Purpose <p>To evaluate the accuracy of Kane, Hill-RBF, and PEARL-DGS compared with traditional intraocular lens (IOL) formulas in highly myopic eyes undergoing cataract surgery.</p> Methods <p>A systematic review registered in PROSPERO (CRD420261372807) and conducted in accordance with PRISMA 2020 evaluated studies comparing Kane, Hill-RBF, and/or PEARL-DGS with conventional IOL formulas in highly myopic eyes. PubMed, Embase, and the Cochrane Library were searched from inception to April 8, 2026 using reconstructed database-specific strategies combining concepts for high myopia or long axial length, cataract surgery and IOL power calculation, and the formula names Kane, Hill-RBF, and PEARL-DGS. Two independent reviewers performed screening, data extraction, and adapted PROBAST-style risk-of-bias assessment, with disagreements resolved by a third reviewer. Eligible studies included original human clinical studies reporting postoperative refractive prediction outcomes in highly myopic eyes, preferentially defined as axial length (AL) &gt; = 26.0&#xa0;mm, or in separately extractable high-myopia subgroups. Random-effects quantitative synthesis was performed for the most comparable threshold endpoint when exact percentages and denominators were available. Primary outcomes included the proportion of eyes within +/-0.50 D of prediction error and mean absolute error (MAE), when reported using sufficiently comparable definitions. Secondary outcomes included MedAE, ME, SD of prediction error, RMSAE, and the proportions of eyes within +/-0.25 D and +/-1.00 D.</p> Results <p>The final included evidence set comprised 11 original comparative studies published online or in print from 2020 to 2026. Five studies were threshold-relevant in the narrative layer, 4 had numeric +/-0.50 D rows represented in the extraction seed, and 3 entered the pooled target-formula model. Across the included studies, Kane, Hill-RBF, and PEARL-DGS generally showed favorable refractive prediction performance in highly myopic eyes, but rankings varied by axial-length subgroup, formula version, biometry inputs, constant optimization, mean error zeroing, IOL design, and outcome family. Verified findings included a MedAE of 0.26 D for Kane in Cheng 2021, an MAE of 0.40 +/- 0.39 D with 71.44% within +/-0.50 D for Hill-RBF 2.0 in Chen 2021, and in Jiang 2025 a lowest overall MAE of 0.50 D for Hill-RBF 3.0 with the highest overall +/-0.50 D proportion of 69.57% for PEARL-DGS. For the exploratory cross-formula target benchmark, three independent studies contributed exact overall threshold rows, yielding a pooled proportion within +/-0.50 D of 70.90% (95% CI, 68.34% to 73.33%; I2 = 0.0%). A secondary Hill-RBF overall synthesis from two studies yielded 71.03% (95% CI, 68.35% to 73.58%; I2 = 0.0%). Because the main pooled model contains only 3 studies and combines architecture-distinct target formulas, I2 should be interpreted as a descriptive statistic with limited power rather than as evidence of biological or algorithmic homogeneity.</p> Conclusions <p>Current evidence supports Kane, Hill-RBF, and PEARL-DGS as reasonable front-line options for highly myopic eyes, and the threshold synthesis provides a cautious benchmark for currently extractable overall target-formula threshold performance. However, the evidence does not establish a single formula as uniformly best across all long-eye settings, nor does the 3-study pooled model constitute a formula ranking. Interpretation should remain anchored to threshold-based accuracy and to study-level differences in population definition, formula implementation, IOL design, and analytical handling.</p> Registration <p>This review was registered in PROSPERO under CRD420261372807.</p>