{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,6,29]],"date-time":"2026-06-29T10:45:01Z","timestamp":1782729901597,"version":"3.54.5"},"reference-count":26,"publisher":"MDPI AG","issue":"13","license":[{"start":{"date-parts":[[2026,6,28]],"date-time":"2026-06-28T00:00:00Z","timestamp":1782604800000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["JCM"],"abstract":"<jats:p>Background: We aimed to evaluate the feasibility, safety, and efficiency of Corneal Lenticule Extraction for Advanced Refractive Correction (CLEAR) enhancement performed after primary CLEAR. Methods: Six eyes from five patients underwent enhancement to correct residual myopic error. All procedures were carried out with the low-energy FEMTO LDV Z8 laser platform (Ziemer Ophthalmic Systems AG, Port, Switzerland) equipped with integrated optical coherence tomography enabling precise lenticule positioning. Results: The myopic residual refractive sphere was fully corrected in all cases, with refraction remaining stable over the follow-up period. All eyes showed improvement in uncorrected distance visual acuity after retreatment with CLEAR and achieved 20\/20 vision or better at the final follow-up visit. Conclusions: Our results suggest that CLEAR enhancement is a safe and effective option for treating residual myopic refractive error after primary CLEAR, keeping the procedure flapless.<\/jats:p>","DOI":"10.3390\/jcm15135036","type":"journal-article","created":{"date-parts":[[2026,6,29]],"date-time":"2026-06-29T08:45:20Z","timestamp":1782722720000},"page":"5036","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["CLEAR Lenticule Extraction for Enhancement After Primary Lenticule Extraction Surgery"],"prefix":"10.3390","volume":"15","author":[{"ORCID":"https:\/\/orcid.org\/0009-0008-8272-5828","authenticated-orcid":false,"given":"Sungho","family":"Choi","sequence":"first","affiliation":[{"name":"First Samsung Eye Clinic, Seoul 06621, Republic of Korea"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0001-4551-3323","authenticated-orcid":false,"given":"Yoonseong","family":"Choi","sequence":"additional","affiliation":[{"name":"College of Arts and Science, New York University, New York, NY 10012, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0001-6730-926X","authenticated-orcid":false,"given":"Deok Jo","family":"Nam","sequence":"additional","affiliation":[{"name":"First Samsung Eye Clinic, Seoul 06621, Republic of Korea"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2026,6,28]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"813","DOI":"10.1016\/j.ophtha.2017.01.053","article-title":"Enhancement after Small-Incision Lenticule Extraction: Incidence, Risk Factors, and Outcomes","volume":"124","author":"Liu","year":"2017","journal-title":"Ophthalmology"},{"key":"ref_2","first-page":"328","article-title":"Beyond the First Cut: Evaluating LASIK Reoperation Trends","volume":"69","author":"Joshi","year":"2025","journal-title":"Rom. J. Ophthalmol."},{"key":"ref_3","first-page":"e43926","article-title":"A Literature Review of the Incidence, Management, and Prognosis of Corneal Epithelial-Related Complications After Laser-Assisted In Situ Keratomileusis (LASIK), Photorefractive Keratectomy (PRK), and Small Incision Lenticule Extraction (SMILE)","volume":"15","author":"Moshirfar","year":"2023","journal-title":"Cureus"},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"1384","DOI":"10.1016\/j.jcrs.2018.07.047","article-title":"Surgical options for retreatment after small-incision lenticule extraction: Advantages and disadvantages","volume":"44","author":"Moshirfar","year":"2018","journal-title":"J. Cataract Refract. Surg."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"3033","DOI":"10.2147\/OPTH.S381319","article-title":"Photorefractive Keratectomy Enhancement (PRK) After Small-Incision Lenticule Extraction (SMILE)","volume":"16","author":"Moshirfar","year":"2022","journal-title":"Clin. Ophthalmol."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"14","DOI":"10.1167\/tvst.13.1.14","article-title":"Corneal Epithelial Remodeling Induced by Photorefractive Keratectomy Enhancement After Small-Incision Lenticule Extraction","volume":"13","author":"Ye","year":"2024","journal-title":"Transl. Vis. Sci. Technol."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"533","DOI":"10.1007\/s00347-025-02239-1","article-title":"Nachbehandlung nach keratorefraktiver Lentikelextraktion (KLEx)","volume":"122","author":"Muqbel","year":"2025","journal-title":"Die Ophthalmol."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"798","DOI":"10.1159\/000527331","article-title":"Refractive Corneal Lenticule Extraction on Previous Photorefractive Keratectomy, with Optical Coherence Tomography Study","volume":"13","author":"Leccisotti","year":"2022","journal-title":"Case Rep. Ophthalmol."},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"e898","DOI":"10.3928\/1081597X-20241016-01","article-title":"Keratorefractive Lenticule Extraction Using the Ziemer FEMTO LDV Z8 Platform (CLEAR): One-Year Results","volume":"40","author":"Bteich","year":"2024","journal-title":"J. Refract. Surg."