Blue Eye

K241591 · The Standard Co., Ltd. · PLL · Jul 3, 2024 · Gastroenterology, Urology

Device Facts

Record IDK241591
Device NameBlue Eye
ApplicantThe Standard Co., Ltd.
Product CodePLL · Gastroenterology, Urology
Decision DateJul 3, 2024
DecisionSESE
Submission TypeSpecial
Regulation21 CFR 876.1500
Device ClassClass 2
AttributesTherapeutic

Indications for Use

The Blue Eye is indicated for use in gastrointestinal endoscopic procedures for submucosal lift of polyps, adenomas, early-stage cancers or other gastrointestinal mucosal lesions prior to excision with a snare or endoscopic device.

Device Story

Blue Eye is a sterile, single-use submucosal injection agent provided in a 10 mL prefilled syringe. It consists of a solution containing water, hydroxyethyl cellulose, glycerin, methylene blue, benzyl alcohol, sodium phosphate, and potassium phosphate. During gastrointestinal endoscopic procedures, a physician injects the solution into the submucosal layer to create a lift, facilitating the subsequent excision of polyps, adenomas, or early-stage cancers using a snare or other endoscopic device. The device is used in clinical settings by trained medical professionals. The lift provided by the agent improves the safety and efficacy of the endoscopic resection process.

Clinical Evidence

Bench testing only. Performance data included syringe performance (ISO 11040-6, ISO 80369-7, ISO 7886-1), transportation/shipping validation (ASTM D 4169), steam sterilization validation (ISO 17655-1, ISO 11737-1/2), packaging validation (ASTM F 88/F88M, ASTM F 1929), and shelf-life testing (ASTM F 1980).

Technological Characteristics

Submucosal injection agent; 10mL prefilled syringe. Ingredients: water, hydroxyethyl cellulose, glycerin, methylene blue, benzyl alcohol, sodium phosphate, potassium phosphate. Sterilization: steam. Standards: ISO 11040-6, ISO 80369-7, ISO 7886-1, ISO 17655-1, ISO 11737-1/2, ASTM D 4169, ASTM F 88/F88M, ASTM F 1929, ASTM F 1980.

Indications for Use

Indicated for submucosal lift of polyps, adenomas, early-stage cancers, or other gastrointestinal mucosal lesions prior to endoscopic excision. Target population: adults; excludes pregnant/lactating women and children under 18.

Regulatory Classification

Identification

An endoscope and accessories is a device used to provide access, illumination, and allow observation or manipulation of body cavities, hollow organs, and canals. The device consists of various rigid or flexible instruments that are inserted into body spaces and may include an optical system for conveying an image to the user's eye and their accessories may assist in gaining access or increase the versatility and augment the capabilities of the devices. Examples of devices that are within this generic type of device include cleaning accessories for endoscopes, photographic accessories for endoscopes, nonpowered anoscopes, binolcular attachments for endoscopes, pocket battery boxes, flexible or rigid choledochoscopes, colonoscopes, diagnostic cystoscopes, cystourethroscopes, enteroscopes, esophagogastroduodenoscopes, rigid esophagoscopes, fiberoptic illuminators for endoscopes, incandescent endoscope lamps, biliary pancreatoscopes, proctoscopes, resectoscopes, nephroscopes, sigmoidoscopes, ureteroscopes, urethroscopes, endomagnetic retrievers, cytology brushes for endoscopes, and lubricating jelly for transurethral surgical instruments. This section does not apply to endoscopes that have specialized uses in other medical specialty areas and that are covered by classification regulations in other parts of the device classification regulations.

Special Controls

*Classification* —(1)*Class II (special controls).* The device, when it is an endoscope disinfectant basin, which consists solely of a container that holds disinfectant and endoscopes and accessories; an endoscopic magnetic retriever intended for single use; sterile scissors for cystoscope intended for single use; a disposable, non-powered endoscopic grasping/cutting instrument intended for single use; a diagnostic incandescent light source; a fiberoptic photographic light source; a routine fiberoptic light source; an endoscopic sponge carrier; a xenon arc endoscope light source; an endoscope transformer; an LED light source; or a gastroenterology-urology endoscopic guidewire, is exempt from the premarket notification procedures in subpart E of part 807 of this chapter subject to the limitations in § 876.9.(2) Class I for the photographic accessories for endoscope, miscellaneous bulb adapter for endoscope, binocular attachment for endoscope, eyepiece attachment for prescription lens, teaching attachment, inflation bulb, measuring device for panendoscope, photographic equipment for physiologic function monitor, special lens instrument for endoscope, smoke removal tube, rechargeable battery box, pocket battery box, bite block for endoscope, and cleaning brush for endoscope. The devices subject to this paragraph (b)(2) are exempt from the premarket notification procedures in subpart E of part 807of this chapter, subject to the limitations in § 876.9.

