Purpose: To compare the parameters of capsulorrhexis and intraocular lens decentration after femtosecond laser capsulotomy and manual continuous curvilinear capsulorrhexis in high myopic patients with cataracts.Methods: This is a prospective consecutive non-randomized comparative cohort study. Selected patients with axial length > 26.0 mm were divided into femtosecond laser capsulotomy (FS) group and manual continuous curvilinear capsulorrhexis (CCC) group. Five experienced phacoemulsification surgeons conducted all surgeries. Intraoperative complications and post-operative anterior segment photography were recorded. Intraocular lens decentration, area of capsulorrhexis, circularity, and capsule overlap were measured at 1 week, 1 month, and 2 years after surgery. Between group differences of parameters were determined with independent-sample t-test or the Mann–Whitney U-test, analysis of variance test, Pearson chi-square test, and Spearman rank correlation test.Results: The study included 142 eyes (108 patients), 68 eyes in the FS group, and 74 eyes in the CCC group. At 1 week, 1 month, and 2 years after surgery, the area of capsulorrhexis in the CCC group was significantly larger than in the FS group (P < 0.05), while no significant difference was noted in circularity values. The complete overlap ratio in the FS group was significantly higher than that in the CCC group (P < 0.05) at each measured timepoint. Significant correlations were noted between the anterior chamber depth and the area of capsulorrhexis in the CCC group (R = 0.25, P = 0.04), but did not correlate in the FS group (P > 0.05). In patients with an anterior chamber depth >3 mm, the capsule-intraocular lens (IOL) overlap of the CCC group was less than that of the FS group at all measured timepoints after surgery (P < 0.05). Meanwhile, the IOL decentration in the CCC group was significantly greater than that of the FS group in those patients at 2 years after surgery (P < 0.05).Conclusion: In high myopic patients with cataracts, with anterior chamber depth more than 3 mm, femtosecond laser capsulotomy can achieve better capsulorrhexis sizing and centering. Due to more precise capsulotomy and a better capsule-IOL overlap in the FS group, femtosecond laser capsulotomy resulted in better long-term centration of the IOL.