Surgical Image Guidance Functionality, software used with NGENUITY 3D Visualization System, Part Number: 8065000399
This recall is currently active, issued July 18, 2024. It was issued by Alcon Research Llc Aspex Facility.
- Recall Initiated
- May 23, 2024
- Posted
- July 18, 2024
- Recall Number
- Z-2412-2024
- Quantity
- 230
- Firm Location
- Worth, TX
- Official Source
- View on FDA website ↗
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.
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.
Lot / Code Info
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, 007-4610122, 007-4610123, 007-4610124, 007-4610125, 007-4610127, 007-4610132, 007-4610138, 007-4610166, 007-4610167, 007-4610179, 007-4610181, 007-4610186, 007-4610217, 007-4610219, 007-4610220, 007-4610226, 007-4610229, 007-4610230, 007-4610262, 007-4610275, 007-4610283, 007-4610287, 007-4610288, 007-4610308, 007-4610309, 007-4610351, 007-4610355, 007-4610359, 007-4610360, 007-4610366, 007-4610394, 007-4610404, 007-4610405, 007-4610406, 007-4610409, 009-4570001, 009-4570004, 009-4570005, 009-4570007, 009-4570013, 009-4570014, 009-4570015, 009-4570016, 009-4570019, 009-4570022, 009-4570033, 009-4570035, 009-4570044, 009-4570047, 009-4570048, 009-4570049, 009-4570051,009-4570052, 009-4570053 009-4570054,009-4570057, 009-4570059, 009-4570060, 009-4570064, 009-4570068, 009-4570070, 009-4570072, 009-4570073, 009-4570096, 009-4570097, 009-4570099, 009-4570100, 009-4570114, 009-4570116, 009-4570125, 009-4570127, 009-4570129, 009-4570130, 009-4570136, 009-4570137, 009-4570144, 009-4570148, 009-4570149, 009-4570150, 009-4570153, 009-4570155, 009-4570156, 009-4570158, 009-4570160, 009-4570161, 009-4570167, 009-4570171, 009-4570173, 009-4570176,009-4570178, 009-4570179, 009-4570180, 009-4570183, 009-4570184, 009-4570200, 009-4570204, 009-4570207, 009-4570233, 009-4570249, 009-4570256, 009-4570259, 009-4570263, 009-4570270, 009-4570275, 009-4570278, 009-4570281, 009-4570289, 009-4570293, 009-4570294, 009-4570300, 009-4570308, 009-4570317, 009-4570320, 009-4570331, 009-4570342, 009-4570343, 009-4570350, 009-4570353, 009-4570357, 009-4570365, 009-4570368, 009-4570393, 009-4570397, 009-4570425, 009-4570431, 009-4570435, 009-4570440, 009-4570448, 009-4570449, 009-4570451, 009-4570455, 009-4570457, 009-4570459, 009-4570460, 009-4570474, 009-4570489, 009-4570508, 009-4570510, DM550021, DM550024, DM550043, DM550051, DM550054
Root 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.