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A non-healthcare professional reported during intraocular lens (iol) implant procedure, the surgeon noticed part of the lens broke and would not deploy, deemed defective.The lens was explanted during initial procedure.The procedure was completed on same day by using another lens with same diopter and model.Additional information has been requested but is not available at the time of this report.
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The lens was returned for evaluation.Dried solution is observed on the lens.The lens was crushed and returned adhered to the bottom of the lens case lid.The lens is broken, cracked, and in several pieces.Three posts in the lens case base are broken along with damage to the locking mechanism.The locking mechanism on the lens case lid is also damaged.A batch 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 medical device file were met.The file indicates the use of a non-qualified cartridge and a handpiece.Lens damage was observed.The root cause is most likely a failure to follow the ifu (instruction for use).The account used an unqualified lens/company combination.The company model is only qualified for use in the company (b) and (c) cartridges.Company foldable iols (intraocular lens) are qualified for use with an company qualified delivery system (handpiece and cartridge) and ophthalmic viscosurgical device (ovd) (ophthalmic viscoelastic device) 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.Use the company¿ cartridge at operating room temperatures between 18° c (64° f) and 23° c (73° f).Temperature greater than 23° c (73° f).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 and cause damage.The manufacturer internal reference number is: (b)(4).
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