In combination with the general controls of the FD&C Act, the integrated operating table-electromechanical surgical system is subject to the following special controls: 1. (1) Premarket clinical performance testing, or a combination of premarket clinical performance testing and postmarket surveillance (in accordance with special control (2)), must include the following: 1. (i) Objective performance measures (e.g., rate and number of conversions to other surgical modalities, rate of device related adverse events (including tissue injury, hematoma, and increased blood loss), and their severity, cause, and outcomes) must be reported with relevant descriptive comparator performance measures. 2. (ii) The data must demonstrate the performance of the device for providing accurate and precise control of attached surgical instruments in range of clinical conditions relevant to the device's intended use. 3. (iii) The test dataset must include data collected from a patient population representative of the intended patient population under anticipated conditions of use. 2. (2) Data obtained from postmarket surveillance must demonstrate, in consideration of the premarket data obtained in accordance with special control (1), that the device performs in accordance with special control (1), unless FDA determines, based on the totality of the premarket data, that data from postmarket surveillance is not required to demonstrate that the device performs as intended. Such postmarket surveillance must be conducted per a protocol determined appropriate by FDA to demonstrate that the device performs as intended (in consideration of the premarket data obtained in accordance with special control (1)), and must include initiation, enrollment, and reporting requirements to ensure timely periodic updates to FDA on post-market surveillance progress and outcomes. 3. (3) Animal performance testing must evaluate the extent of port site trauma due to repositioning of table during surgical procedures when utilizing robotic minimally invasive and laparoscopic approaches 4. (4) The device manufacturer must develop, and update as necessary, a device-specific use training program that ensures proper device setup/use/shutdown, accurate control of instruments to perform the intended surgical procedures, troubleshooting and handling during unexpected events or emergencies, and safe practices to mitigate use error. 5. (5) The device manufacturer may only distribute the device to facilities that implement and maintain the device-specific use training program and ensure that users of the device have completed the device-specific use training program. (6) Human factors assessment must demonstrate that the user can correctly use the device system across all intended use environments with the provided instructions and training materials, including patient access during normal operating conditions and emergency situations, and effects arising from the integrated nature of the operating table and robotic surgical arms. (7) Labeling must include: (i) A detailed summary of clinical performance testing conducted with the device, including study population, results, adverse events, and comparisons to any comparator groups identified; (ii) A statement in the labeling that the safety and effectiveness for the representative specific procedures was based on evaluation of the device as a surgical tool and did not include evaluation of outcomes related to the treatment of the patient's underlying disease or condition, unless FDA determines that it can be removed or modified based on clinical performance data submitted to FDA; (iii) Identification of compatible devices; (iv) The list of surgical procedures for which the device has been determined to be safe with clinical justification; (v) Reprocessing instructions for reusable components; (vi) A shelf life for any sterile components; (vii) A description of the device-specific use training program; (viii) A statement that the device is only for distribution to facilities that implement and maintain the device-specific use training program and ensure that users of the device have completed the device-specific use training program; and (ix) A summary of any completed postmarket surveillance data collected as required by special control (2), including updated labeling to accurately reflect outcomes observed in postmarket surveillance. (8) Non-clinical performance testing must demonstrate that the device performs as intended under anticipated conditions of use and must include: (i) Device motion accuracy and repeatability; (ii) System testing; (iii) Instrument reliability; (iv) Crosstalk; (v) Table motion control; (vi) Thermal effects on tissue; (vii) User-device interface performance; (viii) Workspace access testing; and (ix) Performance testing with compatible devices. (9) Software verification, validation, and hazard analysis must be performed. (10) Electromagnetic compatibility and electrical, thermal, and mechanical safety testing must be performed. (11) Performance data must demonstrate the sterility of all patient-contacting device components. (12) Performance data must support the shelf life of the device components provided sterile by demonstrating continued sterility and package integrity over the labeled shelf life. (13) Performance data must validate the reprocessing instructions for the reusable components of the device. (14) Performance data must demonstrate that all patient-contacting components of the device are biocompatible. (15) Performance data must demonstrate that all patient-contacting components of the device are non-pyrogenic. (16) The device manufacturer must submit a report to the FDA annually on the anniversary of initial marketing authorization for the device, until such time as FDA may terminate such reporting, which comprises the following information: (i) Cumulative summary, by year, of complaints and adverse events since date of initial marketing authorization; and (ii) Identification and rationale for changes made to the device, labeling, or device specific use training program, which did not require submission of a premarket notification during the reporting period.

