MAUDE MDR 5317141

MDR report key
5317141
Report number
9615030-2015-00010
Event key
0
Event type
3
Date of event
2015-07-13
Date received
2015-12-21
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
1IOLMASTER 500BIOMICROSCOPE, SLIT-LAMP, AC-POWEREDCARL ZEISS MEDITEC AG (JENA)HJONA000000-1692-983NAY Y

Patients#

Sequence, Received, Treatment table
SequenceReceivedTreatmentOutcome
12015-12-2101. O

Event Narratives#

D

Patient 1

THE HEALTH CARE PROFESSIONAL REPORTED THE FOLLOWING: THE POST REFRACTIVE OUTCOME FOR AN EYE CATARACT SURGERY WITH INTRAOCULAR LENS (IOL) IMPLANTATION WAS -8 DIOPTERS. THE HEALTHCARE PROFESSIONAL MADE A DECISION TO EXCHANGE THE IOL. THE IOLMASTER WAS USED FOR THE ORIGINAL BIOMETRY MEASUREMENTS AND IOL CALCULATIONS AS WELL AS FOR THE SECOND MEASUREMENT AND CALCULATION.

N

Patient 1

A ZEISS FIELD SERVICE ENGINEER (FSE) INSPECTED THE DEVICE ON SITE, AND CONFIRMED THAT THE IOLM 500 IS WORKING WITHIN SPECIFICATION. THE MANUFACTURER EVALUATED THE PATIENT RELATED MEASUREMENT AND CALCULATION PRINTOUTS AS WELL AS THE DEVICE LOG FILES. BASED ON THE INFORMATION OBTAINED, THE MANUFACTURER WAS ABLE TO REPRODUCE THE SEQUENCE OF THE PATIENT MEASUREMENTS DONE BY THE OPERATOR OF THE IOLM 500 CONCLUDING THAT THE INITIAL FIVE (5) AXIAL LENGTH MEASUREMENTS FOR THE PATIENT WERE FROM ANOTHER PATIENT. THESE INITIAL FIVE MEASUREMENTS WERE PRINTED AND SAVED. LATER, FURTHER FIVE (5) MEASUREMENTS WERE PERFORMED WITH THE CORRECT PATIENT UNDER THE SAME PATIENT SESSION. THE COMBINED DATA OF THESE (10) MEASUREMENTS WAS USED FOR THE CALCULATION OF THE INTRA-OCULAR LENS (IOL) RESULTING IN AN INCORRECT IOL POWER VALUE. BOTH PRINTOUTS FOR MEASUREMENT AND CALCULATION CONTAINED A WARNING MESSAGE REGARDING THE AXIAL LENGTH VALUES OBTAINED FOR THE AFFECTED PATIENT DUE TO THE VARIATION OF THE AXIAL LENGTH MEASUREMENTS. THE SECOND PATIENT WAS MEASURED LATER AGAIN AND ALL MEASUREMENT VALUES FOR THIS PATIENT WERE CORRECT. HOW TO USE THE IOLMASTER 500 FOR IOL CALCULATION AND HOW TO USE THE LENS CONSTANTS IS DESCRIBED IN THE USER MANUAL. FOR INSTANCE ON PAGE 65 OF USER MANUAL (00000-1692-983_GA_GB_260210) IT IS STATED "AS A RULE, THE AXIAL LENGTH SHOULD BE VIEWED TOGETHER WITH THE CORNEAL K'S AND OVERALL REFRACTION, AND CHECKED FOR PLAUSIBILITY. IT IS LIKEWISE HELPFUL TO COMPARE THE RIGHT AND LEFT EYES."