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A facility representative reported during intraocular lens (iol) implant procedure, the surgeon noticed that the lens was not visible in the injector and it was wrapped around the blue plunger that advances the lens forward.Additional information was requested and received stating that when the surgeon was about to prime the lens, they noticed the lens was not in its usual place, when the plunger was pushed forward the lens was wrapped around the blue plunger.There was no patient contact.
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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 over the iol.The iol (intraocular lens) is partially exiting the nozzle tip.The leading haptic is broken.We are unable to determine the root cause of the reported complaint "lens not visible in injector, lens was not in its usual place & wrapped around blue plunger".Plunger override was observed.Plunger override 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 ovds (ophthalmic viscosurgical device) 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 override the lens.¿ if the operating room temperature is too high (> 23°c / 73° f) lens folding consistency is negatively affected, the lens is more adherent, and this may inhibit lens advancement.¿ if ovd has not been allowed to come to operating room temperature over a 20-minute timeframe prior to use.Colder temperatures can increase the ovd viscosity, creating greater resistance during iol delivery, causing potential unsuccessful delivery outcomes.Any of the above listed causes alone, or in combination, may create the reported event.The original position of the lens before priming cannot be confirmed.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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