentation. Laser iris depigmentation has been used clinically for aesthetic purposes without receiving official approval or licensing. The technique can be performed in an outpatient clinic thanks to the use of neodymium: yttrium–aluminum–garnet (Nd:YAG) lasers, but scientific literature data about this treatment is very limited. Cosmetic iris implants are neither CE-marked nor Food and Drug Administration (FDA)-approved, and lead to severe complications arising from their placement including uveitis, hyphema, glaucoma, cataract, corneal endothelial damage and severe vision loss. Management of complications resulting from iris implants might require several surgical procedures, and the follow-up is difficult among these poorly informed patients. Keratopigmentation is the most extensively studied technique and had long been investigated before being introduced into clinical practice: already introduced centuries ago, it was recently developed, reporting adequate levels of safety and efficacy. The medium- and long-term cosmetic outcomes of keratopigmentation and patient satisfaction have been the subject of recent reports. The available level of evidence suggests that cosmetic keratopigmentation is the best evidence-supported surgical choice for patients seeking a permanent cosmetic eye color change. Still, additional investigation is needed to optimize the outcomes, minimize postoperative complications and further develop this and other new surgical alternatives such as laser procedures. [ABSTRACT FROM AUTHOR]