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A nurse reported during intraocular lens (iol) implant procedure, the lens scratched when the haptics unfolded, the procedure was completed on the same day.Additional information was requested and received stating that the lens was explanted during initial procedure.There was no patient harm.
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The lens was returned positioned incorrectly in the lens case.Solution was dried on the lens.The optic was torn (possibly cut) into multiple pieces.The torn optic portions had multiple scratches and scrape marks on the anterior and posterior sides of the lens.A used non-qualified company specific cartridge was returned.Adequate viscoelastic was observed in the cartridge.The cartridge shows evidence that it has been placed into a handpiece.A light amount of tip stress was observed (not a malfunction).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.The file indicated the use of a non-qualified company specific cartridge.The company specific diopter lens is not qualified for use with the company specific cartridge.The diopter range for this model with the d cartridge is 6.0-25.0.The correct cartridge is indicated on the carton label and on the lens case label.The file indicated the use of a qualified viscoelastic and handpiece.The root cause is most likely related to failure to follow the ifu.The file indicated that the customer used a non-qualified lens/cartridge combination.The company specific diopter lens is not qualified for use with the company specific cartridge.The diopter range for this model with the d cartridge is 6.0-25.0.The correct cartridge is indicated on the carton label and on the lens case label.The ifu instructs: company specific foldable iols are qualified for use with a company specific qualified delivery system (handpiece and cartridge) and ophthalmic viscosurgical device (ovd) combination.The ifu instructs that a company specific 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.Important: 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.The handpiece ifu instructs: 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.The manufacturer internal reference number is: (b)(4).
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