MAUDE Adverse Event Report: RXSIGHT, INC. LIGHT ADJUSTABLE LENS (LAL); LIGHT ADJUSTABLE LENS (LAL), PRODUCT CODE: PZK

Model Number	60005
Medical Device Problem Code	Optical Distortion (3000)
Health Effect - Clinical Code	Visual Impairment (2138)
Type of Reportable Event	Serious Injury
Additional Manufacturer Narrative
Patient reported a change in visual acuity several days after the first lockin.The light adjustable lens was explanted from the left eye.No additional information was provided.Rxsight's first awareness was (b)(6) 2021.Device history record for the lens was reviewed.No issues were noted.Visual inspection of the returned lens found the lens had been cut into multiple fragments.Visual inspection and optical testing of the lens found no issues with the lens.
Event or Problem Description
Patient reported a change in visual acuity several days after the first lockin.The light adjustable lens was explanted from the left eye.No additional information was provided.Rxsight's first awareness was (b)(6) 2021.

• Brand Name: LIGHT ADJUSTABLE LENS (LAL)
• Common Device Name: LIGHT ADJUSTABLE LENS (LAL), PRODUCT CODE: PZK
• Manufacturer (Section D): RXSIGHT, INC.; 100 columbia; aliso viejo CA 92656
• MDR Report Key: 12606280
• Report Number: 3012712027-2021-00060
• Device Sequence Number: 4038637
• Product Code: PZK
• UDI-Device Identifier: 00818806020180
• UDI-Public: 01008188060201801120091417230831
• Combination Product (Y/N): N
• Initial Reporter State: FL
• 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: Physician
• Type of Report: Initial
• Report Date (Section B): 10/08/2021

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 Expiration Date: 08/31/2023
• Device Model Number: 60005
• Device Catalogue Number: 60005
• Device Lot Number: L02-001828
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 09/14/2021
• Type of Report(Section G): Initial
• Initial Date Received by Manufacturer: 09/14/2021
• Initial Report FDA Received Date: 10/11/2021
• 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