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

Model Number	TMICL12.6
Medical Device Problem Codes	Adverse Event Without Identified Device or Use Problem (2993); No Apparent Adverse Event (3189)
Health Effect - Clinical Code	No Clinical Signs, Symptoms or Conditions (4582)
Date of Event	02/16/2021
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
Weight: unk, ethnicity: unk, race: unk.Explant date: unk.Lens work order search-no similar complaint type events reported for units within the same lot.Claim # (b)(4).
Event or Problem Description
The reporter indicated that a 12.6mm tmicl12.6 implantable collamer lens, -14.0/+1.5/078 (sphere/cylinder/axis) tore during insertion.There was no patient injury and a backup lens was implanted.This occurred on (b)(6) 2021.
Additional Manufacturer Narrative
H3.Device evaluation: the lens was returned in liquid in a micro-centrifuge vial.There was residue on the lens surface.Visual inspection found that the haptic was torn.Claim# (b)(4).
Additional Manufacturer Narrative
B5-corrected info: reportedly the lens was implanted, removed, and replaced intraoperatively.The icl footplate was stuck under the plunger of the injector so it got torn off.Claim# (b)(4).

• Brand Name: IMPLANTABLE COLLAMER LENS
• Common Device Name: PHAKIC TORIC INTRAOCULAR LENS
• Manufacturer (Section D): STAAR SURGICAL COMPANY; 1911 walker avenue; monrovia CA 91016
• MDR Report Key: 12021870
• Report Number: 2023826-2021-01990
• Device Sequence Number: 17198392
• Product Code: QCB
• UDI-Device Identifier: 00841542107419
• UDI-Public: 00841542107419
• Combination Product (Y/N): N
• Initial Reporter State: FL
• Initial Reporter Country: US
• PMA/510(K) Number: P030016
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2021
• Device Explanted Year: 2021
• Serviced by Third Party (Y/N): Unknown
• Reporter Type: Manufacturer
• Report Source: company representative,health
• Initial Reporter Occupation: Physician
• Type of Report: Initial,Followup,Followup
• Report Date (Section B): 05/24/2021

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?: Yes
• Operator of Device: Health Professional
• Device Expiration Date: 09/30/2022
• Device Model Number: TMICL12.6
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 06/07/2021
• Initial Date Received by Manufacturer: 05/24/2021
• Supplement Date Received by Manufacturer: 06/14/2021; 07/13/2021
• Initial Report FDA Received Date: 06/17/2021
• Supplement Report FDA Received Date: 07/11/2021; 08/04/2021
• 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
• Patient Age: 22 YR