Purpose: To present the outcome of photorefractive keratectomy (PRK) using a new neodymium:YAG (Nd:YAG) laser in patients with irregular astigmatism.Setting: Claremont Eye Clinic, Claremont, and the University of Western Australia, Perth, Australia.Methods: In 3 patients with irregular astigmatism, PRK was performed with a solid-state, 213 nm wavelength, 300 Hz scanning-spot, diode-pumped Nd:YAG ablative laser (CustomVis(R) Pulzar(R) laser system). The 3 patients had had previous PRK with penetrating keratoplasty, astigmatic keratotomy, or limbal relaxing incisions. At 3 and 6 months, best spectacle-corrected visual acuity (BSCVA), uncorrected visual acuity (UCVA), manifest refraction, contrast sensitivity, and corneal topography were measured.Results: The first patient had a 1-line improvement in BSCVA and a 4-line improvement in UCVA, a 3.00 diopter (D) decrease in keratometric cylinder, and improvement in contrast sensitivity. The second patient had a 7.00 D decrease in myopia in 1 meridian and a 4.25 D decrease in the refractive cylinder in the other meridian. The third patient had a 2-line improvement in BSCVA, a 5-line improvement in UCVA, a 2.00 D decrease in the refractive cylinder, and improvement in contrast sensitivity.Conclusion: The laser's combination of a small spot, a fast pulse rate, and ultrafast tracking/scanning resulted in good results in 3 patients with difficult irregular astigmatism. (C) 2004 ASCRS and ESCRS.