Sang Beom Han

doi:10.63375/icrs.25.015

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Case Report
Large incisional tear caused by abrupt Bell’s phenomenon during pocket irrigation in femtosecond laser-assisted small incision lenticule extraction: Sang Beom Han; Insights in Cataract and Refractive Surgery 2026;11(1):23-25.
DOI: https://doi.org/10.63375/icrs.25.015
Published online: February 26, 2026

Saevit Eye Hospital, Goyang, Korea

Correspondence to: Sang Beom Han Saevit Eye Hospital, 1065 Jungang-ro, Ilsandong-gu, Goyang 10447, Korea Tel: +82-31-900-7700 E-mail: msbhan@saeviteye.com

• Received: December 22, 2025 • Revised: January 4, 2026 • Accepted: January 5, 2026

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (https://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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Abstract
Introduction
Case Report
Discussion
Article Information
References

Abstract

Purpose
This study reports a case of a large incisional tear caused by abrupt Bell’s phenomenon during pocket irrigation in femtosecond laser-assisted small incision lenticule extraction (SMILE).
Case summary
A 28-year-old male patient underwent SMILE surgery. During pocket irrigation of the right eye, Bell’s phenomenon suddenly occurred, resulting in a large inferior arcuate extension of the incision that reached the inferior cap margin. After confirming wound integrity and the absence of additional tissue damage, a bandage contact lens was applied. On postoperative day 7, the incision was self-sealed with intact wound integrity. Three months postoperatively, uncorrected distance visual acuity was 20/20 in both eyes. The right cornea remained stable, although a faint residual scar was observed at the site of the incisional tear.
Conclusion
Abrupt eye movements during pocket irrigation in SMILE can cause large incisional tears. Surgeons should exercise heightened vigilance during irrigation, particularly in anxious or uncooperative patients, to prevent such complications.
Keywords: Bell’s phenomenon; Incisional tear; Pocket irrigation; Small incision lenticule extraction; Case reports

Introduction

Femtosecond laser-assisted small incision lenticule extraction (SMILE) is a minimally invasive refractive surgery that involves extraction of refractive lenticule created using a femtosecond laser through a 2 to 3 mm corneal incision [1]. Therefore, this procedure eliminates flap‑related complications such as irregular or incomplete flaps, free caps, and flap dislocation [1,2]. However, SMILE can still be associated with complications, including suction loss, cap perforation, incisional tears, and epithelial ingrowth, although these complications are relatively rare and usually resolve without visual sequelae [1-3]. We herein present a case of a large incisional tear secondary to Bell’s phenomenon during pocket irrigation in SMILE. The patient’s consent form for publication was obtained.

Case Report

A 28-year-old Asian male patient underwent SMILE surgery using a femtosecond laser platform (VisuMax, Carl Zeiss Meditec AG). In the right eye, lenticule creation, formation of the 3-mm corneal incision, and lenticule extraction were uneventful. Pocket irrigation was then initiated using a 27-gauge blunt cannula. During irrigation, a sudden upward eye movement occurred due to Bell’s phenomenon (Fig. 1A). This abrupt movement caused the cannula to exert mechanical traction on the incision and cap, resulting in an inferior arcuate extension of approximately 6 mm, nearly reaching the inferior cap margin (Fig. 1B). Irrigation was immediately discontinued, and gentle pressure was applied on the cap using a sponge to stabilize the wound. After confirming wound integrity and the absence of additional tissue damage, a bandage contact lens was placed. The procedure in the left eye was completed uneventfully. Postoperatively, the patient was instructed to instill topical levofloxacin 1.5% (Santen) and fluorometholone 0.1% (Samil Pharmaceutical) four times daily.

On postoperative day 7, uncorrected distance visual acuity (UDVA) was 20/20, and the patient reported no symptoms. Slit lamp examination revealed a self-sealed incision with intact wound integrity (Fig. 2A), and the bandage contact lens was removed. At 3 months postoperatively, UDVA remained 20/20. Although a faint residual scar at the site of the incisional tear was still visible, the cornea was otherwise clear (Fig. 2B). Corneal topography (Oculyzer II, WaveLight AG) showed no abnormal findings (Fig. 2C).

