PURPOSE To evaluate the efficacy of astigmatic keratotomy (AK) by paired linear (transverse)-long incisions within a small optical zone in older patients with 3.00 diopters (D) or more of astigmatism who are intolerant of contact lenses, spectacles, or both. DESIGN Prospective, noncomparative case series. PARTICIPANTS Twenty-one eyes (20 patients; age range, 58-87 years) treated at clinics of the Taipei Veterans General Hospital were included in this study. METHODS Paired linear incisions (90 degrees in length) with a central optical zone (OZ) of 4.5 mm were made to correct high astigmatism in older patients. The incisions were 80% of the corneal thickness and parallel to the axis of the steepest cylinder. MAIN OUTCOME MEASURES Refraction, keratometry, corneal topography, and visual acuity with and without correction were measured as the outcome indicators. RESULTS The mean course of the stabilization of corneal curvature was 1.8 months. Significant improvement from a preoperative corneal astigmatism of 4.52+/-1.39 D to a postoperative value of 1.82+/-0.88 D (P<0.0001) was shown. Marked axis deviations of more than 30 degrees were observed in 5 cases and corneal perforation was observed in 1 case. When the corneal curvature stabilized, uncorrected visual acuity was improved by 2 lines or more in 15 eyes (71.4%). Spherical equivalents and best-corrected visual acuity did not change significantly. Postoperative glare was absent in all patients. CONCLUSIONS We conclude that AK by linear-long incisions extending from a small OZ is effective and safe for correcting astigmatism.