MAUDE Adverse Event Report: CARL ZEISS MEDITEC PRODUCTION LLC CT LUCIA 602; CT LUCIA 602, PRODUCT CODE: HQL, PRODUCT CODE: HQL

Model Number	003500-0050-671
Medical Device Problem Codes	Off-Label Use (1494); Use of Device Problem (1670)
Health Effect - Clinical Codes	Retinal Detachment (2047); Visual Impairment (2138)
Date of Event	11/30/2022
Type of Reportable Event	Serious Injury
Additional Manufacturer Narrative
It was reported that after the doctor implanted a ct lucia 602 using the yamane technique on pod5 the iol was experiencing a "rotisserie" tilt.The lens was removed, and a competitor lens was implanted.It was stated that the tech "manhandled" one of the haptics when loading the lens and it was a bit of a challenge to get it into the lumen of the tsk needle.No patient injury or clinically significant delay in procedure reported.The device is not being sent back.Thus, a proper device analysis could not be completed, nor the reported issues confirmed.The customers stated that there was no damage noted during preparation for use indicating a product quality issue did not contribute to the reported issues.Additionally, it was stated by the customers that they are using the yamane technique to implant the lenses.This technique induces a larger amount of force while trying to position the haptics in the scleral tunnel.Our lenses are intended to be implanted in the capsular bag.The lenes are being used off- label based on the information provided, the risk assessment for the lucia product and based on our experience and other complaints that have already been resolved we have determined that the following factors may have cause or contributed to the damaged haptic is but is not limited to: loading strategy; lens placement technique; accessory device support; poor handling during folding and inserting.The device history records were reviewed and there were no non-conformities or deviations noted during the manufacturing of the lens that would have caused or contributed to the nature of this complaint.Additionally, our lenses are 100% inspected before they leave our manufacturing site.Therefore, we are confident that the lens was processed per standard operating procedures and inspections and met all criteria for release.
Event or Problem Description
It was reported that after the doctor implanted a ct lucia 602 using the yamane technique on pod5 the iol was experiencing a "rotisserie" tilt.The lens was removed, and a competitor lens was implanted.It was stated that the tech "manhandled" one of the haptics when loading the lens and it was a bit of a challenge to get it into the lumen of the tsk needle.No patient injury or clinically significant delay in procedure reported.
Additional Manufacturer Narrative
Description of changes: field b2: checked "disability or permanent damage".Field b4: added "date of this report" 04/15/2025.Field b5: additional information field d9: updated to "no" field g3: updated "date received by manufacturer" to "03/26/2025".Field g6: checked "30 days", updated to "follow-up, # 1." field h2: checked "additional information." field h6: added codes - "health effect - clinical code " code 2047, "health effect - impact code" code 4614, "type of investigation" codes 4115, and 4109, "investigation findings" code 4248, "investigation conclusions." code 18.Field h11: added description of changes.
Event or Problem Description
Back on (b)(6) 2022, it was reported that after the doctor implanted a ct lucia 602 using the yamane technique on pod5, the iol was experiencing a "rotisserie" tilt.The lens was removed, and a competitor lens was implanted.It was stated that the tech "manhandled" one of the haptics when loading the lens and it was a bit of a challenge to get it into the lumen of the tsk needle.No patient injury or clinically significant delay in procedure reported by the customer site.However, on (b)(6) 2025, the patient involved in the event contacted zeiss and reported complications including a detached retina, a permanently dilated pupil, and persistent visual distortion.

• Brand Name: CT LUCIA 602
• Common Device Name: CT LUCIA 602, PRODUCT CODE: HQL, PRODUCT CODE: HQL
• 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: manjaya hegde ; 5300 central parkway; dublin, CA 94568 ; 9252164697
• MDR Report Key: 16127892
• Report Number: 3010126268-2023-00005
• Device Sequence Number: 14256197
• Product Code: HQL
• UDI-Device Identifier: 00843045100928
• UDI-Public: (01)00843045100928(17)260228
• Combination Product (Y/N): N
• Initial Reporter State: NH
• Initial Reporter Country: US
• PMA/510(K) Number: P100016-S008
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2022
• Device Explanted Year: 2022
• Serviced by Third Party (Y/N): Unknown
• Reporter Type: Manufacturer
• Report Source: Health Professional,Company Representative
• Initial Reporter Occupation: Physician
• Type of Report: Initial,Followup
• Report Date (Section B): 04/16/2025

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: 02/28/2026
• Device Model Number: 003500-0050-671
• Device Catalogue Number: 003500-0050-671
• Device Lot Number: 3S210318
• 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: 12/14/2022
• Supplement Date Received by Manufacturer: 03/26/2025
• Initial Report FDA Received Date: 01/09/2023
• Supplement Report FDA Received Date: 04/16/2025
• Was Device Evaluated by Manufacturer? (Y/N): Device Not Returned to Manufacturer
• Date Device Manufactured: 03/26/2021
• 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: Disability; Required Intervention
• Patient Sex: Unknown