},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"675","DOI":"10.1097\/ICO.0000000000003074","article-title":"Femtosecond LASIK Retreatments After Primary Myopic Photorefractive Keratectomy","volume":"42","author":"Leccisotti","year":"2023","journal-title":"Cornea"},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"708","DOI":"10.3928\/1081597X-20150928-04","article-title":"Preliminary Evidence of Successful Enhancement After a Primary SMILE Procedure With the Sub-Cap-Lenticule-Extraction Technique","volume":"31","author":"Donate","year":"2015","journal-title":"J. Refract. Surg."},{"key":"ref_12","doi-asserted-by":"crossref","unstructured":"Sedky, A.N., Wahba, S.S., Roshdy, M.M., and Ayaad, N.R. (2018). Cap-preserving SMILE Enhancement Surgery. BMC Ophthalmol., 18.","DOI":"10.1186\/s12886-018-0712-7"},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"193","DOI":"10.3928\/1081597X-20161221-01","article-title":"Biomechanical Weakening of Different Re-treatment Options After Small Incision Lenticule Extraction (SMILE)","volume":"33","author":"Kling","year":"2017","journal-title":"J. Refract. Surg."},{"key":"ref_14","doi-asserted-by":"crossref","unstructured":"Riau, A.K., Liu, Y.C., Lim, C.H.L., Lwin, N.C., Teo, E.P., Yam, G.H., Tan, D.T., and Mehta, J.S. (2017). Retreatment strategies following Small Incision Lenticule Extraction (SMILE): In vivo tissue responses. PLoS ONE, 12.","DOI":"10.1371\/journal.pone.0180941"},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"285","DOI":"10.3928\/1081597X-20190416-01","article-title":"SMILE With Low Energy Levels: Assessment of Early Visual and Optical Quality Recovery","volume":"35","author":"Donate","year":"2019","journal-title":"J. Refract. Surg."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"1247","DOI":"10.1097\/ICO.0000000000003123","article-title":"Refractive Corneal Lenticule Extraction With the CLEAR Femtosecond Laser Application","volume":"42","author":"Leccisotti","year":"2023","journal-title":"Cornea"},{"key":"ref_17","unstructured":"Reinstein, D.Z., Archer, T.J., and Carp, G.I. (2018). The Surgeon\u2019s Guide to SMILE: Small Incision Lenticule Extraction, Slack Incorporated."},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"812","DOI":"10.3928\/1081597X-20141113-07","article-title":"Outcomes of small incision lenticule extraction (SMILE) in low myopia","volume":"30","author":"Reinstein","year":"2014","journal-title":"J. Refract. Surg."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"578","DOI":"10.3928\/1081597X-20180717-02","article-title":"Outcomes of Re-treatment by LASIK After SMILE","volume":"34","author":"Reinstein","year":"2018","journal-title":"J. Refract. Surg."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"1656","DOI":"10.1136\/bjophthalmol-2020-316601","article-title":"Evolution of corneal thickness and optical density after laser in situ keratomileusis versus small incision lenticule extraction for myopia correction","volume":"105","author":"Alio","year":"2021","journal-title":"Br. J. Ophthalmol."},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"655","DOI":"10.1097\/ICO.0b013e3181c377d5","article-title":"Flap buttonhole in thin-flap laser in situ keratomileusis: Case series and review","volume":"29","author":"Jain","year":"2010","journal-title":"Cornea"},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"513","DOI":"10.3928\/1081597X-20170602-01","article-title":"Enhancement After Myopic Small Incision Lenticule Extraction (SMILE) Using Surface Ablation","volume":"33","author":"Siedlecki","year":"2017","journal-title":"J. Refract. Surg."},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"961","DOI":"10.1097\/ICO.0000000000001231","article-title":"Corneal Breakthrough Haze After Photorefractive Keratectomy With Mitomycin C: Incidence and Risk Factors","volume":"36","author":"Kaiserman","year":"2017","journal-title":"Cornea"},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"108136","DOI":"10.1016\/j.exer.2020.108136","article-title":"Biology of keratorefractive surgery- PRK, PTK, LASIK, SMILE, inlays and other refractive procedures","volume":"198","author":"Wilson","year":"2020","journal-title":"Exp. Eye Res."},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"897","DOI":"10.18240\/ijo.2025.05.16","article-title":"Early assessment of visual outcomes and corneal stability in eyes with a pre-planned residual stromal thickness of 280 to 300 \u00b5m following small incision lenticule extraction","volume":"18","author":"Liu","year":"2025","journal-title":"Int. J. Ophthalmol."},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"341","DOI":"10.1136\/bjophthalmol-2020-316865","article-title":"Influence of age on small incision lenticule extraction outcomes","volume":"106","author":"Primavera","year":"2022","journal-title":"Br. J. Ophthalmol."}],"container-title":["Journal of Clinical Medicine"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2077-0383\/15\/13\/5036\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,6,29]],"date-time":"2026-06-29T09:53:12Z","timestamp":1782726792000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2077-0383\/15\/13\/5036"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,6,28]]},"references-count":26,"journal-issue":{"issue":"13","published-online":{"date-parts":[[2026,7]]}},"alternative-id":["jcm15135036"],"URL":"https:\/\/doi.org\/10.3390\/jcm15135036","relation":{},"ISSN":["2077-0383"],"issn-type":[{"value":"2077-0383","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,6,28]]}}}