MAUDE Adverse Event Report: HOYA SURGICAL OPTICS, INC. HOYA ISERT 250; INTRAOCULAR LENS

Model Number	HOYA ISERT 250 (+19.50 D)
Medical Device Problem Code	Break (1069)
Health Effect - Clinical Code	No Known Impact Or Consequence To Patient (2692)
Date of Event	02/15/2016
Type of Reportable Event	Serious Injury
Additional Manufacturer Narrative
This report is being submitted after the initial 30-day reporting period deadline; it is part of a corrective action being implemented per internal document capa-(b)(4) for outside us like products reporting.This initial and final emdr is being submitted to fda for outside us like products reporting.Parts of the device were returned to the manufacturer, and the product investigation was conducted.The results are listed below: the lens was not returned and only blue pmma tips were received.Both blue pmma tips were torn and ejected out from the injector tip.The slider and the rod could advance properly.Trace of lubricant was found inside the injector tip.Review of the production records showed no irregularities or abnormities during its manufacturing and/or inspection processes.Exact root cause is not determined.Risk analysis conducted on the product line and failure code is noted below: a review of the most recent complaint trending data indicates that no significant trends have been identified at this time, and no capa is required as part of the product evaluation.
Event or Problem Description
After the lens was inserted into the patients eye, the surgeon noticed a chup in the optic.One of our distributor's representatives was present for the operation, so proper lubrication was used.The lens had to be cut from the patients eye and replaced with another lens.The plunger tip looks damaged.Photographs provided.

• Brand Name: HOYA ISERT 250
• Common Device Name: INTRAOCULAR LENS
• Manufacturer (Section D): HOYA SURGICAL OPTICS, INC.; 15335 fairfield ranch rd.; suite 250; chino hills CA 91709
• MDR Report Key: 8689709
• Report Number: 3006723646-2019-00078
• Device Sequence Number: 11390705
• Product Code: HQL
• UDI-Device Identifier: 04547480480770
• UDI-Public: 04547480480770
• Combination Product (Y/N): N
• Initial Reporter Country: UK
• PMA/510(K) Number: P080004
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2016
• Device Explanted Year: 2016
• Reporter Type: Manufacturer
• Report Source: company representative,foreig
• Initial Reporter Occupation: Other
• Type of Report: Initial
• Report Date (Section B): 02/29/2016

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?: Yes
• Operator of Device: Health Professional
• Device Expiration Date: 08/31/2017
• Device Model Number: HOYA ISERT 250 (+19.50 D)
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 03/21/2016
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 02/29/2016
• Initial Report FDA Received Date: 06/11/2019
• 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