Predicate Devices

Submission Summary (Full Text)

{0}------------------------------------------------ Image /page/0/Picture/0 description: The image contains the logo of the U.S. Food and Drug Administration (FDA). On the left is the Department of Health & Human Services logo. To the right of that is the FDA logo in blue. Underneath the FDA logo is the word "ADMINISTRATION". July 3, 2024 The Standard Co., Ltd. % Priscilla Chung Regulatory Affairs Consultant LK Consulting Group USA, Inc. 18881 Von Karman Ave STE 160 Irvine, California 92612 Re: K241591 Trade/Device Name: Blue Eye Regulation Number: 21 CFR 876.1500 Regulation Name: Endoscope And Accessories Regulatory Class: Class II Product Code: PLL Dated: June 3, 2024 Received: June 3, 2024 Dear Priscilla Chung: We have reviewed your section 510(k) premarket notification of intent to market the device referenced above and have determined the device is substantially equivalent (for the indications for use stated in the enclosure) to legally marketed predicate devices marketed in interstate commerce prior to May 28, 1976, the enactment date of the Medical Device Amendments, or to devices that have been reclassified in accordance with the provisions of the Federal Food, Drug, and Cosmetic Act (the Act) that do not require approval of a premarket approval application (PMA). You may, therefore, market the device, subject to the general controls provisions of the Act. Although this letter refers to your product as a device, please be aware that some cleared products may instead be combination products. The 510(k) Premarket Notification Database available at https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfpmn/pmn.cfm identifies combination product submissions. The general controls provisions of the Act include requirements for annual registration, listing of devices, good manufacturing practice, labeling, and prohibitions against misbranding and adulteration. Please note: CDRH does not evaluate information related to contract liability warranties. We remind you, however, that device labeling must be truthful and not misleading. {1}------------------------------------------------ If your device is classified (see above) into either class II (Special Controls) or class III (PMA), it may be subject to additional controls. Existing major regulations affecting your device can be found in the Code of Federal Regulations, Title 21, Parts 800 to 898. In addition, FDA may publish further announcements concerning your device in the Federal Register. Additional information about changes that may require a new premarket notification are provided in the FDA guidance documents entitled "Deciding When to Submit a 510(k) for a Change to an Existing Device" (https://www.fda.gov/media/99812/download) and "Deciding When to Submit a 510(k) for a Software Change to an Existing Device" (https://www.fda.gov/media/99785/download). Your device is also subject to, among other requirements, the Quality System (QS) regulation (21 CFR Part 820), which includes, but is not limited to, 21 CFR 820.30, Design controls; 21 CFR 820.90, Nonconforming product; and 21 CFR 820.100, Corrective and preventive action. Please note that regardless of whether a change requires premarket review, the QS regulation requires device manufacturers to review and approve changes to device design and production (21 CFR 820.30 and 21 CFR 820.70) and document changes and approvals in the device master record (21 CFR 820.181). Please be advised that FDA's issuance of a substantial equivalence determination does not mean that FDA has made a determination that your device complies with other requirements of the Act or any Federal statutes and regulations administered by other Federal agencies. You must comply with all the Act's requirements, including, but not limited to: registration and listing (21 CFR Part 807); labeling (21 CFR Part 801); medical device reporting of medical device-related adverse events) (21 CFR Part 803) for devices or postmarketing safety reporting (21 CFR Part 4, Subpart B) for combination products (see https://www.fda.gov/combination-products/guidance-regulatory-information/postmarketing-safety-reportingcombination-products); good manufacturing practice requirements as set forth in the quality systems (QS) regulation (21 CFR Part 820) for devices or current good manufacturing practices (21 CFR Part 4, Subpart A) for combination products; and, if applicable, the electronic product radiation control provisions (Sections 531-542 of the Act); 21 CFR Parts 1000-1050. Also, please note the regulation entitled, "Misbranding by reference to premarket notification" (21 CFR 807.97). For questions regarding the reporting of adverse events under the MDR regulation (21 CFR Part 803), please go to https://www.fda.gov/medical-device-safety/medical-device-reportingmdr-how-report-medical-device-problems. {2}------------------------------------------------ 3 For comprehensive