Comparison of the visual and optical outcomes after different corneal refractive surgeries for asymmetric corneal astigmatism.

PURPOSE: To compare visual and optical outcomes after selective corneal wavefront aberration-guided femtosecond laser-assisted in situ keratomileusis (CW-FS-LASIK), aspheric aberration-free femtosecond laser-assisted in situ keratomileusis (AF-FS-LASIK), and small-incision lenticule extraction (SMILE) in patients with asymmetric corneal astigmatism. METHODS: This retrospective comparative study included 269 patients (269 eyes) who underwent CW-FS-LASIK (67 eyes), AF-FS-LASIK (69 eyes), or SMILE (133 eyes) for myopia with asymmetric corneal astigmatism. Asymmetric corneal astigmatism was defined as an inferior-superior (I-S) dioptric difference of at least 1.00 D within the central 3 mm anterior corneal zone on the anterior sagittal curvature map. Visual and refractive outcomes, functional optical zone (FOZ), decentration, and corneal higher-order aberrations (HOAs) at analysis diameters of 4 and 6 mm were compared at 1 month postoperatively. RESULTS: Baseline characteristics were comparable among the three groups except for sex distribution. At 1 month, visual and refractive outcomes were comparable, and no significant difference in decentration was observed. FOZ was larger in the SMILE group than in the other groups (P < 0.001). At the 4 mm analysis diameter, postoperative total HOAs and total coma were lower in the CW-FS-LASIK group. At the 6 mm analysis diameter, induced total coma was lowest in the CW-FS-LASIK group, whereas induced spherical aberration was lowest in the SMILE group. CONCLUSIONS: All three procedures achieved similarly favorable early visual and refractive outcomes in eyes with asymmetric corneal astigmatism. CW-FS-LASIK showed lower corneal coma, but its clinical relevance remains uncertain and requires further validation with patient-reported outcomes.