MAUDE Adverse Event Report: STAAR SURGICAL COMPANY SEE H10; INTRAOCULAR LENS

Model Number	CQ2015A
Medical Device Problem Code	Device Operates Differently Than Expected (2913)
Health Effect - Clinical Code	No Consequences Or Impact To Patient (2199)
Date of Event	02/21/2018
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
Device name: collamer ultraviolet-absorbing posterior chamber three piece foldable intraocular lens.Device evaluation: lens was returned in liquid, in lens vial.Visual inspection found the lens torn in two pieces and a tear in the optic.Work order search: no similar complaint type event was reported for units within the same lot.(b)(4).
Event or Problem Description
The reporter indicated that a cq2015a intraocular lens, +19.0 diopter, was damaged during insertion.The lens was removed and the back up lens was implanted within the same surgery with no issues.A staar injection system was used, unable to provide lot numbers.
Additional Manufacturer Narrative
Corrected data: concomitant medical products: cartridge lot number corrected from "unk" to "1390717".Claim# (b)(4).

• Brand Name: SEE H10
• Common Device Name: INTRAOCULAR LENS
• Manufacturer (Section D): STAAR SURGICAL COMPANY; 1911 walker avenue; monrovia CA 91016
• MDR Report Key: 7366363
• Report Number: 2023826-2018-00458
• Device Sequence Number: 19323603
• Product Code: HQL
• UDI-Device Identifier: 00841542101967
• UDI-Public: 00841542101967
• Combination Product (Y/N): N
• Initial Reporter State: MA
• Initial Reporter Country: US
• PMA/510(K) Number: P990013
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2018
• Device Explanted Year: 2018
• Reporter Type: Manufacturer
• Report Source: health professional
• Initial Reporter Occupation: Other
• Type of Report: Initial,Followup
• Report Date (Section B): 02/21/2018

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Is this an Adverse Event Report?: No
• Is this a Product Problem Report?: Yes
• Operator of Device: Physician
• Device Expiration Date: 06/30/2019
• Device Model Number: CQ2015A
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 03/07/2018
• Was the Report Sent to FDA?: No
• Initial Date Received by Manufacturer: 02/21/2018
• Supplement Date Received by Manufacturer: 04/27/2018
• Initial Report FDA Received Date: 03/23/2018
• Supplement Report FDA Received Date: 05/08/2018
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1
• Patient Age: 66 YR