MAUDE Adverse Event Report: ALCON RESEARCH, LLC - HOUSTON CUSTOM-PAK SURGICAL PROCEDURE PACK; GENERAL SURGERY TRAY (KIT)

Catalog Number 18376

Device Problem Adverse Event Without Identified Device or Use Problem (2993)

Patient Problems Conjunctivitis (1784); Inflammation (1932); Uveitis (2122); Vitritis (2181); Toxic Anterior Segment Syndrome (TASS) (4469)

Event Type  Injury  

Manufacturer Narrative

No sample has been received at manufacturing for evaluation.Investigation including root cause analysis is in progress.A supplemental mdr will be filed as necessary in accordance with 21 cfr 803.56 when additional reportable information becomes available.This is the third of eight reports for this reported patient event.The manufacturer internal reference number is: (b)(4).

Event Description

A surgeon reported that a patient experienced toxic anterior segment syndrome (tass) following a cataract extraction procedure and laser treatment.Upon post-operative examination of the patient, the surgeon noted 3+ aqueous cell, less than 1+ conjunctival inflammation, less than 1+ vitreous inflammation and aqueous fibrin.No cultures were performed and no intervention treatment was provided.The patient's symptoms have resolved without any additional treatment.This report represents the first of three patients for this surgeon.

Manufacturer Narrative

The manufacturer internal reference number is: (b)(4).

Manufacturer Narrative

No sample has been returned for evaluation; therefore, the condition of the product could not be verified.A review of the device history record (dhr) traceable to the reported lot number indicates that the product was processed and released according to the product¿s acceptance criteria.All the procedure paks are single-use devices provided to the customer in a sterile manner.The root cause of the customer's complaint could not be established as a sample has not been received and the condition of the product could not be verified.Without analysis of the sample, it is not possible to isolate the root cause.As the root cause is unknown, the relationship, if any, of the device to the reported incident cannot be determined.The root cause for this complaint is not known, therefore, specific action with regards to this complaint cannot be taken.All the procedure paks are single-use devices provided to the customer in a sterile manner.Quality assurance has reviewed this complaint and will continue to monitor data for evidence of adverse trending and take further action, as appropriate.The manufacturer internal reference number is: (b)(4).

• Brand Name: CUSTOM-PAK SURGICAL PROCEDURE PACK
• Type of Device: GENERAL SURGERY TRAY (KIT)
• Manufacturer (Section D): ALCON RESEARCH, LLC - HOUSTON; 9965 buffalo speedway; houston TX 77054
• Manufacturer (Section G): ALCON RESEARCH, LLC - HOUSTON; 9965 buffalo speedway; houston TX 77054
• Manufacturer Contact: jonathan schlech ; 6201 south freeway; mail stop ab2-6; fort worth, TX 76134 ; 8175514979
• MDR Report Key: 12094636
• MDR Text Key: 259225670
• Report Number: 1644019-2021-00445
• Device Sequence Number: 1
• Product Code: LRO
• Combination Product (y/n): N
• Reporter Country Code: US
• PMA/PMN Number: K880961
• Number of Events Reported: 1
• Summary Report (Y/N): N
• Report Source: Manufacturer
• Source Type: Health Professional
• Reporter Occupation: Physician
• Type of Report: Initial,Followup,Followup
• Report Date: 11/29/2021

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
• Device Operator: Health Professional
• Device Expiration Date: 01/31/2022
• Device Catalogue Number: 18376
• Device Lot Number: JZ5054868
• Was Device Available for Evaluation?: No
• Is the Reporter a Health Professional?: Yes
• Initial Date Manufacturer Received: 06/09/2021
• Initial Date FDA Received: 06/30/2021
• Supplement Dates Manufacturer Received: 08/04/2021; 11/05/2021
• Supplement Dates FDA Received: 08/20/2021; 11/30/2021
• Was Device Evaluated by Manufacturer?: Device Not Returned to Manufacturer
• Date Device Manufactured: 11/26/2020
• Is This a Reprocessed and Reused Single-Use Device?: No
• Type of Device Usage: Initial
• Patient Sequence Number: 1
• Treatment: BALANCED SALT SOLUTION; BESIVANCE; CENTURION PROCEDURE PAK; CENTURION VISION SYSTEM; CETAPHIL FACE WASH; CHANG CANNULA; CLEARCUT KNIVES; CYCLOPENTOLATE; DUOVISC VISCOELASTIC SYSTEM; DUREZOL; INTREPID DISPOSABLE I/A SET; KETOROLAC; LIDOCAINE; MALYUGIN RING; PCB00 (TECNIS IOL); PHENYLEPHRINE; POVIDONE IODINE; TETRACAINE; TYLENOL; VISCOAT VISCOSURGICAL DEVICE; BALANCED SALT SOLUTION; BESIVANCE; CENTURION PROCEDURE PAK; CENTURION VISION SYSTEM; CETAPHIL FACE WASH; CHANG CANNULA; CLEARCUT KNIVES; CYCLOPENTOLATE; DUOVISC VISCOELASTIC SYSTEM; DUREZOL; INTREPID DISPOSABLE I/A SET; KETOROLAC; LIDOCAINE; MALYUGIN RING; PCB00 (TECNIS IOL); PHENYLEPHRINE; POVIDONE IODINE; TETRACAINE; TYLENOL; VISCOAT VISCOSURGICAL DEVICE
• Patient Outcome(s): Other
• Patient Age: 74 YR
• Patient Sex: Male