Background: To compare the clinical outcomes of wavefront-optimized (WFO) transepithelial photorefractive keratectomy (trans-PRK) and corneal wavefront-guided (CWFG) trans-PRK for myopic eyes with moderate to high astigmatism. Methods: One hundred ninety-six eyes (196 patients) with moderate to high astigmatism (≥ 1.75 D) treated with WFO or CWFG trans-PRK (101 and 95 eyes, respectively) were retrospectively registered. Safety, efficacy, predictability, vector analysis, and corneal aberrations were compared between groups preoperatively and at 6 months postoperatively. Results: At postoperative 6 months, the mean logMAR uncorrected distance visual acuity was similar in the WFO (- 0.07 ± 0.08) and CWFG (- 0.07 ± 0.07) groups. Safety, efficacy, and predictability of refractive and visual outcomes were also similar. The correction indices were 1.02 ± 0.14 and 1.03 ± 0.13 in the WFO and CWFG groups, respectively, with no significant difference. The absolute values of the angle of error were significantly higher in the WFO group (2.28 ± 2.44 vs. 1.40 ± 1.40; P = 0.002). Corneal total root mean square higher-order aberrations and corneal spherical aberrations increased postoperatively in both groups; however, the change was smaller in the CWFG group. Corneal coma showed a significant increase postoperatively only in the WFO group. Conclusions: WFO and CWFG trans-PRK are safe and effective for correcting moderate to high astigmatism. However, CWFG trans-PRK provides a more predictable astigmatism correction axis and fewer induced corneal aberrations.
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