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A non-healthcare professional reported during intraocular lens (iol) implant procedure, the lens would not discharge, the plunger slide under lens with patient contact and no patient harm.The lens remained in the delivery system.The procedure was completed on same day.Additional information has been requested.
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Additional information was provided in d.9., h.3., h.6.And h.11.The product was returned for analysis and the reported complaint was observed.The device was returned loose in a plastic bag.The lock-out assembly has been removed.Viscoelastic is observed in the device.The plunger has been fully advanced outside the nozzle tip and is advanced under the intraocular lens (iol).The iol is advanced into the nozzle entry and is damaged.The plunger tip is bent/damaged, this could possibly be due to the device being returned loose in a plastic bag.We are unable to determine the root cause for the reported complaint "would not discharge, plunger slide under lens, patient contact with no harm".Plunger underride was observed.Plunger underride may occur: if the lens has become misaligned in the lens bay during the manufacturing process.Due to the use of a non-qualified viscoelastic.Material properties of non-qualified ophthalmic viscosurgical device (ovd) may contribute to underfill, overfill, misfolding of the haptics, or other inconsistent folding outcomes.If inadequate viscoelastic is placed in the device this will cause inadequate coverage of the lens fold path which may cause the lens to advance incorrectly or become "stuck" in the device allowing the plunger to underride the lens.If the operating room temperature is too high (greater than 23 degrees centigrade / 73 degrees fahrenheit) lens folding consistency is negatively affected, the lens is more adherent and this may inhibit lens advancement.Any of the above listed causes alone, or in combination, may create the reported event.Based on the results from the product history record, the products met release criteria.The manufacturer internal reference number is: (b)(4).
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