| Model Number |
SN6AT5 |
| Medical Device Problem Code |
Device Damaged by Another Device (2915)
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| Health Effect - Clinical Code |
Insufficient Information (4580)
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| Date of Event |
12/09/2025
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Type of Reportable Event
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Malfunction
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Event or Problem Description
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A pharmacist reported that during an intraocular lens (iol) implant procedure, during insertion of lens into the eye, the injector pierced the lens.A backup lens was used to complete the procedure on the same day.Additional information has been requested.
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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).
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Additional Manufacturer Narrative
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Additional information was provided in d.9., h.3., h.6 and h.11.The lens was not returned in a delivery system as described.The lens was returned positioned incorrectly posterior side up in the lens case.Solution was dried on the lens.Both haptic tips were broken (not returned).No associated cartridge was returned for evaluation.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.Balanced salt solution (bss) was indicated as the viscoelastic used.Which is non-qualified to be used in place of a viscoelastic inside a cartridge.The associated cartridge and handpiece were not provided.It is unknown if qualified products were used.The lens was not returned in a delivery system as described.The lens was returned positioned incorrectly posterior side up in the lens case.Solution was dried on the lens.Both haptic tips were broken.The root cause for the reported complaint is most likely related to a failure to follow the instructions for use (ifu).Bss was indicated as the viscoelastic used.Which is non-qualified to be used in place of a viscoelastic inside a cartridge.The associated cartridge and handpiece were not provided.It is unknown if qualified products were used.The ifu instructs: company foldable intraocular lens (iol) are qualified for use with an company qualified delivery system (handpiece and cartridge) and ophthalmic viscosurgical device (ovd) combination.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.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 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 manufacturer internal reference number is: (b)(4).
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Search Alerts/Recalls
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