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

Model Number	60005
Medical Device Problem Code	Optical Distortion (3000)
Health Effect - Clinical Code	Visual Disturbances (2140)
Date of Event	02/09/2021
Type of Reportable Event	Serious Injury
Additional Manufacturer Narrative
Patient reported experiencing halos, glare, and blurry vision.The light adjustable lens was explanted on (b)(6) 2021 from the left eye.Rxsight's first awareness of the issue was 2/16/2021.Device history record for the lens was reviewed.No issues were noted.The explanted lens has been received and is currently under evaluation.
Event or Problem Description
Patient reported experiencing halos, glare, and blurry vision.The light adjustable lens was explanted on (b)(6)2021 from the left eye.Rxsight's first awareness of the issue was 2/16/2021.
Additional Manufacturer Narrative
Patient reported experiencing halos, glare, and blurry vision.The light adjustable lens was explanted on (b)(6) 2021 from the left eye.The explanted lens was returned for evaluation.Inspection of the returned lens confirmed the presence of a zone in the center of the lens which is indicative of premature photopolymerization of the lens.
Event or Problem Description
Patient reported experiencing halos, glare, and blurry vision.The light adjustable lens was explanted on (b)(6) 2021 from the left eye.

• 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: 11478319
• Report Number: 3012712027-2021-00010
• Device Sequence Number: 3430769
• Product Code: PZK
• UDI-Device Identifier: 00818806020173
• UDI-Public: 01008188060201731120061617230531
• Combination Product (Y/N): N
• Initial Reporter State: IN
• Initial Reporter Country: US
• PMA/510(K) Number: P160055
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2020
• Device Explanted Year: 2021
• Serviced by Third Party (Y/N): Unknown
• Reporter Type: Manufacturer
• Report Source: health professional,user faci
• Initial Reporter Occupation: Physician
• Type of Report: Initial,Followup
• Report Date (Section B): 03/12/2021

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: Health Professional
• Device Model Number: 60005
• Device Catalogue Number: 60005
• Device Lot Number: L02-001684
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 03/05/2021
• Type of Report(Section G): Initial
• Initial Date Received by Manufacturer: 02/16/2021
• Supplement Date Received by Manufacturer: 02/16/2021
• Initial Report FDA Received Date: 03/12/2021
• Supplement Report FDA Received Date: 04/07/2021
• 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