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Dear Editor, F emtosecond laser (FSL) assisted laser in situ keratomileusis (LASIK) has been popularized because of its greater accuracy and predictability. But FSL also have some unique complications especially some gas bubble related complications. Vertical gas breakthrough (VGB) is a rare and serious complication during flap creation. Some surgeons had reported that VGB was treated with microkeratome or photorefractive keratectomy. To our knowledge, FSL-LASIK has not been reported as a remedy fort VGB (from PubMed). We present a VGB case who was successfully salvaged using FSL-LASIK. CASE PRESENTATION A 19-year-old man without any medical or ocular histories required FSL-LASIK. The corneas were unremarkable on slitlamp examination. The manifest refracton (MR) was -6.00 DS+0.50 DC×90 in the right eye and -5.75 DS in the left eye. The corneal curvature was 43.00@89 and 41.75@179 in the right eye. The curvature of left eye was 42.75@153 and 42.00@63. The corrected distant vision acuity (CDVA) were 20/20 in both eyes. Preoperative ultrasound pachymetry was 552 μm in the right eye and 550 μm in the left eye. Keratoconus was excluded by the examination of Oculyzer. The flap was created by FS-200 FSL. The presetting parameters of right eye were as follow: flap thickness, 95 μm; flap diameter, 8.5 mm; canal length offset, -0.1 mm; pulse energy in bed and side cut, 0.80 mJ. A gas bubble appeared between the cornea and the applanation cone at the beginning of bed cutting (Figure 1). The operation was aborted temporary after the side cut completed. The left eye had the FSL-LASIK with the similar parameters. There was no adverse event in the left eye. The reoperation of FSL-LASIK in the right eye was performed immediately after the left eye surgery finished (Figure 2). The presetting parameters during flap creating were as follow: flap thickness, 95 μm; flap diameter, 8.0 mm; canal length offset, 0.3 mm; pulse energy in bed and side cut, 0.80 mJ. The flap was created and lifted successfully. After excimer laser ablation, the flap repositioning required carefully alignment because of two side cuts. The patients were prescribed levofloxacin eye drops (Santen Pharmaceutical Co., Ltd, Osaka, Japan) 4 times daily for 1wk and fluorometholone eye drops (Santen Pharmaceutical Co., Ltd, Osaka, Japan) 4 times daily tapered for 4wk. On the first postoperative day, the uncorrected distant vision acuity (UCVA) was 20/25 in the right eye and 20/20 in the left eye.

Managements of vertical gas breakthrough in femtosecond laser assisted LASIK