MAUDE Adverse Event Report: CARL ZEISS MEDITEC PRODUCTION LLC CT LUCIA; CT LUCIA 621P

Model Number	621P
Medical Device Problem Code	Failure to Advance (2524)
Health Effect - Clinical Code	Visual Impairment (2138)
Date of Event	07/08/2024
Type of Reportable Event	Serious Injury
Event or Problem Description
It was reported that the haptic of a ct lucia 621p lens was stuck and did not come out of the injector correctly.This caused it to be inserted into the cornea.The doctor removed the lens and used a new lens.
Additional Manufacturer Narrative
As the device has not been returned, a definitive root cause cannot be provided, but based on the information provided, the risk assessment for the lucia product, and based on our experience we have determined that the following factors may have caused or contributed to the injection issue is but is not limited to: misplacement of the lens: this which may occur during ovd application, the cannula may catch the edge of the lens or haptic; thus, removing the lens off the "track" which is inside the cartridge.This may also cause the lens to fold improperly.The lens should fold in a "u" shape and if it does not this will cause the lens to not eject correctly and could even cause the lens to get damaged.Inadequate application of ovd: the ifu asks for generous amount of ovd to be applied, which covers the lens and the blue cushion.If ovd is not placed on the blue cushion advancement of the plunger may be inhibited by high frictional force and appear to become stuck.Dwell time after preparation: the ifu recommends that after the lens is advanced into the conical section the lens must be injected immediately.Dwell scenarios where the lens sits in this position for a prolong time prior to injection may lead to stuck iol issue.Viscoelastic materials may lose their lubricity if allowed to stand too long.

• Brand Name: CT LUCIA
• Common Device Name: CT LUCIA 621P
• 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 ; 9255574100
• MDR Report Key: 19922322
• Report Number: 3010126268-2024-00082
• Device Sequence Number: 7244280
• Product Code: HQL
• UDI-Device Identifier: 00843045102311
• UDI-Public: (01)00843045102311(11)230511(17)260430
• Combination Product (Y/N): N
• Initial Reporter State: MN
• Initial Reporter Country: US
• PMA/510(K) Number: P10016-S008
• 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: Health Professional,User Facility
• Initial Reporter Occupation: Other Health Care Professional
• Type of Report: Initial
• Report Date (Section B): 08/06/2024

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: 04/30/2026
• Device Model Number: 621P
• Device Catalogue Number: 003500-0056-485
• Device Lot Number: 3S230550
• 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: 07/08/2024
• Initial Report FDA Received Date: 08/06/2024
• Was Device Evaluated by Manufacturer? (Y/N): No
• Date Device Manufactured: 11/05/2023
• 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
• Outcome Attributed to Adverse Event: Required Intervention
• Patient Sex: Unknown