This is a final report.An onsite investigation of the affected device revealed, that the arveo worked according to specification, there was no indication of a malfunction.Lamp 1 was found to be engaged and "brightcare plus" was disabled.Because of this we assume, that the device was used in this setting during the surgical procedure.As such we conclude that the 2nd degree burn was caused by high light intensity.The identified root cause for the observed burn is that the user applied a light intensity which was too high for the low working distance used, while "brightcare plus" was deactivated.The user failed to follow the instructions given in the ifu, namely, to start with a low light intensity.But also, to use less light for shorter working distances than for longer working distances, in particular when "brightcare plus" is deactivated.Based on the review of the complaint and mdr database with no (0) similar or identical complaints the issue is evaluated an isolated event.The warnings in the ifu are considered adequate to advice the user on how to properly adjust the light intensity.During an onsite visit we ensured, that the "brightcare plus" function was set to activated in all user settings on all leica surgical operating microscopes belonging to the hospital.Additionally, the users were informed on how to properly activate and deactivate "brightcare plus".
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