FDA Adverse Event Injury Summary report: N

MALTZMAN INTRAOCULAR IRRIGATION/ASPIRATION

MDR report key: 12326 · Received March 28, 1994

Report

Report Number
MW1001250
Event Type
Injury
Date Received
March 28, 1994
Date of Event
February 9, 1994
Manufacturer
XOMED-TREACE
Product Code
HQC
Adverse Event
Yes
Product Problem
Yes
Report Source
Voluntary report
Reporter Location
ME, US
Reporter Occupation
RISK MANAGER

Narratives

Description of Event or Problem · 1

DURING SURGERY FOR REMOVAL OF A CATARACT, ANOTHER CO'S AUTOMATIC ASPIRATOR/IRRIGATOR FAILED. WHILE THIS WAS BEING ASSESSED AND THE SVC TECH TELEPHONED, THE SURGEON REQUESTED THIS MANUAL EQUIPMENT TO ASPIRATE AND IRRIGATE THE PARTICULATE MATTER (THE FRAGMENTED NUCLEUS.). THE RUBBER SEAL DID NOT FUNCTION. AT THAT POINT, A THIRD DEVICE WAS REQUESTED. THE CONDOM PORTION OF THE DISPOSABLE PORTION HAD LOST ITS ELASTICITY. AS A RESULT, IT WAS ONLY WITH GREAT DIFFICULTY, EXTENSION OF THE TIME THE EYE WAS OPEN AND TRAUMA TO THE TISSUE THAT THE PROCEDURE WAS COMPLETED. THE PACKAGING ON THIS EQUIPMENT HAS NO EXPIRATION DATE, THEREFORE HAD REMAINED AVAILABLE TO THE STAFF. THE MFR WAS NOTIFIED AND HAS VISITED HOSP TO INVESTIGATE THE EQUIPMENT. THE EXTENT OF THE PERMANENT DAMAGE TO PT'S EYE HAS NOT YET BEEN DETERMINED BY THE SURGEON. THIS IS THE FIRST INCIDENT OF THIS SEVERITY TO HAVE TAKEN PLACE IN HOSP SINCE THE MSDA WAS IMPLEMENTED. (ALSO SEE 1001251 AND 1001252.)

Devices

Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
1 MALTZMAN INTRAOCULAR IRRIGATION/ASPIRATION HQC XOMED-TREACE 14611

Patients

Seq Age Sex Outcome Treatment
1 66 YR Not Applicable| O