PURPOSE: To compare the difference and agreement of corneal higher-order aberrations (HOAs) in keratoconic eyes using Scheimpflug and dual Scheimpflug-Placido imaging systems. SETTING: Emory University, Atlanta, Georgia, and the University of Southern California, Los Angeles, California, USA. DESIGN: Retrospective between-devices reliability and agreement study. METHODS: Patients diagnosed with keratoconus were evaluated sequentially by Scheimpflug and dual Scheimpflug-Placido devices. Differences, correlations, and agreement between values for total root mean square (RMS), trefoil, coma, and spherical aberration were analyzed, and Bland-Altman plots were generated. RESULTS: Fifty eyes from 50 patients (31 men, 19 women) were evaluated. Trefoil at 30 degrees, spherical aberration, and total RMS were significantly different between groups (P < .05), whereas trefoil at 0 degrees and total coma values were not statistically different. There was a weak positive correlation between devices for trefoil at 0 degrees (r = 0.228), and a moderate positive correlation for trefoil at 30 degrees (r = 0.473), horizontal coma (r = 0.430), and for total corneal RMS (r = 0.637). Vertical coma (r = 0.816) and spherical aberration (r = 0.874) showed a strong positive correlation. The 95% limits of agreement (LoA) for absolute values were 1.963 µm for trefoil at 30 degrees, 2.449 µm for trefoil at 0 degrees, 3.530 µm for horizontal coma, 2.145 µm for vertical coma, 1.242 µm for spherical aberration, and 10.527 µm for RMS. CONCLUSION: Significant differences were found between measurements of corneal HOAs generated by Scheimpflug and dual Scheimpflug-Placido devices in patients with keratoconus, with generally limited correlations and wide LoA. HOAs measurements from these devices should not be considered equivalent.