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

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.