regulatory information about mediation-emitting products, including information about labeling regulations, please see Device Advice (https://www.fda.gov/medicaldevices/device-advice-comprehensive-regulatory-assistance) and CDRH Learn (https://www.fda.gov/training-and-continuing-education/cdrh-learn). Additionally, you may contact the Division of Industry and Consumer Education (DICE) to ask a question about a specific regulatory topic. See the DICE website (https://www.fda.gov/medical-device-advice-comprehensive-regulatoryassistance/contact-us-division-industry-and-consumer-education-dice) for more information or contact DICE by email (DICE@fda.hhs.gov) or phone (1-800-638-2041 or 301-796-7100). Sincerely, # Sivakami Venkatachalam -S for Shanil P. Haugen, Ph.D. Assistant Director DHT3A: Division of Renal, Gastrointestinal, Obesity and Transplant Devices OHT3: Office of GastroRenal, ObGyn, General Hospital and Urology Devices Office of Product Evaluation and Quality Center for Devices and Radiological Health Enclosure {3}------------------------------------------------ ## Indications for Use Submission Number (if known) K241591 Device Name Blue Eye Indications for Use (Describe) The Blue Eye is indicated for use in gastrointestinal endoscopic procedures for submucosal lift of polyps, adenomas, early-stage cancers or other gastrointestinal mucosal lesions prior to excision with a snare or endoscopic device. Type of Use (Select one or both, as applicable) ( Prescription Use (Part 21 CFR 801 Subpart D) Over-The-Counter Use (21 CFR 801 Subpart C) #### CONTINUE ON A SEPARATE PAGE IF NEEDED. This section applies only to requirements of the Paperwork Reduction Act of 1995. #### *DO NOT SEND YOUR COMPLETED FORM TO THE PRA STAFF EMAIL ADDRESS BELOW.* The burden time for this collection of information is estimated to average 79 hours per response, including the time to review instructions, search existing data sources, gather and maintain the data needed and complete and review the collection of information. Send comments regarding this burden estimate or any other aspect of this information collection, including suggestions for reducing this burden, to: > Department of Health and Human Services Food and Drug Administration Office of Chief Information Officer Paperwork Reduction Act (PRA) Staff PRAStaff@fda.hhs.gov "An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB number." {4}------------------------------------------------ # 510(k) Summary Date: June 1, 2024 This summary of 510(k) information is being submitted in accordance with requirements of 21 CFR 807.92. #### 1. Submitter: | Name | The Standard Co., Ltd. | |---------------|----------------------------------------------------------------------------------| | Address | 120, Gunpocheomdansaneop 2-ro, Gunpo-si,<br>Gyeonggido, 15880, Republic of Korea | | Phone | +82 2 838-5533 | | Fax | +82 2 838-5523 | | Contact | Mr. Sang-wook, Yang / QMR | | Date prepared | May 10, 2024 | #### 2. Device Information: - . Trade name: Blue Eye - Common name: Submucosal injection agent ● - Classification name: Endoscope and Accessories (21CFR 876.1500, Product code: PLL) . #### 3. Predicate Device: - Blue Eye (K220434) manufactured by The Standard Co., Ltd. . Blue Eye (TS-910) [subject device] is substantially equivalent in terms of its intended use to the claimed predicate device, the 5mL Blue Eye (TS-905) (K220434) with respect to device design, fundamental technology, physical characteristics, performance and intended use. The device design and fundamental technology of the subject device are nearly identical to that of the predicate device. The formulation and composition of the primary packaging materials are identical. There are slight differences in the dimensions of the subject device and predicate device which do not impact safety or effectiveness. Both the subject and predicate devices are delivered sterile and are indicated for single-use only. #### 4. Device Description: Blue Eye, submucosal injection agent, is a solution used for submucosal lift of polyps, adenomas, early-stage cancers or other gastrointestinal mucosal lesions prior to excision with a snare or {5}------------------------------------------------ endoscopic device in gastrointestinal endoscopic procedures. The main materials of the solution are sodium hyaluronate and saline, and it is provided in prefilled syringe. It is supplied sterile and disposable. Blue Eye is indicated for use in gastrointestinal endoscopic procedures for submucosal lift of polyps, adenomas, early-stage cancers or other gastrointestinal mucosal lesions prior to excision with a snare or endoscopic device. | | Subject Device | Predicate Device | Differences | |--------------------------------------------------|-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|-------------| | Manufacturer | The Standard Co., Ltd. | The Standard Co., Ltd. | - | | Device Name | Blue Eye (TS-910) | Blue Eye (TS-905) | - | | 