Mohamed Nagy Elmohamady, Walid Abdelghaffar, Ahmed Daifalla, Tamer Salem Ophthalmology Department, Benha University, Banha, Egypt Purpose: To evaluate femtosecond laser in flap and cap creation, detect some corneal biomechanical changes, and evaluate dry eye after laser in situ keratomileusis (LASIK), FemtoLASIK, and small incision lenticule extraction (SMILE) with 3-year follow-up. Patients and methods: Preoperative evaluation taken: full ophthalmic examination, Pentacam, ocular response analyzer, ocular surface disease index (OSDI), and tear breakup time (TBUT). LASIK flap was created using Moria microkeratome in 30 eyes (LASIK group) and using VisuMax femtosecond laser in 38 eyes (FS-LASIK group) and SMILE was done by VisuMax in 35 eyes (SMILE group). Postoperative evaluation: anterior segment optical coherence tomography to measure flap and cap thickness, ocular response analyzer to measure corneal hysteresis (CH) and corneal resistance factor (CRF), OSDI, and TBUT at 1, 3, 6, 12, 24, and 36 months after surgery. Results: This study included 103 eyes of 103 patients. The mean deviation of central cap or flap thickness from intended was statistically higher in the LASIK group (P<0.001). Both CH and CRF showed significant reduction postoperatively but were significantly higher in the SMILE group during follow up (P<0.05). The mean OSDI scores were significantly elevated in all groups postoperatively (P<0.01) but were significantly lower in the SMILE group 3 months postoperatively (P<0.05). The mean TBUT was significantly decreased in all groups postoperatively (P<0.01) but was significantly higher in the SMILE group 6 months postoperatively (P<0.05). Conclusion: Femtosecond laser is more accurate than microkeratomes. CH and CRF changes were least after SMILE. The three procedures led to significant dryness but for shorter duration with SMILE. Keywords: LASIK, femtosecond laser, SMILE, dry eye, corneal biomechanics, myopia