Management of sliding suction loss during keratorefractive lenticule extraction performed with VisuMax 800 femtosecond laser using CIRCLE software: a case report

BACKGROUND: Keratorefractive lenticule extraction (KLEx) is a widely used refractive procedure, but intraoperative suction loss remains a critical complication. While the faster laser frequency of the VisuMax 800 theoretically reduces this risk, it can still occur, occasionally presenting as sliding suction loss. In this phenomenon, the globe shifts while partial suction is maintained, resulting in a complete but decentered lamellar plane. This creates a surgical dilemma where standard re-docking protocols risk double cuts. In this report, we describe the first case of using the CIRCLE software as a rescue strategy specifically for sliding suction loss. CASE PRESENTATION: A 30-year-old male with - 4.25 diopter (D) myopia and - 0.25 D astigmatism underwent KLEx surgery using the VisuMax 800. During the peripheral cap cut, a sudden Bell's phenomenon caused the eye to shift, resulting in a sliding suction loss. The cap cut was completed in an inferiorly decentered position, while the subsequent incision was interrupted at 48.5%. To avoid corneal irregularities from standard re-initiation, the procedure was aborted. The following day, a rescue procedure was performed using CIRCLE software. By creating a junction (5.5 mm diameter, with a vertical offset of ± 5 μm) that precisely integrated with the existing decentered cap plane, the surgeon successfully bypassed the irregular incision and extracted the lenticule uneventfully. One month postoperatively, the patient achieved an uncorrected distance visual acuity of -0.04 logMAR, with stable refraction and a well-centered treatment zone confirmed by tomography. CONCLUSION: Sliding suction loss represents a specific intraoperative challenge that can occur even with high-speed laser systems. This case demonstrates that the CIRCLE software is a highly effective rescue tool for managing such complex interfaces. By enabling safe access to existing lamellar planes, CIRCLE software extends its utility from refractive enhancement to a vital intraoperative rescue strategy, preventing permanent corneal irregularities and ensuring excellent visual outcomes.