AL-SCAN
Received Jul 26, 2016 · Event occurred Aug 17, 2015
Report 3002807715-2016-00030 · MDR key 5823535
Device
Product problems
- Display or Visual Feedback Problem
- Display or Visual Feedback Problem
Patient
Not reported
- Therapeutic Effects, Unexpected
- Therapeutic Effects, Unexpected
Narrative
Additional Manufacturer Narrative
DEVICE HAS NOT BEEN EVALUATED IN THIS CASE. HOWEVER, BASED ON THE INVESTIGATION INCLUDING INTERNAL TEST, THE NCO WAS ABLE TO DUPLICATE THE SIMILAR UNUSUAL AXIAL LENGTH AND WAVEFORMS BY ELECTRONIC DISCHARGE EXCEEDED THE CRITERIA. THE NCO CONSIDERED EXTERNAL ELECTROMAGNETIC DISTURBANCE IN ABNORMAL OPERATING CONDITIONS POSSIBLY MAY HAVE CAUSED TO AL-SCAN WHICH CONFORMS TO INTERNATIONAL STANDARDS FOR ELECTROMAGNETIC COMPATIBILITY OF MEDICAL DEVICE AND HAS BEEN VERIFIED TO OPERATE PROPERLY UNDER NORMAL OPERATING CONDITION. IN ORDER TO PREVENT THE INCIDENT IN CUSTOMER SITE IN THE UNITED STATES, NCO REQUESTED NIDEK INC. WHICH IS USA SUBSIDIARY OF NCO TO ALERT TO THIS SYMPTOM AND ALSO RECOMMENDED THAT THE SOFTWARE SHOULD BE UPGRADED WITH THE NEW VERSION. RECALL HAS BEEN INITIATED BY US UNDER RECALL REPORT NUMBER :2936921-7/01/2016-001-C. TWO PATIENTS WERE AFFECTED SO TWO SEPARATE MDRS WILL BE SUBMITTED FOR EACH EVENT. PLEASE REFER MODEL:, SERIAL NUMBER:, COMPLAINT:, MDR #:, AL-SCAN, (B)(4), RECALL INJURY, 3002807715-2016-00030; AL-SCAN, (B)(4), RECALL INJURY, 3002807715-2016-00031.
Description of Event or Problem
THE MANUFACTURER,NIDEK CO., LTD.(ABBREVIATED: NCO) RECEIVED FOLLOWING INFORMATION FROM AN AUTHORIZED DISTRIBUTOR BY (B)(4). THE AXIAL LENGTH OF 2 PATIENTS ARE MEASURED 20.6MM IN EACH EYE. IOL +32D AND +33D WERE INSERTED FOR THOSE PATIENTS AS RECOMMENDED ACCORDING TO THE IOL POWER FORMULA. HOWEVER, THOSE PATIENTS GOT NEARSIGHTED BY -9D AFTER THE SURGERY. BEFORE THE SURGERY, THE QUALITY OF THE SCANNING OF AL-SCAN WERE GOOD WITH HIGH SIGNAL TO NOISE RATIO. THERE WERE NO CORNEAL OPACITIES AND IT WAS A STANDARD CATARACT IN A LOW HYPEROPIA. AFTER THE SURGERY, THE AXIAL LENGTH WAS MEASURED AGAIN AND ALL FOUR EYES RESULTED IN 23.3-23.6MM. BOTH PATIENTS NEED IOL REPLACEMENT. NO SUCH ISSUES HAVE BEEN OCCURRED IN THE PAST EXCEPT THESE TWO PATIENTS.
Remedial action
- Recall