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

Model Number	VTICMO 12.1
Medical Device Problem Code	Adverse Event Without Identified Device or Use Problem (2993)
Health Effect - Clinical Code	Blurred Vision (2137)
Date of Event	12/15/2023
Type of Reportable Event	Serious Injury
Additional Manufacturer Narrative
H6- investigation type code: 4110- lens work order search-no similar complaint event(s) within associated lots were found.(b)(4).
Event or Problem Description
The reporter indicated that the surgeon implanted a 12.1mm vticmo 12.1 implantable collamer lens of diopter -15.00/1.5/090 (sphere/cylinder/axis) into the patients left eye (os) on (b)(6) 2023.The patient experienced refractive surprise.On (b)(6) 2023 the lens was exchanged for the same model and length and the problem was resolved.The reporter indicated the cause of the event is unknown.
Additional Manufacturer Narrative
Devicev evaluation: h3 - type of investigation code: 10- device evaluation: the lens was returned in a microcentrifuge vial with moisture and residue/debris on product.Visual inspection found no visible damage.Dimensional and functional inspection found the lens to be within specifications.Corrected data: b5-the reporter indicated that the surgeon implanted a 12.1mm vticmo 12.1 implantable collamer lens of diopter -15.00/1.5/090 (sphere/cylinder/axis) into the patients left eye (os) on (b)(6) 2023.The patient experienced refractive surprise.The lens was repositioned.On (b)(6) 2023 the lens was exchanged for the same model and length; different power and the problem was resolved.The reporter indicated the cause of the event is unknown.H6- health effect- impact code (f): "4628" should be added.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 SUGICAL COMPANY; 1911 walker avenue; monrovia CA 91016
• Manufacturer Contact: joselene muniz ; 1911 walker avenue; monrovia, CA 91016 ; 6263037902
• MDR Report Key: 19367053
• Report Number: 2023826-2024-02380
• Device Sequence Number: 19779582
• Product Code: QCB
• UDI-Device Identifier: 00840311318445
• UDI-Public: 00840311318445
• Combination Product (Y/N): N
• Initial Reporter Country: CH
• PMA/510(K) Number: P030016
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2023
• Device Explanted Year: 2023
• Serviced by Third Party (Y/N): Unknown
• Reporter Type: Manufacturer
• Report Source: Other,Foreign,Health Professional,Distributor
• Initial Reporter Occupation: Physician
• Type of Report: Initial,Followup
• Report Date (Section B): 05/20/2024

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: 06/30/2026
• Device Model Number: VTICMO 12.1
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Is the Reporter a Health Professional?: Yes
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 05/20/2024
• Supplement Date Received by Manufacturer: 07/18/2024
• Initial Report FDA Received Date: 05/21/2024
• Supplement Report FDA Received Date: 07/19/2024
• Was Device Evaluated by Manufacturer? (Y/N): Yes
• Date Device Manufactured: 07/12/2023
• 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
• Usage of Device: Initial
• Patient Sequence Number: 1
• Concomitant Medical Products and Therapy/Usage Dates: CARTRIDGE MODEL: SFC-45: LOT# 1677784; FOAM TIP PLUNGER (FTP), LOT# 1662682; MSI-PF, LOT# 1449235
• Outcome Attributed to Adverse Event: Required Intervention
• Patient Age: 36 YR
• Patient Sex: Female