MAUDE Adverse Event Report: STAAR SURGICAL COMPANY IMPLANTABLE COLLAMER LENS (ICL); PHAKIC TORIC INTRAOCULAR LENS

Model Number VTICM5_12.6

Device Problems Improper or Incorrect Procedure or Method (2017); Unintended Movement (3026)

Patient Problem No Clinical Signs, Symptoms or Conditions (4582)

Event Date 11/29/2023

Event Type  Injury  

Manufacturer Narrative

D2 - product code: unk (esubmitter software does not allow for a blank or 'unk' entry) (b)(4).

Event Description

The reporter indicated that the surgeon implanted an implantable collamer lens.Lens observed upside down.Additional information has been requested but none has been forthcoming.

Event Description

The reporter indicated that the surgeon implanted a 12.6mm vticm5_12.6.-12.0/2.0/148 (sphere/cylinder/axis) implantable collamer lens into the patient's right eye (od) on (b)(6)2023.Wrong cylinder axis for calculation was used by surgeon.Lens remains implanted.Additional information has been requested but none has been forthcoming.

Manufacturer Narrative

Additional information entered within form.

Manufacturer Narrative

B5 - the lens was repositioned on (b)(6) 2024.This resolved the problem.Reportedly "all is fine" and "patient is happy".Claim #(b)(4).

• 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: 18346590
• MDR Text Key: 330810109
• Report Number: 2023826-2023-05629
• Device Sequence Number: 1
• Product Code: QCB
• UDI-Device Identifier: 00840311308422
• UDI-Public: 00840311308422
• Combination Product (y/n): N
• Reporter Country Code: GM
• PMA/PMN Number: P030016
• Number of Events Reported: 1
• Summary Report (Y/N): N
• Report Source: Manufacturer
• Source Type: Other,Foreign,Health Professional,Company Representative
• Reporter Occupation: Physician
• Type of Report: Initial,Followup,Followup
• Report Date: 01/31/2024

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_12.6
• 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: 11/29/2023
• Initial Date FDA Received: 12/18/2023
• Supplement Dates Manufacturer Received: 12/20/2023; 01/30/2024
• Supplement Dates FDA Received: 12/20/2023; 01/31/2024
• Was Device Evaluated by Manufacturer?: Device Not Returned to Manufacturer
• Date Device Manufactured: 12/21/2022
• 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#UNK; FOAMTIPPLUNGER MODEL#FTP,LOT#UNK; INJECTOR MODEL#MSI-PF,LOT#UNK
• Patient Age: 35 YR