Technique to rescue a retained kerato lenticule using a non-CIRCLE approach

Background: Lenticule extraction is becoming more popular due to its minimally invasive and ocular surface compatible nature. However, retained lenticule is a recognized intraoperative complication of kerato lenticule extraction (KLex) surgeries requiring urgent and effective intervention to provide visual rehabilitation. Rescuing retained lenticule is a challenging task as one needs to reopen a pocket and access the retained lenticule. Management of retained lenticule involves repeat lenticule extraction below the cap and surface ablation augmented by mytomycin C or CIRCLE software. [1] CIRCLE software has been developed to convert cap into flap and retreatment following small incision lenticule extraction (SMILE). [2,3] CIRCLE software pattern D creates a lamellar ring adjacent to the SMILE pocket cut at the same depth of pocket. However, it is not compatible with corneal lenticule extraction for advanced refractive correction (CLEAR) surgical platforms. Purpose: The purpose is to demonstrate a novel, simple, and effective approach to rescue a retained kerato lenticule using a non-CIRCLE approach. Synopsis: The video shows the role of intraoperative OCT in rescuing the retained lenticule during CLEAR surgery. A 33 years old female with normal anterior segment parameters underwent CLEAR. Right eye CLEAR was uneventful. However, in the left eye, the incision cut did not open with a lot of loose or lying epithelium [Video 1]. To prevent a false plane of dissection, the procedure was aborted, resulting in retained lenticule. The postoperative day 1 uncorrected distance visual acuity (UDVA) in the left eye was 20/400. In the present case, dissection of the lenticule from the second cut incision was also attempted; however, we could not succeed the same due to loose, fragile epithelium and fear of cap tear and perforation [Video 1]. Second, one cannot perform surface ablation as the postsurgery recovery is slow and painful and involves a risk of corneal haze. Also, its outcome may not be predictable due to the presence of retained lenticule. Thus, the lenticule rescue was planned using Intra op OCT, a unique feature of CLEAR platform. An intra op OCT helped understand the depth at which the lenticule was retained, making it easy to access the same. A femtosecond lenticule extraction (FLEX) procedure was carried out to successfully rescue the same [Video 1]. Postoperative on day 1 FLEX, UDVA improved to 20/80, and at 1 month follow-up, UDVA was 20/20 blur. Recently, GS Sachdev et al . [4] demonstrated the utility of CIRCLE software from SMILE platform for enhancement of the post-CLEAR procedure. However, in the present case, we did not have an access to CIRCLE software as it is not compatible with CLEAR platform; thus, we used an intraoperative OCT, a unique feature of CLEAR platform, to create a flap and gain access to the entire lenticule. Highlights: Rescuing a retained lenticule is challenging, and the application of intraoperative OCT, a unique feature of CLEAR platform, is vital as it helped match the cap cut of the lenticule with the LASIK flap cut. Thus, using this technique, it is possible to rescue a retained lenticule in the absence of CIRCLE software. Video Link: https://youtu.be/QiLJO3bWaSc