Brand Name | IMPLANTABLE COLLAMER LENS (ICL) |
Type of Device | PHAKIC TORIC INTRAOCULAR LENS |
Manufacturer (Section D) |
STAAR SURGICAL COMPANY |
1911 walker avenue |
monrovia CA 91016 |
|
Manufacturer (Section G) |
STAAR SURGICAL COMPANY |
1911 walker avenue |
|
monrovia CA 91016 |
|
Manufacturer Contact |
joselene
muniz
|
1911 walker avenue |
monrovia, CA 91016
|
|
MDR Report Key | 17216372 |
MDR Text Key | 318033194 |
Report Number | 2023826-2023-02432 |
Device Sequence Number | 1 |
Product Code |
QCB
|
Combination Product (y/n) | N |
Reporter Country Code | KS |
PMA/PMN Number | P030016 |
Number of Events Reported | 1 |
Summary Report (Y/N) | N |
Report Source |
Manufacturer
|
Source Type |
Other,Foreign,Health Professional,Distributor |
Reporter Occupation |
Physician
|
Type of Report
| Initial,Followup |
Report Date |
06/07/2023 |
1 Device was Involved in the Event |
|
1 Patient was Involved in the Event |
|
Is this an Adverse Event Report? |
No
|
Is this a Product Problem Report? |
Yes
|
Device Operator |
Health Professional
|
Device Model Number | VTICM5_12.1 |
Device Catalogue Number | N/A |
Device Lot Number | N/A |
Was Device Available for Evaluation? |
No
|
Is the Reporter a Health Professional? |
Yes
|
Initial Date Manufacturer Received |
06/07/2023
|
Initial Date FDA Received | 06/28/2023 |
Supplement Dates Manufacturer Received | 01/03/2024
|
Supplement Dates FDA Received | 01/03/2024
|
Was Device Evaluated by Manufacturer? |
Device Not Returned to Manufacturer
|
Date Device Manufactured | 04/08/2023 |
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 |
Treatment | CARTRIDGE MODEL# SFC-45,LOT# 1589904.; FOAMTIPPLUNGER MODEL# FTP,LOT# 1587602.; INJECTOR MODEL# MSI-PF,LOT# 1576113 OR 1577284. |
Patient Age | 23 YR |
Patient Sex | Male |