MAUDE Adverse Event Report: GLAUKOS CORPORATION ISTENT INFINITE TRABECULAR MICRO-BYPASS SYSTEM; AQUEOUS SHUNT

Model Number IS3-US

Device Problem Malposition of Device (2616)

Patient Problem Foreign Body In Patient (2687)

Event Date 12/18/2023

Event Type  malfunction  

Manufacturer Narrative

Additional information: the device was not available; therefore, product testing on the actual device could not be performed.The device history record review of the manufacturing lot was performed and there were no non-conformities found to be related to the reported event.A review of the device labeling was completed.Malpositioned stent is identified in the labeling as a known inherent risk of trabecular micro-bypass stent procedure.The ifu adequately provides instructions for stent implantation, precautions, and warnings for the proper use and handling of the device.An adverse event appears to have occurred, but does not appear to have been a problem with the device or the way it was used.Malpositioned stent is an established risk associated with use of the device, which is clearly specified in the product''s labeling.Based on the information received, the root cause of the reported event could not be conclusively identified.Mfr# reference: (b)(4).

Event Description

It was reported that following the implantation of three (3) stents from trabecular microbypass stent system, the stents dislodged during phacoemulsification (cataract surgery).Reportedly, two (2) stents were successfully retrieved, however the third stent occluded the injection/aspiration (ia) port and was no longer visible in the ia port or inside the eye.The report noted that the trabecular microbypass stent procedure was performed before phaco.The report also noted that the patient presented with intraoperative floppy iris syndrome (ifis) and a malyugin ring was used intraoperatively.There was no report of patient injury.Additional information has been requested.

Manufacturer Narrative

Additional information: mfr# reference: (b)(4).

Event Description

Through follow-up, the following information was received.Per report, the patient's status was described as "all has been fine with normal healing.".

Manufacturer Narrative

Additional information: mfr# reference: (b)(4).

Event Description

Through follow-up, the surgeon provided the following additional information.Per report, the three (3) stents did not seat well in the trabecular meshwork (tm), resulting in all three (3) stents becoming "loose" intraoperatively in the right eye (od).Reportedly, two (2) stents were recovered with intraocular forceps, and one (1) stent was visualized at the paracentesis site.Per report, when removal was attempted, the implant could no longer be visualized and possibly may have been irrigated out of the eye.There was no adverse patient impact and no further intervention was required.The event was noted as ongoing with the patient scheduled for a follow-up- gonioscopy examination to check if the stent is in the anterior chamber (ac).

• Brand Name: ISTENT INFINITE TRABECULAR MICRO-BYPASS SYSTEM
• Type of Device: AQUEOUS SHUNT
• Manufacturer (Section D): GLAUKOS CORPORATION; 229 avenida fabricante; san clemente CA 92672
• Manufacturer (Section G): GLAUKOS CORPORATION; 229 avenida fabricante; san clemente CA 92672
• Manufacturer Contact: brittany massey ; 229 avenida fabricante; san clemente, CA 92672 ; 949367960
• MDR Report Key: 18495247
• MDR Text Key: 333098524
• Report Number: 2032546-2024-00010
• Device Sequence Number: 1
• Product Code: KYF
• UDI-Device Identifier: 00853704002449
• UDI-Public: 0100853704002449
• Combination Product (y/n): N
• Reporter Country Code: US
• PMA/PMN Number: K220032
• Number of Events Reported: 1
• Summary Report (Y/N): N
• Report Source: Manufacturer
• Source Type: Health Professional,Company Representative
• Reporter Occupation: Physician
• Type of Report: Initial,Followup,Followup
• Report Date: 03/07/2024

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Date FDA Received: 01/11/2024
• Is this an Adverse Event Report?: No
• Is this a Product Problem Report?: Yes
• Device Operator: Health Professional
• Device Model Number: IS3-US
• Device Lot Number: 313190
• Was Device Available for Evaluation?: No
• Is the Reporter a Health Professional?: Yes
• Was Device Evaluated by Manufacturer?: Device Not Returned to Manufacturer
• Date Device Manufactured: 07/14/2023
• Is the Device Single Use?: Yes
• Is This a Reprocessed and Reused Single-Use Device?: No
• Type of Device Usage: Initial
• Patient Sequence Number: 1
• Patient Outcome(s): Other
• Patient Age: 74 YR
• Patient Sex: Male