Recall Z-2412-2024

Alcon Research LLC · initiated May 23, 2024

Class II Open, Classified

Class II – products that might cause a temporary health problem or pose a slight threat of a serious nature

Product

Surgical Image Guidance Functionality, software used with NGENUITY 3D Visualization System, Part Number: 8065000399

Codes / lots: UDI-DI: 00380650003997. Software Version: 1.5. Serial Numbers: 004-0680001, 004-0680002, 004-0680003, 004-0680004, 004-0680007, 004-0680008, 004-0680017, 004-0680026, 004-0680036, 004-0680047, 004-0680048, 004-0680086, 004-0680090, 004-0680092, 004-0680096, 004-0680100, 004-0680107, 004-0680112, 004-0680120 004-0680127,004-0680131, 004-0680134, 004-0680140, 004-0680152, 004-0680153, 004-0680161, 004-0680163, 004-0680188, 004-0680190,004-0680203, 004-0680206, 004-0680266, 004-0680267, 004-0680271, 004-0680273, 004-0680274, 004-0680283, 004-0680288, 004-0680293, 004-0680294, 004-0680306, 004-0680311, 004-0680315, 004-0680319, 004-0680325, 004-0680334, 004-0680336, 004-0680337, 004-0680338, 004-0680339, 004-0680346, 004-0680348, 004-0680352, 004-0680362, 004-0680404, 004-0680417, 004-0680418, 005-7230003, 005-7230005, 005-7230007, 005-7230017, 005-7230019, 005-7230021, 005-7230022, 005-7230023, 005-7230031, 005-7230035, 005-7230057, 005-7230081, 005-7230085, 005-7230086, 005-7230102, 005-7230108, 005-7230109, 005-7230186, 007-4610018, 007-4610023, 007-4610030, 007-4610032, 007-4610033, 007-4610034, 007-4610037, 007-4610044, 007-4610074, 007-4610107, 007-4610112, 007-4610115…

Reason for recall

After surgery initiation, while using surgical image guidance, if significant eye rotation/movement occurs, a software anomaly may cause re-establishment of incorrect new registration angle, range indicator will display incorrectly, which could result in incorrect placement of toric IOL axis, which could cause astigmatic error under/over correction resulting in decreased uncorrected visual acuity.

FDA-determined cause: Software design

Action taken

On 5/23/24, correction notices were mailed to customers informing them of the following: Prior to ending procedure, re-perform registration to ensure proper axis alignment. Firm is expediting a software update that is expected to be released to upgrade systems running on software version 1.5 starting mid-June 2024. Firm's Technical Service representative will contact you to schedule your service appointment for this software upgrade. If you choose to use the image guidance functionality for toric alignment, to mitigate the potential for this anomaly, users are advised to re-perform registration prior to ending the case or if any axis discrepancy is noted during the case. To re-perform registration, go to the registration step, re-confirm the reference image to the new surgery image, adjust the registration angle (if necessary), select "Confirm" and proceed to toric alignment or desired step. Complete and return the response form via email to Market.Actions@Alcon.com If you have any questions regarding this issue, please contact your Firm representative or Technical Support at 1-800-832-7827 or contact your local Sales Representative.

Details

Recall number
Z-2412-2024
Initiated
May 23, 2024
Posted by FDA
July 18, 2024
Product code
FWJ – Camera, Cine, Microsurgical, Without Audio
Quantity
230
Distribution
Worldwide - US Nationwide distribution including in the states of AL, AR, CA, CO, CT, FL, GA, HI, IA, IL, KS, KY, LA, MA, MD, ME, MI, MN, MO, MT, NC, NE, NJ, NV, NY, OH, OK, PA, SC, TN, TX, WA, WI, PR and the countries of Canada, Japan, France.
Recalling firm
Alcon Research LLC, Fort Worth, TX

Official FDA recall record