MAUDE MDR 5302267

MDR report key
5302267
Report number
9615010-2015-00012
Event key
0
Event type
3
Date of event
2015-08-10
Date received
2015-12-16
Adverse event
3
Product problem
3
Patients in event
0
Reporter occupation
0
Health professional
3
Initial report to FDA
3
Event location
3

Manufacturer Contact#

Contact
MR. WILLIAM GUSTAFSON
Address
5160 HACIENDA DRIVE 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 700MICROSCOPE, SURGICAL, GENERAL & PLASTIC SURGERYCARL ZEISS MEDITEC AG (OBERKOCHEN)HRMNA305953-9900-000NAN *

Patients#

Sequence, Received, Treatment table
SequenceReceivedTreatmentOutcome
12015-12-1601. O

Event Narratives#

D

Patient 1

THE HEALTHCARE PROVIDER REPORTED FOLLOWING: THE LIGHT OF THE OPMI LUMERA 700 MICROSCOPE STARTED FLICKERING DURING AN OPHTHALMIC SURGERY. ALTHOUGH THE LIGHT INTENSITY WAS INCREASED THE SURGEON STILL DID NOT HAVE A CLEAR VIEW. AT THIS STAGE A CENTRAL POSTERIOR CAPSULAR HOLE WAS NOTED. THE SITE DETERMINED THAT THE PHACO TIP HAD GONE THROUGH THE POSTERIOR CAPSULE DUE TO AN UNCLEAR VIEW.

N

Patient 1

MANUFACTURER NARRATIVE: THE DISTRIBUTOR'S FIELD SERVICE ENGINEER WENT ONSITE AND WAS ABLE TO REPRODUCE THE LIGHT FLICKERING. HE MADE A VIDEO AND SENT IT TO THE MANUFACTURER. THE MANUFACTURER EVALUATED THE VIDEO AND CONFIRMED THAT THIS LIGHT FLICKERING IS NOT PART OF THE NORMAL BEHAVIOR OF XENON LIGHT BULBS. EVEN THE FLICKERING WAS VISIBLE, THE MANUFACTURER CONCLUDED THAT THE BRIGHT TO DARK VARIATION SEEN ON THE VIDEO WOULD NOT IMPACT ADVERSELY THE SURGEON'S VISIBILITY OR WORK. THE MOST LIKELY ROOT CAUSE COULD BE AN ISSUE WITH THE ATTENUATOR WHEEL OF THE LAMP CONTROL BOARD. THE DISTRIBUTOR DISCARDED THE RELATED PARTS, WHY A FINAL ROOT CAUSE CONCLUSION IS NOT POSSIBLE. THE USER MANUAL G-30-1673-EN DESCRIBES HOW TO HANDLE DIFFERENT ILLUMINATION ISSUES DURING SURGERY AND ADVISES ON PAGE 245: "IF THE BACKUP LAMP IS DEFECTIVE AND REPLACEMENT IS NOT POSSIBLE, CONTINUE SURGERY USING AN EXTERNAL OR ILLUMINATOR.". DEVICE EVALUATED BY MANUFACTURER. (B)(4).