Purpose Comparison of visual acuity, refractive, and wavefront outcomes associated with optimized prolate ablation (OPA) and optical path difference custom aspheric treatment (OPDCAT) algorithms for correction of myopia exceeding 8 diopters (D). Patients and Methods Patients were randomly assigned to have photorefractive keratectomy (PRK) with OPA (n ¼ 32) or OPDCAT (n ¼ 21) algorithms. Visual acuity, manifest refraction, ocular and corneal higher-order aberrations, corneal asphericity, modulated-transfer function, and pointspread function were compared 1, 3, and 6 months postoperatively. Results Mean manifest-refraction spherical equivalents at 6 months were À 0.24 D in both groups. All patients in both groups had an uncorrected-distance visual acuity of 20/20 or better. Predictability ( ± 1 D from intended refraction) at 6 months was 94% in the OPA group, and in the OPDCAT group it was 86%. The OPA group had less induced corneal and ocular spherical aberrations (SAs) than the OPDCAT group. Postoperative corneal asphericity change was lowest in the OPA group. Both the groups exhibited significantlyimproved AreaRatio-Total value and insignificantly deteriorated AreaRatio-HO value throughout the postoperative period. The OPA group had significantly-higher AreaRatio-Total compared with OPDCAT group at both 1 and 6 months after the operation. Six months after surgery, the Strehl ratio had decreased in both groups, and there was no significant difference between the groups. Conclusion The OPA algorithms yielded higher-objective visual quality and predictability, induced less corneal and ocular SAs, and preserved more preoperativecorneal asphericity than the OPDCAT algorithms.