Agreement of Wavefront-Based Refraction with Autorefraction and Manifest Refraction Across Refractive and Astigmatic Profiles in Refractive Surgery Candidates

Background: To assess the agreement between wavefront-based refraction (WFR) using a pyramidal aberrometer (PERAMIS) and conventional non-cycloplegic (NCR), cycloplegic (CR), and manifest refraction (MR) techniques across refractive types and astigmatic axes Methods: This cross-sectional study evaluated 111 right eyes of refractive surgery candidates. WFR from PERAMIS was compared with NCR, CR, and MR for sphere, cylinder, spherical equivalent (M), blur (B), and astigmatic vectors (J0, J45). Agreement was assessed using ICC, R², Bland-Altman analysis, and paired t-tests (Mean difference: MD). Subgroup analyses examined myopic vs. hyperopic eyes, ametropia severity, and astigmatic axis. Results: WFR demonstrated excellent agreement with NCR (ICC = 0.98), CR (ICC = 0.96), and MR (ICC = 0.97) for M. Agreement remained high for other refractive components (ICC > 0.90) except J45, where moderate agreement was observed (ICC: 0.75–0.82). A consistent refractive trend: CR < MR <NCR < WFR was observed for M, even within the subgroups. WFR consistently yielded more myopic measurements than CR, MR, and NCR (M-MD: −0.56D (p < 0.001), −0.39D (p < 0.001), and -0.1D (P<0.05), respectively). Agreement was superior in myopic eyes (ICC values >0.90 except for J45; MDs almost <0.50D) compared to hyperopic eyes (ICC values ranging from 0.71 (WFR-MR cylinder) to 0.93 (WFR-NCR sphere, MDs < 0.75D). WFR showed greater myopic shifts with increasing ametropia severity, both in myopes (M-MDs reaching −0.99D for WFR-CR in severe myopia) and hyperopes (M-MDs up to −0.90D for WFR-CR in moderate hyperopia). Furthermore, WFR showed an excellent agreement with NCR, CR, and MR across astigmatism types (ICC-M: 0.93-0.99, M-MDs < 0.75D), although levels of agreement were narrower in with-the-rule than against-the-rule and oblique astigmatism groups. Conclusion: Pyramidal WFR yields highly consistent results and may be a valuable alternative to conventional autorefraction in myopic patients. However, its tendency toward myopic bias, particularly in hyperopia, limits its interchangeability with CR or MR. Clinicians should interpret WFR cautiously in hyperopic eyes and consider confirming measurements with subjective methods. These findings support the utility of WFR as an efficient initial estimate in refractive evaluations, especially for surgical screening, but not as a standalone replacement for traditional refraction.