BEUDAMED
    FDA Adverse Event Injury Summary report: N

    ITERO ELEMENT FLEX

    MDR report key: 19294205 · Received May 10, 2024

    Report

    Report Number
    3009646999-2024-01289
    Event Type
    Injury
    Date Received
    May 10, 2024
    Date of Event
    April 4, 2024
    Report Date
    November 26, 2024
    Manufacturer
    ALIGN TECHNOLOGY, LTD.
    Product Code
    NOF
    UDI-DI
    00816063020295
    Adverse Event
    Yes
    Report Source
    Manufacturer report
    Reporter Location
    WI, US
    Reporter Occupation
    PHYSICIAN
    Health Professional
    Yes

    Narratives

    Additional Manufacturer Narrative · 0

    UPDATES WERE MADE AFTER REVIEWING THE QUALITY OF DEVICE IDENTIFICATION INFORMATION SUBMITTED PREVIOUSLY AGAINST DATA IN THE GUDID.

    Additional Manufacturer Narrative · 0

    THE DEVICE WAS RETURNED TO THE MANUFACTURER AND A SPECIALIST IN THE FIELD WAS CONSULTED. IT IS CONCLUDED THAT THE ASSOCIATED MEDICAL DEVICE WAS MANUFACTURED ACCORDING TO INTERNAL AND EXTERNAL REQUIREMENTS, AND NO MALFUNCTION OCCURRED. THE REPORTED SYMPTOM OF TORN RETINA AND THE OTHER REPORTED SYMPTOMS ARE CONCLUDED NOT LIKELY TO BE RELATED TO THE USE OF AN ALIGN TECHNOLOGY, LTD,. MEDICAL DEVICE, BUT MAY BE ATTRIBUTED TO PATIENT'S PRE-EXISTING MEDICAL CONDITION.

    Additional Manufacturer Narrative · 0

    THE PATIENT REPORTED THAT THE ITERO LIGHT WAS ACTIVATED ON THE WAND OUTSIDE OF PATIENT'S MOUTH ON THE PATIENT'S RIGHT SIDE NEAR THE EYE, AND PATIENT REPORTED THAT WHILE BEING SCANNED, THERE WERE FLASHES OF LIGHT DURING THE PROCEDURE. THE CURRENT USER MANUAL FOR THE ITERO ELEMENT FLEX IMAGING SYSTEM CONTAINS THE FOLLOWING SCANNER PRECAUTIONS: "WHEN THE SYSTEM IS NOT IN USE, THE WAND SHOULD BE PLACED IN THE CRADLE WITH THE OPTICAL SURFACE FACING THE CRADLE, IN ORDER TO AVOID EYE CONTACT WITH THE LASER BEAM OR THE FLICKERING WHITE LED EMISSION. EYE CONTACT COULD CAUSE DAMAGE TO THE EYES". THE OPHTHALMOLOGIST SHARED THAT THE ROOT CAUSE OF THE TORN RETINA COULD HAVE BEEN DUE TO RAPID EYE MOVEMENTS FROM THE FLASHING LIGHT FROM THE ITERO WAND, AND THE NURSE PRACTITIONER SHARED THAT THE ROOT CAUSE OF THE EAR ISSUES COULD HAVE BEEN RELATED TO THE TORN RETINA AND ASSOCIATED EYE ISSUES. THIS EVENT IS BEING FILED AS AN MDR AS THE PATIENT EXPERIENCED A TORN RETINA AND REQUIRED SURGICAL INTERVENTION, AND THE ALIGN TECHNOLOGY, LTD. MEDICAL DEVICE WAS BEING USED. INVESTIGATION OF THIS EVENT IS CURRENTLY ONGOING. A SUPPLEMENTAL REPORT WILL BE SUBMITTED WHEN ADDITIONAL INFORMATION BECOMES AVAILABLE.

    Description of Event or Problem · 0

    THE PATIENT REPORTED THE FOLLOWING SYMPTOMS: SEEING BLACK DOTS AND BLACK SQUIGGLY LINES IN VISION, TORN RETINA, NAUSEA, DIZZINESS, IRRITATION, DIFFICULTY SLEEPING, FLUID IN RIGHT EAR AND INFLAMMATION, EYE SORENESS, TINGLING AND ODD SENSATIONS IN THE HEAD, STRESS. TTHE PATIENT REPORTED REQUIRING THE FOLLOWING MEDICAL INTERVENTION TO ALLEVIATE THE REPORTED SYMPTOMS: CONSULTATIONS WITH NURSE ADVISORS ON (B)(6) 2024, OPHTHALMOLOGIST VISIT (INITIAL VISIT ON (B)(6) 2024 AND FOLLOW UP APPOINTMENT ON (B)(6) 2024), LASER EYE SURGERY (SURGERY PERFORMED (B)(6) 2024), URGENT CARE VISIT ON (B)(6) 2024, NP VISIT ON (B)(6) 2024, CALL WITH OPHTHALMOLOGIST ON (B)(6) 2024 AND (B)(6) 2024, AND VESTIBULAR THERAPY ON (B)(6) 2024. THE PATIENT REPORTED REQUIRING THE FOLLOWING PRESCRIPTION MEDICATIONS TO ALLEVIATE THE REPORTED SYMPTOMS: IV, MEDICATION FOR NAUSEA, AND OTC EYE DROPS.

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    905593 ITERO ELEMENT FLEX SYSTEM, OPTICAL IMPRESSION, COMPUTER ASSISTED DESIGN AND MANUFACTURING (CAD/CAM) NOF ALIGN TECHNOLOGY, LTD. 202964 00816063020295

    Patients

    Seq Age Sex Outcome Treatment
    1 47 YR Female Required Intervention| O