PURPOSE: To identify the potential risk factors that increase the likelihood of requiring re-treatment following refractive surgery in patients with high astigmatism (3.00 diopters or greater). METHODS: This retrospective study included patients who underwent laser in situ keratomileusis (LASIK) or photorefractive keratectomy (PRK) between January 2005 and December 2019 at the Care-Vision Laser Centers, Tel-Aviv, Israel. Patients with high astigmatism (3.00 diopters or greater) were included and divided into two groups according to whether or not they underwent additional refractive surgery (re-treatment) during the study period. RESULTS: Overall, 2,024 eyes (2,024 patients) were included in the final analysis of this study. In total, 3.1% of the eyes (n = 63) underwent re-treatment. Throughout the study period, there was a significant reduction in the 2-year annual re-treatment rates, with a decline from 7.0% for primary surgeries performed in 2005 to 0.0% for primary surgeries performed in 2017 (r =-0.65, P = .015). The re-treatment group had significantly older preoperative age. They were also more likely to be male and have preoperative against-the-rule astigmatism and preoperative mixed astigmatism. Binary logistic regression analysis demonstrated that preoperative age, male gender, mixed astigmatism, and earlier year of surgery were all associated with higher re-treatment rates. CONCLUSIONS: The following factors are associated with higher rates of re-treatment in patients with high astigmatism: Older preoperative age, male gender, and mixed astigmatism. These factors may be incorporated into nomograms to reduce future re-treatment rates in this population.