FDA Adverse Event Malfunction Summary report: N

RAYONE ASPHERIC

MDR report key: 15903983 · Received December 2, 2022

Report

Report Number
3012304651-2022-00114
Event Type
Malfunction
Date Received
December 2, 2022
Date of Event
November 18, 2022
Report Date
December 2, 2022
Manufacturer
RAYNER INTRAOCULAR LENSES LIMITED
Product Code
HQL
UDI-DI
05029867691720
PMA / PMN Number
P060011
Adverse Event
Yes
Report Source
Manufacturer report
Reporter Location
AU
Reporter Occupation
PHYSICIAN
Health Professional
Yes

Narratives

Additional Manufacturer Narrative · 0

THE REFERENCE (B)(6) HAS BEEN ALLOCATED TO THIS CASE BY RAYNER. THE PATIENT UNDERWENT IOL IMPLANTATION ON (B)(6) 2022 AND ONE DAY POST-OPERATIVELY PRESENTED WITH TOXIC ANTERIOR SEGMENT SYNDROME (TASS). DISPOSABLE SURGICAL INSTRUMENTS WERE USED AND SURGERY WAS PERFORMED WITHOUT COMPLICATION. THE PATIENT HAS BEEN PRESCRIBED YELLOX X2 DAILY, VANCOMYCIN FORTUM INFUSIONS, HAS UNDERGONE PARS PLANA VITRECTOMY AND VITROEUS TAP (NO GERM DETECTABLE). THE HEALTHCRE FACILITY HAS CONFIRMED THAT THE PATIENT'S SYMPTOMS HAVE RESOLVED FOLLOWING TREATMENT. THE AETIOLOGY OF TASS MAY BE MULTI-FACTORIAL WITH NUMEROUS POTENTIAL CAUSES INCLUDING BUT NOT LIMITED TO; BACTERIAL ENDOTOXINS OR PARTICULATE CONTAMINATION OF BALANCED SALT SOLUTIONS, INTRAOCULAR IRRIGATING SOLUTIONS WITH ABNORMAL PH, OSMOLARITY OR IONIC COMPOSITION, DENATURED OPHTHALMIC VISCOSURGICAL DEVICES (OVD), INTRAOCULAR MEDICATIONS (ANTIBIOTICS IN THE IRRIGATION SOLUTIONS OR INTRACAMERAL ANTIBIOTICS), TOPICAL OINTMENTS, INADEQUATE STERILIZATION OF SURGICAL INSTRUMENTS AND TUBING, INADEQUATE FLUSHING OF INSTRUMENTS BETWEEN CASES RESULTING IN BUILD-UP OF OPHTHALMIC VISCOSURGICAL DEVICES (OVD), PRESERVATIVE AND METALLIC PRECIPITATE. EVERY BATCH OF IOLS MANUFACTURED BY RAYNER ARE TESTED FOR ENDOTOXIN AND BIOBURDEN. RAYNER'S ENDOTOXIN ACCEPTABLE TOLERANCES ARE DERIVED FROM BS EN ISO 11979-08 (2017) OPHTHALMIC IMPLANTS - INTRAOCULAR LENSES PART 8 FUNDAMENTAL REQUIREMENTS. WE HAVE SET OUR OWN LIMITS FOR BIOBURDEN AS THERE IS NO STANDARD THAT PRESCRIBES ACCEPTABLE LIMITS. OUR REVIEW OF ENDOTOXIN AND BIOBURDEN RECORDS FOR THE BATCH CONFIRMS THAT THE PRODUCT TESTED WITHIN ACCEPTABLE TOLERANCE OF THE RESPECTIVE LIMITS. NO RAYNER MICROBIOLOGICAL CAUSE FOR THE ONSET OF POST-OPERATIVE TASS WAS IDENTIFIED. THE ROOT CAUSE OF THE EVENT HAS NOT BEEN ESTABLISHED.

Description of Event or Problem · 0

ON 29TH NOVEMBER 2022, RAYNER RECEIVED NOTIFICATION FROM AN AUSTRIAN HEALTHCARE FACILITY OF AN EVENT THAT OCCURRED FOLLOWING IMPLANTATION OF A RAYONE ASPHERIC RAO600C. THE EVENT DESCRIPTION PROVIDED STATES THAT ONE DAY POST-OPERATIVELY THE PATIENT PRESENTED WITH TOXIC ANTERIOR SEGMENT SYNDROME (TASS).

Devices

Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
345090 RAYONE ASPHERIC RAYONE ASPHERIC HQL RAYNER INTRAOCULAR LENSES LIMITED RAO600C 072196359 05029867691720

Patients

Seq Age Sex Outcome Treatment
1 81 YR Female Required Intervention