510(k) numbear | - | K220434 | - | | Product Code | PLL | PLL | Same | | Device Class | Class II | Class II | Same | | Classification<br>Name | Endoscope and accessories | Endoscope and accessories | Same | | Device Common<br>Name | Submucosal Injection Agent | Submucosal Injection Agent | Same | | Regulation<br>Number | 21 CFR 876.1500 | 21 CFR 876.1500 | Same | | Indication for Use | The Blue Eye is indicated for use in<br>gastrointestinal endoscopic<br>procedures for submucosal lift of<br>polyps, adenomas, early-stage<br>cancers or other gastrointestinal<br>mucosal lesions prior to excision<br>with a snare or endoscopic device. | The Blue Eye is indicated for use in<br>gastrointestinal endoscopic<br>procedures for submucosal lift of<br>polyps, adenomas, early-stage<br>cancers or other gastrointestinal<br>mucosal lesions prior to excision<br>with a snare or endoscopic device. | Same | | Prescription or<br>Over-the-Counter<br>(OTC) Use | Prescription Use | Prescription Use | Same | | Anatomical Site | gastrointestinal mucosal lesions | gastrointestinal mucosal lesions | Same | | Target Population | Regular Adults<br>(exclusion for pregnant or lactating<br>women or children under 18 years of<br>age) | Regular Adults<br>(exclusion for pregnant or lactating<br>women or children under 18 years of<br>age) | Same | | Sterilization<br>method | Steam sterilization | Steam sterilization | Same | ### 5. Summary of the technical characteristics between the new device and the predicate: {6}------------------------------------------------ | | Subject Device | Predicate Device | Differences | |-------------|------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|--------------------------------------------------------------------------------------------| | Packaging | Provided in 10 mL single-use<br>prefilled syringe packed inside a<br>Tyvek paper and tray. Ten (5) of the<br>sealed trays are packed into a paper<br>box.<br><br>Image: [Paper box] | Provided in 5 mL single-use<br>prefilled syringe packed inside a<br>Tyvek paper and tray. Ten (10) of<br>the sealed trays are packed into a<br>canister.<br><br>Image: [Canister] | Different.<br>The secondary<br>packaging<br>material and<br>capacity are<br>different. | | Composition | Each steam sterilized syringe<br>contains 10mL of lifting agent with<br>the following ingredients:<br>• Water<br>• Hydroxyethyl Cellulose<br>• Glycerin<br>• Methylene Blue<br>• Benzyl Alcohol<br>• Sodium Phosphate<br>• Potassium phosphate | Each steam sterilized syringe<br>Contains 5mL of lifting agent with<br>the following ingredients:<br>• Water<br>• Hydroxyethyl Cellulose<br>• Glycerin<br>• Methylene Blue<br>• Benzyl Alcohol<br>• Sodium Phosphate<br>• Potassium phosphate | Same<br>concentration;<br>however,<br>Capacity of<br>lifting agent<br>provided<br>differs. | Blue Eye (TS-910) described in this 510(k) has the same intended use and the same technical characteristics as the unmodified device. The subject device and the unmodified device are substantially equivalent, having the same indications for use and raw materials including chemical compositions. The modifications are in volume and secondary packaging material to meet customer needs. Based on the test results submitted in this 510K, we conclude that the subject device is substantially equivalent to the predicate device. {7}------------------------------------------------ ### 6. Summary of Performance data The determination of substantial equivalence is based on an assessment of non-clinical performance data. To verify that the device design modifications meet the functional and performance requirements, the Blue Eye (TS-910) underwent the following performance testing. The tests were performed on the subject device using the same method as the predicate device, and acceptance criteria. - Syringe performance / ISO 11040-6, ISO 80369-7 and ISO 7886-1 . - Transportation Validation and Shipping test / ASTM D 4169: 2022 ● - . Steam Sterilization Validation in heat distribution test, heat penetration test, BI test, Bioburden test and sterility test / ISO 17655-1, ISO 11737-1 and ISO 11737-2 - . Packaging Validation / ASTM F 88/ F88M-23 and ASTM F 1929-15 - . Shelf-life test ASTM F 1980-21 ## 7. Conclusions: Based on the results of the non-clinical performance testing conducted on the subject device, it has been concluded that the proposed Blue Eye (TS-910) is as safe and effective and performs as well as the legally marketed predicate device(K220434). The same indications for use, intended use, technological characteristics, and performance characteristics for the proposed Blue Eye (TS-910) have been assessed to be substantially equivalent to the predicate device, and any differences do not raise different issues of safety and effectiveness when compared to the predicate device. Therefore, Blue Eye (TS-910) is substantially equivalent to the predicate device.
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