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

Model Number	VTICM5_12.1
Medical Device Problem Code	Adverse Event Without Identified Device or Use Problem (2993)
Health Effect - Clinical Code	No Clinical Signs, Symptoms or Conditions (4582)
Date of Event	04/25/2024
Type of Reportable Event	Serious Injury
Additional Manufacturer Narrative
The lens was exchanged with a different model and power but same length lens on (b)(6) 2024 due to low vault with rotation.Claim #(b)(4).
Event or Problem Description
The reporter indicated that the surgeon implanted a 12.1mm vticm5_12.1 implantable collamer lens, of diopter -14.0/1.0/091 (sphere/cylinder/axis), into the patient's right eye (od) on (b)(6) 2024.On (b)(6) 2024 the lens was exchanged with a different model and power but same length lens due to low vault without rotation.This resolved the problem.Cause of event was reported as unknown and unkown if device failed to perform as intended.Status of the eye reported as "fine with vision.Quiet a/c".
Additional Manufacturer Narrative
H6 - 4110 - work order search: no additional similar complaint type events within associated lots were found.Claim # (b)(4).
Additional Manufacturer Narrative
H3 device evaluation: the lens was returned dry in a microcentrifuge vial.Visual inspection found no visible damage to the lens.Dimensional inspection found the lens to be within specifications.(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 muniz ; 1911 walker avenue; monrovia, CA 91016
• MDR Report Key: 19576543
• Report Number: 2023826-2024-02776
• Device Sequence Number: 4159748
• Product Code: QCB
• UDI-Device Identifier: 00840311304547
• UDI-Public: 00840311304547
• Combination Product (Y/N): N
• Initial Reporter Country: TH
• PMA/510(K) Number: P030016
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2024
• Device Explanted Year: 2024
• Serviced by Third Party (Y/N): N
• Reporter Type: Manufacturer
• Report Source: Other,Foreign,Health Professional
• Initial Reporter Occupation: Physician
• Type of Report: Initial,Followup,Followup
• Report Date (Section B): 06/19/2024

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: 09/30/2026
• Device Model Number: VTICM5_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: 06/19/2024
• Supplement Date Received by Manufacturer: 06/20/2024; 08/28/2024
• Initial Report FDA Received Date: 06/20/2024
• Supplement Report FDA Received Date: 06/20/2024; 09/10/2024
• Was Device Evaluated by Manufacturer? (Y/N): Yes
• Date Device Manufactured: 10/09/2023
• 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: CARTRDGE MODEL SFC-45, LOT #UNK.; FOAM TIP PLUNGER MODEL, LOT#-UNK.; INJECTOR MODEL MSI-TF, LOT #UNK.
• Outcome Attributed to Adverse Event: Required Intervention
• Patient Age: 35 YR
• Patient Sex: Female