MAUDE Adverse Event Report: RXSIGHT, INC. LIGHT ADJUSTABLE LENS (LAL)

Model Number	60005
Medical Device Problem Code	Optical Problem (3001)
Health Effect - Clinical Code	Visual Impairment (2138)
Date of Event	12/28/2020
Type of Reportable Event	Serious Injury
Additional Manufacturer Narrative
Site reported that the light adjustable lens was explanted from the patient's left eye as the desired refractive outcome was not achieved after light adjustment treatments.Rxsight's first awareness of the event occurred on 12/29/2020.Device history record for the lens was reviewed.No issues were noted.The lens is in process of being returned for evaluation.
Event or Problem Description
Site reported that the light adjustable lens was explanted from the patient's left eye as the desired refractive outcome was not achieved after light adjustment treatments.Rxsight's first awareness of the event occurred on 12/29/2020.
Additional Manufacturer Narrative
Site reported that the light adjustable lens was explanted from the patient's left eye as the desired refractive outcome was not achieved after light adjustment treatments.Lens fragments that comprised the lens was returned.Visual inspection found no issues with the lens fragments.Optical quality of the lens was also assessed and no issues were noted.
Event or Problem Description
Site reported that the light adjustable lens was explanted from the patient's left eye as the desired refractive outcome was not achieved after light adjustment treatments.

• Brand Name: LIGHT ADJUSTABLE LENS (LAL)
• Common Device Name: LIGHT ADJUSTABLE LENS (LAL)
• Manufacturer (Section D): RXSIGHT, INC.; 100 columbia; aliso viejo CA 92656
• MDR Report Key: 11245137
• Report Number: 3012712027-2021-00003
• Device Sequence Number: 3726820
• Product Code: PZK
• UDI-Device Identifier: 00818806020227
• UDI-Public: 010081880602022717211231
• Combination Product (Y/N): N
• Initial Reporter State: KS
• Initial Reporter Country: US
• PMA/510(K) Number: P160055
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Serviced by Third Party (Y/N): Unknown
• Reporter Type: Manufacturer
• Report Source: health professional,user faci
• Initial Reporter Occupation: Administrator/Supervisor
• Type of Report: Initial,Followup
• Report Date (Section B): 01/28/2021

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Is this an Adverse Event Report?: Yes
• Is this a Product Problem Report?: No
• Operator of Device: No Information
• Device Model Number: 60005
• Device Catalogue Number: 60005
• Device Lot Number: L02-000862
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 01/22/2021
• Initial Date Received by Manufacturer: 12/29/2020
• Supplement Date Received by Manufacturer: 12/29/2020
• Initial Report FDA Received Date: 01/28/2021
• Supplement Report FDA Received Date: 02/08/2021
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1
• Outcome Attributed to Adverse Event: Required Intervention