Objective: To compare the clinical effects of 2 types of topography-guided customized excimer laser  ablations (Contoura Vision-LASEK and Contoura Vision-FS-LASIK) and small incision lenticule extraction (SMILE) for myopic patients with asymmetric corneal astigmatism. Methods: In this  prospective cohort study, a total of 105 patients (105 eyes) underwent one of the 3 types of procedures:  Contoura Vision-LASEK (CV-LASEK), Contoura Vision-FS-LASIK (CV-FS-LASIK) or SMILE. All  patients with | C7 | >0.2 μm or | C8 | >0.2 μm at a 6-mm pupil diameter were examined preoperatively and  postoperatively (1 day, 1 week and 1, 3 and 6 months). Exams included uncorrected visual acuity (UCVA,  logMAR), refractive status, Pentacam HR, intraocular pressure (IOP) and slit lamp microscopy. One eye  of each participant was randomly selected (right or left) then randomly grouped. Subjective refraction was  measured at 6 months after the procedures. MANOVA was used to evaluate the changes and differences in  UCVA, IOP and corneal higher order aberrations (HOAs) in the 3 groups before and after the procedures.  An MA mixed linear model was used to analyze the possible influencing factors of corneal HOAs at the  postoperative time points for the 3 groups. Results: In the CV-LASEK group, one eye lost 1 line and one  eye lost 2 lines at 6 months postoperatively. No eyes in the other 2 groups lost UCVA (P=0.174). There  were significant differences among the groups at every follow-up for IOP, coma and spherical aberration on  the corneal surface (all P<0.05). In addition, fluctuation in IOP was significantly correlated with changes  in HOAs for the 3 groups postoperatively (both P=0.001), but baseline central corneal thickness (CCT)  had a significant effect on spherical aberration (C12) (P=0.003). Conclusion: The three types of refractive  procedures are safe and effective for myopic patients with asymmetric corneal astigmatism. However, there  should be more emphasis on postoperative IOP control for better visual quality.