MAUDE Adverse Event Report: CARL ZEISS MEDITEC PRODUCTION LLC CT LUCIA 602

Model Number	CT LUCIA 602
Medical Device Problem Codes	Off-Label Use (1494); Use of Device Problem (1670)
Health Effect - Clinical Code	Visual Impairment (2138)
Date of Event	05/29/2025
Type of Reportable Event	Serious Injury
Event or Problem Description
The customer reported implanting a ct lucia 602 lens (21.0 d, sn: (b)(6)) on (b)(6) 2025, using the yamane technique.The lens was later explanted on (b)(6) 2025 due to a mechanical complication involving excessive rotation and instability.The lens was successfully replaced with a b&l mx60e (23.50 d, sn: (b)(6)) on the same day.There was no noted lens damage during preparation, no patient injuries or adverse events, and no clinically significant delays.The zeiss r28/z28 injector system was used.
Additional Manufacturer Narrative
The device history records were reviewed and there were no non-conformities or deviations noted during the manufacturing of the lens that would have caused or contributed to the nature of this complaint.Additionally, our lenses are 100% inspected before they leave our manufacturing site.Therefore, we are confident that the lens was processed per standard operating procedures and inspections and have met all criteria for release.Based on the information provided, the risk assessment for the lucia 3-piece product, and our experience, we have determined that the following factor may have caused or contributed to the reported issue: off-label use of the yamane technique: the ct lucia 602 lens is not validated for use with the yamane scleral fixation technique.This off-label method introduces rotational forces and anchoring dynamics that are not accounted for in the design specifications of the lens.In this case, the surgeon reported mechanical complication involving excessive rotation and instability, which ultimately required explantation.The haptics, while ideal for traditional in-the-bag implantation, may not provide the necessary resistance or stability when fixated externally via the yamane technique.The product was manufactured according to specifications, and no product-related deficiency was identified.The reported failure is attributable to off-label handling, not a product malfunction.

• Brand Name: CT LUCIA 602
• Common Device Name: CT LUCIA 602
• 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 ; 9252164697
• MDR Report Key: 22514947
• Report Number: 3010126268-2025-00028
• Device Sequence Number: 8788663
• Product Code: HQL
• UDI-Device Identifier: 00843045100959
• UDI-Public: (01)00843045100959(17)290331
• Combination Product (Y/N): N
• Initial Reporter State: SD
• Initial Reporter Country: US
• PMA/510(K) Number: P100016 S019
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2025
• Device Explanted Year: 2025
• 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): 07/15/2025

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 Model Number: CT LUCIA 602
• Device Catalogue Number: 003500-0050-674
• Device Lot Number: 3S240400
• 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: 06/24/2025
• Initial Report FDA Received Date: 07/15/2025
• Was Device Evaluated by Manufacturer? (Y/N): No
• Date Device Manufactured: 04/18/2024
• 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