MAUDE MDR 4658388

MDR report key
4658388
Report number
3007625547-2015-00001
Event key
0
Event type
3
Date of event
2015-02-04
Date received
2015-03-27
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
JOHN LOCKWOOD
Address
7405 WESTFIELD BLVD INDIANAPOLIS IN 46240 US
Phone
866-866-8669
Report source
M
Manufacturer link flag
Y

Devices#

Seq, Brand, Generic table
SeqBrandGenericManufacturerProduct codeModelCatalogLotPMA510(k)ImplantEvaluatedAvailability
1PICASSO LITE DENTAL LASER SYSTEMAMD GROUP LLCGEXPICASSO LITEPL001-PEW-RTR N

Patients#

Sequence, Received, Treatment table
SequenceReceivedTreatmentOutcome
12015-03-2701. O

Event Narratives#

D

Patient 1

DISTRIBUTOR NOTIFIED AMD LASERS ON (B)(4) 2015 THAT A CUSTOMER OF THEIRS HAD CONTACTED THEM REGARDING "ILL FITTING SAFETY GLASSES AND A LASER BEAM RETINAL BURN." AFTER RECEIVING THE INFO, THE CUSTOMER WAS CONTACTED VIA PHONE ON (B)(6) 2015 TO DISCUSS THE CIRCUMSTANCES OF THE EVENT. CUSTOMER HAD PURCHASED THE LASER UNIT APPROX 1 YEAR PRIOR TO THE EVENT ((B)(6) 2014), HAD TAKEN THE LASER SAFETY TRAINING ((B)(4)) INCLUDED WITH THE DEVICE BUT HAD NOT USED THE LASER ON A PT UNTIL THE DATE OF THE EVENT. CUSTOMER ALSO INDICATED THAT THEY HAD REGISTERED FOR THE "HANDS ON" LASER SAFETY CLASS BEFORE THE EVENT BUT HAD NOT TAKEN THE COURSE AT THE TIME OF THE EVENT. THE CUSTOMER WAS INITIATING THE OPTICAL FIBER TIP WHEN THE INJURY OCCURRED. THIS WAS APPROX 10 MONTHS SINCE COMPLETION OF THE LASER SAFETY TRAINING. THE CUSTOMER WAS USING THE STANDARD ADULT LASER SAFETY GOGGLES AT THE TIME OF THE EVENT. CUSTOMER MENTIONED THAT BASED ON HOW THE GOGGLES FIT ON THE BRIDGE OF HER NOSE, THERE WAS A 1/2 INCH GAP BETWEEN HER FACE AND THE BOTTOM OF THE LENS. AS SHE WAS INITIATING THE FIBER TIP, SHE LOOKED DOWN THROUGH THE GAP DIRECTLY AT THE FIBER TIP AS THE LASER UNIT ACTIVATED, WHICH CAUSED A MINOR RETINAL BURN. CUSTOMER VISITED AN OPHTHALMOLOGIST AFTER THE EVENT TO HAVE HER EYES EXAMINED. THE OPHTHALMOLOGIST INDICATED THAT THERE WAS A MINOR RETINAL BURN BUT THAT IT WOULD HEAL WITHIN SEVERAL DAYS AND THAT THERE WOULD NOT BE ANY RESIDUAL DAMAGE. CUSTOMER INDICATED THAT THEY HAVE USED THE LASER SYSTEM AT LEAST ONE ADDITIONAL TIME AFTER THE EVENT TO TREAT A PT.

N

Patient 1

THE LASER UNIT DID NOT MALFUNCTION. BASE DON THE DISCUSSION WITH THE CUSTOMER, IT IS CLEAR THAT DR (B)(6) DID NOT FOLLOW APPROPRIATE SAFETY GUIDANCE AS INDICATED IN THE PRODUCT LABELING.