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A physician reported that during vitrectomy surgery, tip of the ophthalmic loop was broken and fell into the eye.The broken tip was retrieved from the eye during the same procedure.The product was replaced with another one, and the surgery was completed.There was no patient harm.
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The returned instrument was received in its outer blister, covered by the tyvek foil, showing the lot information.The product shows macroscopic signs of damage: it is evident, that the loop is broke off.It shows any signs of surgery residues.The instrument was visually inspected with the aid of a photomicroscope using various magnification, which confirmed that the loop broken.As the blister was opened by the customer, the product was handled.Therefore, the point in time when the malfunction occurred can no longer be determined, nor can the strain put on the device be reconstructed.The customer¿s complaint is confirmed, but a root cause for the loop deformation cannot be determined.A review of the device history record traceable to the reported lot numbers, indicates that the reported product was processed and released according to the reported product¿s acceptance criteria.Non-conformance report provided by originator.A non-conformance based review of the lot number was performed and did not reveal any potential contributing factors to the reported complaint.No root cause for the customers reported event could be determined, since the situation that lead to the instrument failure cannot be reconstructed.As the root cause and its origin are inconclusive, further investigative or manufacturing actions are not warranted at this time.Receipt of additional relevant information or supporting materials will prompt a re-evaluation of the complaint investigation.Complaint data for all manufacturer products is reviewed monthly to monitor for adverse trends.During the last review, no adverse trends were observed for the reported product and event combination.The complaint data will continue to be monitored for evidence of adverse trending and further action will be taken, as appropriate.No further action warranted at this time.The manufacturer internal reference number is: (b)(4).
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