MAUDE Adverse Event Report: STAAR SURGICAL COMPANY IMPLANTABLE COLLAMER LENS (ICL); PHAKIC INTRAOCULAR LENS

Model Number	MICL13.7
Medical Device Problem Code	Inadequacy of Device Shape and/or Size (1583)
Health Effect - Clinical Codes	Intraocular Pressure Increased (1937); No Code Available (3191)
Date of Event	07/26/2017
Type of Reportable Event	Serious Injury
Additional Manufacturer Narrative
(b)(4).
Event or Problem Description
The reporter indicated that the surgeon implanted a micl13.7, -15.5 diopter, implantable collamer lens in the patient's right eye (od) on (b)(6) 2017.The lens was explanted on (b)(6) 2017 due to incorrect sizing.The lens was exchanged for another lens.
Additional Manufacturer Narrative
Female.The lens was exchanged for a shorter lens on (b)(6) 2017 due to excessive vaulting, elevated iop (intraocular pressure), narrowing of angles, angle closure and shallowing of acd (anterior chamber depth).An iridectomy was performed.Corrected data: date of implantation was corrected to "(b)(6) 2017".The reporter indicated that the surgeon implanted a micl 13.7, -15.5 diopter implantable collamer lens in the patient's right eye (od) on (b)(6) 2017.Device evaluation: the lens was returned in a specimen cup.Visual inspection found no visible damage to the lens.Device manufacture date was corrected to "10-dec-2015".(b)(4).

• Brand Name: IMPLANTABLE COLLAMER LENS (ICL)
• Common Device Name: PHAKIC INTRAOCULAR LENS
• Manufacturer (Section D): STAAR SURGICAL COMPANY; 1911 walker avenue; monrovia CA 91016
• MDR Report Key: 6818692
• Report Number: 2023826-2017-01324
• Device Sequence Number: 132262
• Product Code: MTA
• UDI-Device Identifier: 00841542103671
• UDI-Public: 00841542103671
• Combination Product (Y/N): N
• Initial Reporter State: GA
• Initial Reporter Country: US
• PMA/510(K) Number: P030016
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2017
• Device Explanted Year: 2017
• Reporter Type: Manufacturer
• Report Source: user facility
• Initial Reporter Occupation: Other
• Type of Report: Initial,Followup
• Report Date (Section B): 07/31/2017

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Is this an Adverse Event Report?: Yes
• Is this a Product Problem Report?: No
• Operator of Device: Physician
• Device Expiration Date: 10/31/2017
• Device Model Number: MICL13.7
• Device Catalogue Number: N/A
• Device Lot Number: N/A
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 08/14/2017
• Was the Report Sent to FDA?: No
• Initial Date Received by Manufacturer: 07/31/2017
• Supplement Date Received by Manufacturer: 09/08/2017
• Initial Report FDA Received Date: 08/24/2017
• Supplement Report FDA Received Date: 10/05/2017
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1
• Outcome Attributed to Adverse Event: Required Intervention
• Patient Age: 22 YR