MAUDE Adverse Event Report: BAUSCH + LOMB ADAPTIVE FLUIDICS MICS PREMIUM PACK; UNIT, PHACOFRAGMENTATION

Model Number	BL5115-3
Medical Device Problem Code	Intermittent Communication Failure (4038)
Health Effect - Clinical Code	Eye Burn (2523)
Date of Event	11/21/2023
Type of Reportable Event	Serious Injury
Additional Manufacturer Narrative
Product is not available to return for evaluation.Review of manufacturing and sterilization records, trend analysis, risk assessment, and directions for use is underway.The investigation is ongoing.
Event or Problem Description
A user facility in france reported that the interaction between the handpiece and the sleeve resulted in the incision being burnt, sutures were required.The patient recovered well, with no effect on visual acuity.
Additional Manufacturer Narrative
The device history records, trend and risk analysis were reviewed and considered acceptable with the product performing within anticipated rates.Based on all available information, no causal factors can be determined and no conclusion can be drawn.The investigation is complete.

• Brand Name: ADAPTIVE FLUIDICS MICS PREMIUM PACK
• Common Device Name: UNIT, PHACOFRAGMENTATION
• Manufacturer (Section D): BAUSCH + LOMB; 1400 north goodman street; rochester NY 14609
• Manufacturer (Section G): BAUSCH + LOMB, INC; 3365 treecourt industrial blvd; st. louis MO 63122
• Manufacturer Contact: juli moore ; 3365 treecourt industrial blvd; st. louis, MO 63122 ; 6362263220
• MDR Report Key: 18366668
• Report Number: 0001920664-2023-70148
• Device Sequence Number: 8015037
• Product Code: HQC
• UDI-Device Identifier: 10757770058867
• UDI-Public: (01)10757770058867(10)X4381(17)241113
• Combination Product (Y/N): N
• Initial Reporter Country: FR
• PMA/510(K) Number: K170052
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Serviced by Third Party (Y/N): Unknown
• Reporter Type: Manufacturer
• Report Source: Foreign,Health Professional,Company Representative
• Initial Reporter Occupation: Other
• Type of Report: Initial,Followup
• Report Date (Section B): 11/21/2023

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: 11/13/2024
• Device Model Number: BL5115-3
• Device Lot Number: X4381
• Was Device Available for Evaluation?: No
• Is the Reporter a Health Professional?: No
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: Not provided
• Supplement Date Received by Manufacturer: Not provided
• Initial Report FDA Received Date: 12/20/2023
• Supplement Report FDA Received Date: 02/08/2024
• Was Device Evaluated by Manufacturer? (Y/N): Device Not Returned to Manufacturer
• Date Device Manufactured: 06/13/2023
• 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
• Patient Sequence Number: 1
• Outcome Attributed to Adverse Event: Required Intervention
• Patient Sex: Unknown