MAUDE MDR 4032072

MDR report key
4032072
Report number
9615010-2014-00015
Event key
0
Event type
3
Date received
2014-08-01
Adverse event
3
Product problem
3
Patients in event
0
Reporter occupation
0
Health professional
3
Initial report to FDA
3
Event location
0

Manufacturer Contact#

Contact
JUDY BRIMACOMBE
Address
RUDOLF-EBER-STRASSE 11 OBERKOCHEN D-734 GM
Phone
925-925-9255
Report source
M
Manufacturer link flag
Y

Devices#

Seq, Brand, Generic table
SeqBrandGenericManufacturerProduct codeModelCatalogLotPMA510(k)ImplantEvaluatedAvailability
1OPMI PENTEROMICROSCOPE SURGICAL & PLASTICCARL ZEISS MEDITEC AGFSOPENTERONINAN

Patients#

Sequence, Received, Treatment table
SequenceReceivedTreatmentOutcome
12014-08-0101. O

Event Narratives#

D

Patient 1

THIS IS ONE OF FOUR ADVERSE EVENTS REPORTED IN THE ARTICLE: "AURICULAR BURNS ASSOCIATED WITH OPERATING MICROSCOPE USE DURING OTOLOGIC SURGERY"; LATUSKA, RICHARD F. ET AL.; OTOLOGY & NEUROLOGY 2014; 35:227-233. THIS INFORMATION WAS ORIGINALLY INCLUDED IN MEDWATCH MANUFACTURER REPORT NO. 9615010-2014-0009 SUBMITTED ON JUNE 18, 2014. IN CASE 3, A PATIENT WITH FITZPATRICK SKIN TYPE II UNDERWENT A RIGHT REVISION TYMPANOMASTOIDECTOMY FOR CHRONIC OTITIS MEDIA USING AN OPMI PENTERO MICROSCOPE. THE XENON LIGHT SOURCE WAS USED FOR A CUMULATIVE TIME OF 85 MINUTES AT 100% INTENSITY AND A 250 MM FOCAL LENGTH. AFTER SURGERY, A SECOND-DEGREE BURN WAS NOTED OVER THE POSTEROSUPERIOR HELIX. THE PATIENT WAS MANAGED WITH SIMPLE OBSERVATION. THE OUTCOME: RESOLVED WITHOUT COSMETIC DEFECT.

N

Patient 1

THE MAIN AUTHOR, DR. CARLSON, STATED THAT THERE WAS NO ADDITIONAL INFORMATION BEYOND THE ARTICLE. IT WAS REPORTED THAT THE PATIENT WAS EXPOSED TO 85 MINUTES OF ILLUMINATION AT A 100% INTENSITY AND A 250 MM FOCAL LENGTH. THE USER MANUAL EXPLAINS IN DETAIL THE RISKS OF BURNS, INCLUDING 3RD-DEGREE BURNS, CAUSED BY HIGH ILLUMINATION INTENSITY. THE USER MANUAL INSTRUCTS THE USER TO SET THE ILLUMINATION INTENSITY TO THE MINIMUM VALUE REQUIRED WITH 25% RECOMMENDED AS A STARTING VALUE. A VISUAL WARNING CAN BE DISPLAYED WHEN AN ILLUMINATION THRESHOLD VALUE IS EXCEEDED. THE DEFAULT FACTORY THRESHOLD IS SET TO BE ACTIVE WITH A VALUE OF 25%. THE USER MANUAL ALSO DESCRIBES THE CONTRIBUTION OF FOCAL DISTANCE, TIME AND PATIENT SKIN TYPE TO BURNS. FINALLY THE USER MANUAL DISCUSSES THE SUSCEPTIBILITY OF SKIN AROUND THE INCISION TO BURNS WITH A RECOMMENDATION TO USE WET GAUZE IN THE AREA TO REDUCE THE CHANCE OF BURNS. BASED UPON THE INFORMATION IN THE ARTICLE, IT CAN BE CONCLUDED THAT THE SECOND-DEGREE BURN EXPERIENCED BY THE PATIENT WAS THE RESULT OF USE NOT IN ACCORDANCE WIT THE USER DOCUMENTATION.