VERION DIGITAL MARKER M
Received Jul 16, 2020 · Event occurred May 29, 2020
Report 3010300699-2020-00004 · MDR key 10283462
Device
Generic name
Marker, Ocular
Manufacturer
Wavelight Gmbh (agps)Model number
X-SPMCatalog number
8065998244
Lot number
ASKU
Product problems
- Patient-Device Incompatibility
Patient
71 YR
- Failure of Implant
- Visual Impairment
- Failure of Implant
- Visual Impairment
Narrative
Description of Event or Problem
ADDITIONAL INFORMATION RECEIVED STATES THAT HE AXIS DEVIATION WAS FIXED WITH DATA OBTAINED FROM THE SYSTEM DURING THE INITIAL PROCEDURE. THE AXIS CHANGED FROM 32 DEGREES TO 4 DEGREES AFTER SURGERY. THE PATIENT IS RECOVERED.
Additional Manufacturer Narrative
A REVIEW OF THE DEVICE HISTORY RECORD TRACEABLE TO THE REPORTED SERIAL NUMBER INDICATES THAT THE PRODUCT WAS PROCESSED AND RELEASED ACCORDING TO THE PRODUCT¿S ACCEPTANCE CRITERIA. DATA COLLECTION WAS RECEIVED AND THE DATA WAS INVESTIGATED. AT THE PLANNING SCREEN, A CORRECT MICROSCOPE ORIENTATION WAS SELECTED AND THE MATCHING REGISTRATION PROPOSAL CONFIRMED. THE DIGITAL MARKER SHOWED THE CORRECT AXIS FOR TORIC ALIGNMENT. AT THE END OF THE INITIAL SURGERY THE LENS WAS CORRECTLY ALIGNED TO THE DESIRED POSITION. A SECOND VIDEO OF THE TOUCH UP SURGERY WAS AVAILABLE THAT SHOWS A SUDDEN MISALIGNMENT OF THE LENS. POTENTIALLY, THE LENS WAS ROTATED AFTER THE INITIAL SURGERY. DEVICE WORKED AS INTENDED. IT IS UNKNOWN WHY LENS ROTATED AFTER SURGERY. THE MANUFACTURER INTERNAL REFERENCE NUMBER IS: (B)(4).
Additional Manufacturer Narrative
INVESTIGATION, INCLUDING ROOT CAUSE ANALYSIS, IS IN PROGRESS. A SUPPLEMENTAL MDR WILL BE FILED AS NECESSARY IN ACCORDANCE WITH 21 CFR 803.56 WHEN ADDITIONAL REPORTABLE INFORMATION BECOMES AVAILABLE. THE MANUFACTURER INTERNAL REFERENCE NUMBER IS (B)(4).
Description of Event or Problem
A CUSTOMER REPORTED THAT IT WAS LATER FOUND THAT A PATIENT'S VISUAL ACUITY HAD BEEN UNABLE TO BE PROPERLY ADJUSTED DUE TO AXIS DEVIATION AFTER INSERTION OF A TORIC INTRAOCULAR LENS FOLLOWING THE GUIDANCE DISPLAYED BY THE SYSTEM. IT IS UNKNOWN IF THE DEVIATION WAS CAUSED BY THE CONSOLE OR THE USER. THE PATIENT IS UNRECOVERED. THERE ARE MULTIPLE RELATED REPORTS FOR THIS EVENT. ANOTHER MANUFACTURER REPORT WILL BE FILED FOR THE OTHER PATIENTS.