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A non-healthcare professional reported that, during intraocular lens implantation surgery, the lens was damaged and stuck in the injector with no patient contact.The procedure was completed on the same day.Additional information has been received and it states in surgeon¿s opinion, injector or cartridge caused or contributed to the event.
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The used company cartridge was returned with the lens advanced into the tip.Viscoelastic was observed in the cartridge.The trailing haptic was extended back against the nozzle wall.The lens was misfolded up against the roof of the cartridge.The leading haptic was extended outside of the tip.The tip had heavy stress.The lens position may indicate a plunger underride occurred.The used company cartridge was cleaned for further evaluation.The lens was removed during cleaning.Top coat dye stain testing was conducted with acceptable results.Product history records were reviewed and documentation indicated the product met release criteria.A qualified cartridge and handpiece were indicated.It is unknown if a qualified viscoelastic was used.The root cause for the reported issue appears to be related to a failure to follow the ifu (instructions for use).The trailing haptic was extended back against the nozzle wall.The lens was misfolded up against the roof of the cartridge.The leading haptic was extended outside of the tip.The tip had heavy stress.The lens position may indicate a plunger underride occurred.Top coat dye stain testing was conducted with acceptable results.The ifu instructs: using holding forceps, grasp the lens by the optic edge and gently place the lens anterior side up into the back of the ovd (ophthalmic viscosurgical device) filled cartridge.The lens should be inserted until the optic is a little more than half-way inside the cartridge.Use the holding forceps to gently push down on the lens, verifying that the lens is on the bottom surface of the cartridge.Using holding forceps, take the trailing haptic, and gently fold the haptic onto the anterior side of the optic.Slowly grip or push the optic edge to position the lens as far into the cartridge as the forceps will permit, while ensuring the lens remains on the bottom surface of the cartridge and the trailing haptic remains on the optic.Failure to follow these steps may cause the lens to advance incorrectly causing delivery issues and/or damage.It is unknown if a qualified viscoelastic was used.The ifu instructs that an company qualified delivery system and viscoelastic combination should be used.The use of an unqualified combination may cause damage to the lens and potential complications during the implantation process.Important: the plunger should make initial contact with the cartridge at the ramp.In the event the plunger does not contact the cartridge at the ramp, do not use the handpiece and contact company.The handpiece ifu instructs: verify that the plunger tip is properly engaging the lens optic and that the lens moves forward at the same rate as the plunger while slowly advancing the plunger forward to avoid damaging the lens.When the threads on the knob make contact with the barrel, turn the knob clockwise approximately ½ turn to engage the threads and then stop.The iol will now be in the dwell position.Inspect to ensure the plunger is behind the optic.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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