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

Model Number	60005
Medical Device Problem Code	Insufficient Device Problem Information (3190)
Health Effect - Clinical Code	Visual Impairment (2138)
Type of Reportable Event	Serious Injury
Additional Manufacturer Narrative
The site reported that a light adjustable lens had been explanted from the patient due to dysphotopsia.No additional information has been provided at this time.Rxsight's first awareness of this was (b)(6) 2021.The device history record for the lens was reviewed.No issues were noted.The lens is currently being evaluated.
Event or Problem Description
The site reported that a light adjustable lens had been explanted from the patient due to dysphotopsia.No additional information has been provided at this time.Rxsight's first awareness of this was (b)(6) 2021.
Additional Manufacturer Narrative
The site reported that a light adjustable lens had been explanted from the patient due to dysphotopsia.No additional information has been provided at this time.Rxsight's first awareness of this was 8/17/2021.The explanted lens was returned for evaluation.The lens was cut into multiple fragments.The lens was visually inspected.No issues were found.Optical testing could not be performed due to the condition of the lens.
Event or Problem Description
The site reported that a light adjustable lens had been explanted from the patient due to dysphotopsia.No additional information has been provided at this time.Rxsight's first awareness of this was 8/17/2021.

• 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: 12465037
• Report Number: 3012712027-2021-00053
• Device Sequence Number: 4739286
• Product Code: PZK
• UDI-Device Identifier: 00818806020166
• UDI-Public: 01008188060201661119120917221130
• Combination Product (Y/N): N
• Initial Reporter State: SD
• 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: user facility
• Initial Reporter Occupation: Other
• Type of Report: Initial,Followup
• Report Date (Section B): 09/13/2021

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 Expiration Date: 11/30/2022
• Device Model Number: 60005
• Device Catalogue Number: 60005
• Device Lot Number: L02-001467
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 08/17/2021
• Initial Date Received by Manufacturer: 08/17/2021
• Supplement Date Received by Manufacturer: 08/17/2021
• Initial Report FDA Received Date: 09/13/2021
• Supplement Report FDA Received Date: 09/27/2021
• 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: Other