MAUDE MDR 1407511

MDR report key
1407511
Report number
2431026-2009-00003
Event key
0
Event type
3
Date of event
2009-04-07
Date received
2009-06-25
Adverse event
3
Product problem
3
Patients in event
0
Reporter occupation
1
Health professional
3
Initial report to FDA
3
Event location
0

Manufacturer Contact#

Contact
JUDY BRIMACOMBE
Address
5160 HACIENDA DR. DUBLIN CA 94568 US
Phone
925-925-9255
Report source
M
Manufacturer link flag
Y

Devices#

Seq, Brand, Generic table
SeqBrandGenericManufacturerProduct codeModelCatalogLotPMA510(k)ImplantEvaluatedAvailability
1OPMI LUMERA TSURGICAL MICROSCOPECARL ZEISS SURGICAL GMBHEPT1493-090Y Y

Patients#

Sequence, Received, Treatment table
SequenceReceivedTreatmentOutcome
12009-06-250
22009-06-250

Event Narratives#

D

Patient 1

TWO PATIENTS WERE REPORTED AS HAVING RETINAL DAMAGE AFTER UNDERGOING COMPLEX CATARACT SURGERY (CONGENITAL CATARACT AND ECTOPIA LENTIS CATARACT) AFTER APPROXIMATELY 1.5 HOURS. IN 2009, TWO ADDITIONAL PATIENTS WERE ALSO REPORTED AS HAVING RETINAL DAMAGE.

D

Patient 2

TWO PATIENTS WERE REPORTED AS HAVING RETINAL DAMAGE AFTER UNDERGOING COMPLEX CATARACT SURGERY (CONGENITAL CATARACT AND ECTOPIA LENTIS CATARACT) AFTER APPROXIMATELY 1.5 HOURS. IN 2009, TWO ADDITIONAL PATIENTS WERE ALSO REPORTED AS HAVING RETINAL DAMAGE.

N

Patient 1

THE DEVICE WAS INSPECTED ON SITE AT THE CUSTOMER'S LOCATION AND FOUND TO BE WITHIN SPECIFICATIONS. THE DEVICE WAS CHECKED AGAIN AT THE MANUFACTURER'S LOCATION AND FOUND TO BE WITHIN SPECIFICATIONS. NO MALFUNCTION OF THE DEVICE WAS DETECTED DURING EITHER INSPECTION. THE DEVICE WAS USED FOR COMPLEX CATARACT SURGERIES FOR AN EXTENDED PERIOD OF TIME. ANALYSIS OF THE PATIENT DATA INDICATES THAT CATARACT SURGERY LASTED UP TO 1.5 HOURS WITHOUT THE OPERATOR USING ANY OF THE PROTECTION MECHANISMS INSTALLED IN THE DEVICE. THE "SAFETY" SECTION OF THE USER MANUAL (PAGES 23-30) PROVIDES THE USER WITH INFORMATION CONCERNING THE RISK OF PHOTOTOXIC RETINAL INJURY IN EYE SURGERY. THE USER MANUAL PROVIDES INFORMATION ON THE PROTECTION MECHANISMS INSTALLED IN THE DEVICE, RECOMMENDATIONS FOR MINIMIZING PHOTOTOXIC RISK, AND MAXIMUM RADIATION EXPOSURE TIMES.

N

Patient 2

THE DEVICE WAS INSPECTED ON SITE AT THE CUSTOMER'S LOCATION AND FOUND TO BE WITHIN SPECIFICATIONS. THE DEVICE WAS CHECKED AGAIN AT THE MANUFACTURER'S LOCATION AND FOUND TO BE WITHIN SPECIFICATIONS. NO MALFUNCTION OF THE DEVICE WAS DETECTED DURING EITHER INSPECTION. THE DEVICE WAS USED FOR COMPLEX CATARACT SURGERIES FOR AN EXTENDED PERIOD OF TIME. ANALYSIS OF THE PATIENT DATA INDICATES THAT CATARACT SURGERY LASTED UP TO 1.5 HOURS WITHOUT THE OPERATOR USING ANY OF THE PROTECTION MECHANISMS INSTALLED IN THE DEVICE. THE "SAFETY" SECTION OF THE USER MANUAL (PAGES 23-30) PROVIDES THE USER WITH INFORMATION CONCERNING THE RISK OF PHOTOTOXIC RETINAL INJURY IN EYE SURGERY. THE USER MANUAL PROVIDES INFORMATION ON THE PROTECTION MECHANISMS INSTALLED IN THE DEVICE, RECOMMENDATIONS FOR MINIMIZING PHOTOTOXIC RISK, AND MAXIMUM RADIATION EXPOSURE TIMES.