MAUDE Adverse Event Report: CARL ZEISS MEDITEC PRODUCTION LLC CT LUCIA 602

Model Number	003500-0050-685
Medical Device Problem Codes	Off-Label Use (1494); Use of Device Problem (1670)
Health Effect - Clinical Code	Visual Impairment (2138)
Date of Event	11/01/2021
Type of Reportable Event	Serious Injury
Additional Manufacturer Narrative
During the processing of this complaint, attempts were made to obtain complete event, patient, and device information.It was reported that after implantation of a ct lucia 602 the lens tilted.The doctor removed the lens and replaced it with a backup ct lucia 602 lens during the same surgery.It was noted that the second lens also started to tilt.A special suturing was performed in the attempt to minimize the tilt and was left in the patient's eye.During post op it was noted the iol had tilted and had to be explanted.Another lens was implanted.No adverse patient effects reported.No additional information provided.It was stated by the customer that they are using scleral tunnel fixation to implant lenses.This technique induces a large amount of force while trying to position the haptics in the scleral tunnel.Our lenses are intended to be implanted in the capsular bag; therefore, the technique used to implant the lenses are considered off label use.The device history records were reviewed and there were no non-conformities or deviations noted during the manufacturing of the lenses that would have contributed to the nature of this complaint.Additionally, lenses are 100% inspected before they leave our manufacturing site.Therefore, we are confident that the lens was processed per standard operation procedures and inspections and met all of the criteria for release.Additionally, there was no damage noted to the lens during preparation for use which suggest a product deficiency did not contribute to the reported issue.Iol tilting is known to be caused by numerous factors including, but not limited to: lens placement technique; poor handling during folding and inserting.We have reviewed the information provided and at this time there is no indication of a product quality issue with respect to the manufacturing, design, or labeling of the device.It appears that the reported issue is linked to user error.However, the need to explant the lens is considered need for medical intervention in order to prevent and avoid permanent impairment or damage to a body structure.
Event or Problem Description
It was reported that after implantation of a ct lucia 602 the lens tilted.The doctor removed the lens and replaced it with a backup ct lucia 602 lens during the same surgery.It was noted that the second lens also started to tilt.A special suturing was performed in the attempt to minimize the tilt and was left in the patient's eye.During post op it was noted the iol had tilted and had to be explanted.Another lens was implanted.No adverse patient effects reported.No additional information provided.

• Brand Name: CT LUCIA 602
• Common Device Name: CT LUCIA 602
• Manufacturer (Section D): CARL ZEISS MEDITEC PRODUCTION LLC; 1040 s vintage ave. bld. a; ontario CA 91761
• Manufacturer (Section G): CARL ZEISS MEDITEC PRODUCTION LLC; 1040 s vintage ave. bld. a; ontario CA 91761
• Manufacturer Contact: aileen sanchez ; 1040 s vintage ave. bld. a; ontario, CA 91761 ; 9099065165
• MDR Report Key: 12806820
• Report Number: 3010126268-2021-00005
• Device Sequence Number: 4757502
• Product Code: HQL
• UDI-Device Identifier: 00843045101062
• UDI-Public: (01)00843045101062(17)251231
• Combination Product (Y/N): N
• Initial Reporter State: CA
• Initial Reporter Country: US
• PMA/510(K) Number: P100016
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2021
• Device Explanted Year: 2021
• Serviced by Third Party (Y/N): N
• Reporter Type: Manufacturer
• Report Source: Health Professional,Company Representative
• Initial Reporter Occupation: Physician
• Type of Report: Initial
• Report Date (Section B): 11/11/2021

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: 12/31/2025
• Device Model Number: 003500-0050-685
• Device Catalogue Number: 003500-0050-685
• Device Lot Number: 3S210017
• Was Device Available for Evaluation?: No
• Is the Reporter a Health Professional?: Yes
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 11/01/2021
• Initial Report FDA Received Date: 11/12/2021
• Was Device Evaluated by Manufacturer? (Y/N): No
• Date Device Manufactured: 07/25/2020
• Is the Device Labeled for Single Use? (Y/N): Yes
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Usage of Device: Initial
• Patient Sequence Number: 1
• Outcome Attributed to Adverse Event: Required Intervention
• Patient Sex: Unknown