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

Model Number	60005
Medical Device Problem Code	Adverse Event Without Identified Device or Use Problem (2993)
Health Effect - Clinical Code	Capsular Bag Tear (2639)
Type of Reportable Event	Serious Injury
Additional Manufacturer Narrative
The site reported a capsule tear during implantation of a light adjustable lens.The lens was explanted.No additional information has been provided at this time.Rxsight's first awareness of the event was 11/30/2021.The device history record for the lens was reviewed.No issues were noted.The explanted lens has been returned and is currently being evaluated.
Event or Problem Description
The site reported a capsule tear during implantation of a light adjustable lens.The lens was explanted.No additional information has been provided at this time.Rxsight's first awareness of the event was 11/30/2021.
Additional Manufacturer Narrative
The site reported a capsule tear during implantation of a light adjustable lens.The lens was explanted.No additional information has been provided at this time.Rxsight's first awareness of the event was (b)(6) 2021.The explanted lens was returned for evaluation.The lens was cut into multiple fragments.Visual testing found no issues with the lens.
Event or Problem Description
The site reported a capsule tear during implantation of a light adjustable lens.The lens was explanted.No additional information has been provided at this time.Rxsight's first awareness of the event was (b)(6) 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
• Manufacturer (Section G): RXSIGHT, INC.; 100 columbia; aliso viejo CA 92656
• Manufacturer Contact: kelli carrillo ; 100 columbia; aliso viejo, CA 92656
• MDR Report Key: 12953240
• Report Number: 3012712027-2021-00080
• Device Sequence Number: 14689775
• Product Code: PZK
• UDI-Device Identifier: 00818806020807
• UDI-Public: 01008188060208071121061517240531
• Combination Product (Y/N): N
• Initial Reporter State: MI
• 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: Physician
• Type of Report: Initial,Followup
• Report Date (Section B): 12/06/2021

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: 05/31/2024
• Device Model Number: 60005
• Device Catalogue Number: 60005
• Device Lot Number: L02-003277
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 11/30/2021
• Is the Reporter a Health Professional?: Yes
• Type of Report(Section G): Initial
• Initial Date Received by Manufacturer: 11/30/2021
• Supplement Date Received by Manufacturer: 11/30/2021
• Initial Report FDA Received Date: 12/07/2021
• Supplement Report FDA Received Date: 01/25/2022
• Was Device Evaluated by Manufacturer? (Y/N): Yes
• Date Device Manufactured: 06/15/2021
• 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: Other
• Patient Sex: Unknown