Discussion

To the best of our knowledge, this is the first report of a case in South Korea of a large incisional tear associated with Bell’s phenomenon during pocket irrigation in SMILE. The incidence of small incisional tears has been reported to range from 1.8% to 11.0%, with rates decreasing as the surgeon’s learning curve improves [1,3-5]. An increased risk is associated with smaller incision size, excessive or forceful manipulation during lenticule dissection, and abrupt eye movements while instruments are within the corneal pocket [1,3]. Although most cases involve only small tears and large extensions are rare [1,3-5], Ivarsen et al. [3] reported that long radial tear from the incision occurred in one eye out of 1,800 SMILE cases, caused by pronounced ocular movement. The tear healed with the application of a therapeutic contact lens, and, similar to our case, no significant visual impairment occurred despite the presence of a residual scar [3]. During pocket irrigation, both hands are typically engaged and ocular fixation cannot be maintained, making it difficult to prevent abrupt Bell’s phenomenon. Consequently, this step of the procedure is performed under relatively vulnerable conditions, increasing the risk of large incisional tears, as demonstrated in our case. Therefore, in uncooperative or anxious patients, holding the conjunctiva with one hand to stabilize the eye while performing irrigation with the other hand may help prevent these complications.

Although most small tears resolve without visual sequelae [1-5], large incisional tears can lead to complications such as epithelial ingrowth, wound instability, induced astigmatism, and visual disturbance [3]. Therefore, application of bandage contact lens is recommended to promote wound stability and prevent complications [2,3].

In conclusion, large incisional tears caused by Bell’s phenomenon can occur during pocket irrigation in SMILE. Surgeons should exercise particular caution and closely monitor for abrupt eye movements, particularly in anxious or uncooperative patients.

Article Information

Author contributions

All the work was done by SBH.

Conflicts of interest

No potential conflict of interest relevant to this article was reported.

Funding

This paper was supported by the Basic Science Research Program through the National Research Foundation of Korea (NRF) funded by the Ministry of Education (Grant No. NRF-2021R1F1A1048448).

Data availability

Not applicable.

Fig. 1.

Still images from the intraoperative videos. (A) During pocket irrigation, a sudden upward ocular movement occurred due to Bell’s phenomenon in the right eye. (B) Following the abrupt movement, a large inferior arcuate extension of the incision (arrows) was observed.

Fig. 2.

Postoperative anterior segment photographs (A, B) and postoperative corneal topography (C). (A) An anterior segment photograph obtained on postoperative day 7 showed a self-sealed incision with intact wound integrity (arrowheads). (B) At 3 months postoperatively, a faint scar at the incisional tear site remained visible (arrowheads). (C) Postoperative corneal topography demonstrated no abnormal findings in the right eye (OD).

References

1. Hamed AM, Heikal MA, Soliman TT, et al. Smile intraoperative complications: incidence and management. Int J Ophthalmol 2019;12:280‒3. Article PubMed PMC
2. Asif MI, Bafna RK, Mehta JS, et al. Complications of small incision lenticule extraction. Indian J Ophthalmol 2020;68:2711‒22. Article PubMed PMC
3. Ivarsen A, Asp S, Hjortdal J. Safety and complications of more than 1500 small-incision lenticule extraction procedures. Ophthalmology 2014;121:822‒8. Article PubMed
4. Titiyal JS, Kaur M, Rathi A, et al. Learning curve of small incision lenticule extraction: challenges and complications. Cornea 2017;36:1377‒82. Article PubMed
5. Hamed AM, Abdelwahab SM, Soliman TT. Intraoperative complications of refractive small incision lenticule extraction in the early learning curve. Clin Ophthalmol 2018;12:665‒8. Article PubMed PMC PDF

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Large incisional tear caused by abrupt Bell’s phenomenon during pocket irrigation in femtosecond laser-assisted small incision lenticule extraction

Insights Cataract Refract Surg. 2026;11(1):23-25. Published online February 26, 2026

DOI: https://doi.org/10.63375/icrs.25.015

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Large incisional tear caused by abrupt Bell’s phenomenon during pocket irrigation in femtosecond laser-assisted small incision lenticule extraction

Fig. 1. Still images from the intraoperative videos. (A) During pocket irrigation, a sudden upward ocular movement occurred due to Bell’s phenomenon in the right eye. (B) Following the abrupt movement, a large inferior arcuate extension of the incision (arrows) was observed.

Fig. 2. Postoperative anterior segment photographs (A, B) and postoperative corneal topography (C). (A) An anterior segment photograph obtained on postoperative day 7 showed a self-sealed incision with intact wound integrity (arrowheads). (B) At 3 months postoperatively, a faint scar at the incisional tear site remained visible (arrowheads). (C) Postoperative corneal topography demonstrated no abnormal findings in the right eye (OD).

Fig. 1.

Fig. 2.

Large incisional tear caused by abrupt Bell’s phenomenon during pocket irrigation in femtosecond laser-assisted small incision lenticule extraction