MAUDE Adverse Event Report: STAAR SURGICAL COMPANY IMPLANTABLE COLLAMER LENS (ICL); PHAKIC TORIC INTRAOCULAR LENS

Model Number	VTICM5_13.2
Medical Device Problem Code	Inadequacy of Device Shape and/or Size (1583)
Health Effect - Clinical Codes	Visual Disturbances (2140); Halo (2227)
Date of Event	08/11/2022
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
(device manufacturing date): unk, no serial number reported.(expiration date): unk, no serial number reported.Claim#: (b)(4).
Event or Problem Description
The reporter indicated that a 13.2mm, vticm13.2, implantable collamer lens was implanted into the patients right eye (od) on (b)(6) 2022.The patient experienced excessive vault, galre and haloes, lens remains implanted.Cause of event was unknown.If additional information is received a supplemental medwatch report will be submitted.
Additional Manufacturer Narrative
B5- "the reporter indicated that a 13.2mm vticm13.2" should be corrected to "the reporter indicated that the surgeon implanted a 13.2mm vticm5_13.2." claim# (b)(4).
Additional Manufacturer Narrative
B5- the reporter indicated that a 13.2mm vticm13.2 -8.50/1.0/130 (sphere/cylinder/axis) implantable collamer lens was implanted into the patients right eye (od) on (b)(6) 2022.The patient experienced excessive vault, glare and haloes.Lens remains implanted.Cause of event was unknown.If additional information is received a supplemental medwatch report.H6 - type of investigation - lens work order search: no similar complaint type events reported for units within the same lot.Claim # (b)(4).

• Brand Name: IMPLANTABLE COLLAMER LENS (ICL)
• Common Device Name: PHAKIC TORIC INTRAOCULAR LENS
• Manufacturer (Section D): STAAR SURGICAL COMPANY; 1911 walker avenue; monrovia CA 91016
• Manufacturer (Section G): STAAR SURGICAL COMPANY; 1911 walker avenue; monrovia CA 91016
• Manufacturer Contact: joselene enriquez ; 1911 walker avenue; monrovia, CA 91016
• MDR Report Key: 15591507
• Report Number: 2023826-2022-03594
• Device Sequence Number: 2236564
• Product Code: QCB
• UDI-Device Identifier: 00841542116367
• UDI-Public: 00841542116367
• Combination Product (Y/N): N
• Initial Reporter State: SD
• Initial Reporter Country: US
• PMA/510(K) Number: P030016
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2022
• Serviced by Third Party (Y/N): Unknown
• Reporter Type: Manufacturer
• Report Source: Health Professional
• Initial Reporter Occupation: Physician
• Type of Report: Initial,Followup,Followup
• Report Date (Section B): 09/13/2022

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Is this an Adverse Event Report?: No
• Is this a Product Problem Report?: Yes
• Operator of Device: Health Professional
• Device Expiration Date: 12/31/2023
• Device Model Number: VTICM5_13.2
• Device Catalogue Number: N/A
• Device Lot Number: N/A
• 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: 09/13/2022
• Supplement Date Received by Manufacturer: 10/12/2022; 12/27/2022
• Initial Report FDA Received Date: 10/12/2022
• Supplement Report FDA Received Date: 12/09/2022; 12/27/2022
• Was Device Evaluated by Manufacturer? (Y/N): No
• Date Device Manufactured: 04/02/2022
• 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
• Concomitant Medical Products and Therapy/Usage Dates: INJECTOR MODEL: INJECTOR MODEL: LIOLI-24, LOT# UNK.
• Patient Age: 46 YR
• Patient Sex: Female