inforMED
MalfunctionFTH

VERION DIGITAL MARKER M

Received Oct 10, 2016 · Event occurred Aug 15, 2016

Report 3010300699-2016-00044 · MDR key 6013943

Device

Generic name

Marker, Ocular

Model number

X-SPM

Catalog number

8065998244

Lot number

ASKU

Product problems

  • Positioning Problem

Patient

Not reported

  • No Code Available
  • No Code Available

Narrative

Additional Manufacturer Narrative

ADDITIONAL INFORMATION HAS BEEN REQUESTED. 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. (B)(4).

Description of Event or Problem

AN OPHTHALMOLOGIST REPORTED THAT ONE DAY FOLLOWING TORIC INTRAOCULAR LENS (IOL) IMPLANT SURGERY IN THE LEFT EYE, THE PATIENT PRESENTED WITH AN UNPLANNED LENS ROTATION. THE TARGET AXIS OF THE IOL WAS AT 90 DEGREES, BUT INSTEAD, IT WAS AT 97 DEGREES. THE SURGEON IS CONCERNED THAT THE POSITIONING SYSTEM PROVIDED INCORRECT AXIS PLACEMENT. ADDITIONAL INFORMATION HAS BEEN REQUESTED.

Additional Manufacturer Narrative

NO ANOMALIES FOUND BY REVIEW OF DEVICE HISTORY RECORD, PRODUCT MET ALL SPECIFICATIONS WHEN RELEASED. A WRONG REGISTRATION PROPOSAL WAS CONFIRMED BY THE USER. THIS ANALYSIS ALSO SHOWED THAT SELECTING A DIFFERENT DOCTOR POSITION IN PLANNING SCREEN WOULD HAVE LED TO A CORRECT REGISTRATION PROPOSAL. REPORTED EVENT RESULTED FROM THE FAILURE OF THE CUSTOMER TO FOLLOW PUBLISHED INSTRUCTIONS FOR USE. THE MANUFACTURER INTERNAL REFERENCE NUMBER IS: (B)(4).