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A non-health care professional reported that during the intraocular lens (iol)implantation surgery, the lens was scratched/bent.Hence the lens was removed and replaced with another lens during the same procedure.Additional information was received stating that the physician was unsure on what caused the scratch on the lens, but they suspect the cartridge to be defective.
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Additional information was provided in d.9., h.3., h.6.And h.11.The lens was returned in pieces inside the lens case in a large biohazard bag.Solution was dried on the lens.One haptic was broken in the gusset area and split in the optic/haptic junction.The broken haptic portion was not returned.The other haptic was broken in the haptic/optic junction (returned).The optic was cut into three large portions.Each optic portion had additional damage.One optic portion was scraped on the anterior surface and scuffed on the posterior surface.A second optic portion had long scrape marks on the anterior surface and scuffed on the posterior surface.The third optic portion had small scrape marks and was cracked on the anterior surface and had two very long scrape marks that crossed on the posterior surface.A device history record review and a non-conformance review of the reported lot number was conducted.The deviation review did not reveal any potential contributing factors to the reported complaint and all corresponding production release specifications defined in the device master record were met.Qualified associated products were used.The root cause cannot be determined for the reported complaint.The reported scratch damage was observed.The lens was returned cut into multiple pieces, typical of an insertion and removal.Each optic portion contained scratches and additional damage.The instructions for use (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 ophthalmic viscosurgical device (ovd)-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.The cartridge was not returned to evaluate.The customer indicated the cartridge was filled completely with viscoelastic.The ifu instructs to completely fill the cartridge with ovd immediately prior to loading and delivery of the lens.Do not attempt to load the lens without adequate ovd in the device.Not adequately filling the device with viscoelastic will result in inadequate coverage of lens and the lens fold path with ovd, which may result in damage.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.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.Follow the section regarding directions for use for information on the maximum allowed time for the iol to stay in the folded condition.Failure to adhere to manufacturer¿s recommendations may result in iol damage.During lens loading and insertion, do not allow the iol to remain in a folded condition within the selected iol delivery system for more than 3 minutes prior to completing insertion into the capsular bag.The 20.5 diopter lens was removed and replaced with another 20.5 diopter lens.Per the provided feedback, the customer indicated that they were unsure what caused the lens damage, and they had speculation of a defective cartridge.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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