| Model Number |
ACU0T0 |
| Medical Device Problem Code |
Failure to Advance (2524)
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| Health Effect - Clinical Code |
No Clinical Signs, Symptoms or Conditions (4582)
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| Date of Event |
02/15/2025
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Type of Reportable Event
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Malfunction
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Additional Manufacturer Narrative
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The device with the lens was returned.The plunger lock and lens stop have been removed.The plunger was oriented correctly.Inadequate viscoelastic was observed in the device.No viscoelastic was observed in the nozzle or the tip of the device.Viscoelastic was only observed on/at the area of the lens.The plunger and lens were advanced to mid nozzle.The plunger has overrode the trailing optic edge of the lens.Product history records were reviewed and the documentation indicated the product met release criteria.A qualified viscoelastic was indicated.A plunger override observed.The root cause appears be related to a failure to follow the ifu (instructions for use).No viscoelastic was observed in front of the lens in the device.The ifu instructs: fill the device until viscoelastic can be observed flowing to the line on the nozzle tip.This will require approximately 0.2 milliliters (ml) of viscoelastic.If inadequate viscoelastic is placed in the device this will cause inadequate coverage of the lens fold path which may cause the lens to advance incorrectly or become "stuck" in the device.Only use an company ovd (viscosurgical ophthalmic device) qualified for use with the company pre-loaded delivery system that has been allowed to come to the operating room temperature.Plunger underride may occur: due to rapid advancement faster than the ifu recommend rate.If inadequate viscoelastic is placed in the device, this will cause inadequate coverage of the lens fold path which may cause the lens to advance incorrectly or become "stuck" in the device allowing the plunger to underride the lens.If the operating room temperature is too high (greater than 23 degrees centigrade / 73 degrees fahrenheit) lens folding consistency is negatively affected, the lens is more adherent and this may inhibit lens advancement.Any of the above listed causes alone, or in combination, may create the reported event.Due diligence has been performed in an attempt to obtain further information on this event.File will be reopened if new information is received.The manufacturer internal reference number is: (b)(4).H.10 reflects all related report numbers associated with this product event that have been submitted at this time.
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Additional Manufacturer Narrative
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A product was not returned for analysis.Complaint history and product history records were reviewed and documentation indicated the product met release criteria.Root cause has not been identified.The manufacturer internal reference number is: (b)(4).H.10 reflects all related report numbers associated with this product event that have been submitted at this time.
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Event or Problem Description
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A health care professional reported that during surgery while trying to load the lens, the blue plunger did not engage with the lens within the pre-loaded delivery system, whilst the blue plunger did advance, it was very stiff to load, it was highlighted to the surgeon, the surgeon agreed and it was not used as it could not be advanced.The surgery was able to continue by a new lens of the same diopter.Additional information has received and it states that there was no patient impact.
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Search Alerts/Recalls
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