PURPOSE: To compare refractive outcomes, higher order aberrations (HOAs), and the changes in contrast sensitivity after wavefront-guided femtosecond laser-assisted in situ keratomileusis (WFG LASIK) and optimized small incision lenticule extraction (SMILE) for moderate-to-high astigmatism correction. METHODS: This prospective, randomized study included 87 eyes: 40 eyes in the WFG LASIK group and 47 eyes in the SMILE group. Manual cyclotorsion compensation by marking the horizontal axis before SMILE surgery was used for optimized SMILE. Refractive diopter, aberrations, and contrast sensitivity were assessed 3 months postoperatively. The Alpins vector analysis method was used to analyze the astigmatic changes after surgery. RESULTS: There were no significant differences in the corrected distance visual acuity and refraction between the two groups after surgery. The fitted curve of surgically induced astigmatism versus target induced astigmatism was described as y = 0.9905 x + 0.0009 in the WFG LASIK group and y = 0.9672 x + 0.0026 in the SMILE group. The percentage of corneal astigmatism axis change within 5 degrees was statistically significant (chi-square test: 10.632, = .001). HOAs increased in both the WFG LASIK and SMILE groups after surgery ( = -3.655, = .001, = -3.784, = .001, respectively). However, comparison of the changes of HOAs between both groups was not significant ( = -0.565, = .575). The improvement in contrast sensitivity in the WFG LASIK group was significantly higher than that in the SMILE group. CONCLUSIONS: WFG LASIK and optimized SMILE can achieve similar outcomes for astigmatism correction. Optimized SMILE with marking could achieve good astigmatism correction, even without an eye tracking system. .