PurposeThe aim of this study is to investigate changes in posterior corneal elevation and their correlations with the ablation ratio 3 years after small incision lenticule extraction (SMILE) for high myopia.MethodsEighty eyes underwent SMILE were enrolled in this study. Eyes were classified into two groups based on the ablation ratio (AR, lenticule thickness from SMILE machine/thinnest corneal thickness): group A (< 25%, 40 eyes) and group B (≥ 25%, 40 eyes). Pentacam was used to measure the posterior corneal elevation at the central point, thinnest point, and posterior maximum elevation (PME) and the mean posterior elevation in the central 2-mm area (MPE-2 mm), 4-mm area, and 6-mm area at the 3-year follow-up.ResultsMore than 85% of the eyes had an AR of less than 27%, and no cases of iatrogenic keratectasia developed. In both groups, for central region, posterior elevation decreased implying backward displacement; for peripheral region, it increased indicating forward trend. There was no significant difference in changes in all determined parameters between the two groups (P≥ 0.07). Moreover, no significant correlation was noted between AR and posterior elevation changes. In group A, decreasing changes in PME (r=  − 0.42,P= 0.01) and MPE-2 mm (r= 0.40,P= 0.01) demonstrated negative correlations with residual bed thickness.ConclusionRegion-dependent changes were demonstrated in the eyes that underwent SMILE. The central area showed a subtly declining posterior elevation, and the peripheral area showed a slightly increasing elevation. The limited ablation ratio had no impact on the changes in posterior corneal elevation.