To evaluate intraocular lens (IOL) tilt and decentration and their effects on high-order aberrations (HOAs) after cataract surgery with and without primary posterior continuous curvilinear capsulorrhexis (PPCCC). Fujian Provincial Hospital, Fujian, China. Prospective, intraindividual, randomized, comparative clinical trial. This study enrolled 64 eyes of 32 patients with age-related cataract who underwent bilateral cataract surgery and IOL implantation. In randomized order, all patients had phacoemulsification cataract surgery with PPCCC in one eye (PPCCC group) and routine cataract surgery in the contralateral eye (NPCCC group). IOL decentration, tilt, HOAs, modulation transfer function, and point spread function were measured at 1 day, 1 week, 1 month, and 3 months after surgery using OPD-Scan III. 52 eyes of 26 patients were available for analysis. The mean overall decentration in NPCCC group was significantly higher than in PPCCC group at 3 months (0.302±0.157 mm vs 0.187±0.099 mm, P<0.001). Under 3-mm pupil, internal spherical aberration (SA) 1 day after surgery, and coma 1 week after surgery were lower in PPCCC group compared with NPCCC group (0.15±0.10 μm vs 0.30±0.21 μm, P<0.001, and 0.34±0.18 μm vs 0.47±0.31 μm, P=0.03, respectively). IOL decentration was significantly correlated with ocular and internal coma, ocular and internal SA, and internal HOAs at 5-mm pupil (R=0.083 and R=0.099, R=0.650 and R=0.613, R=0.418, respectively, all P<0.01). Less IOL decentration was observed in PPCCC group at 3 months after surgery, indicating that PPCCC may result in better IOL centrality.